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  • Question 1 - A 47-year-old man with kidney disease develops pulmonary tuberculosis. His recent blood tests...

    Correct

    • A 47-year-old man with kidney disease develops pulmonary tuberculosis. His recent blood tests show an eGFR of 50 ml/min and a creatinine clearance of 30 ml/min. Which ONE drug should be administered in a reduced dose?

      Your Answer: Ethambutol

      Explanation:

      The treatment of tuberculosis is a complex process that requires the expertise of a specialist in the field, such as a respiratory physician or an infectivologist. The first-line drugs used for active tuberculosis without CNS involvement are isoniazid, rifampicin, pyrazinamide, and ethambutol. These drugs are given together for the first 2 months of therapy, followed by continued treatment with just isoniazid and rifampicin for an additional 4 months. Pyridoxine is added to the treatment regimen to reduce the risk of isoniazid-induced peripheral neuropathy. If there is CNS involvement, the four drugs (and pyridoxine) are given together for 2 months, followed by continued treatment with isoniazid (with pyridoxine) and rifampicin for an additional 10 months. It is important to monitor liver function tests before and during treatment, and to educate patients on the potential side effects of the drugs and when to seek medical attention. Treatment-resistant tuberculosis cases are becoming more common and require special management and public health considerations.

    • This question is part of the following fields:

      • Respiratory Medicine
      56.3
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  • Question 2 - A 42-year-old man from Burkina Faso visits his GP with a complaint of...

    Correct

    • A 42-year-old man from Burkina Faso visits his GP with a complaint of a persistent cough and unintentional weight loss of 2kg over the last 8 weeks. He denies experiencing night sweats and has never smoked or consumed alcohol. He works as a baker. During the examination, the doctor observes sensitive, erythematous pretibial nodules. The Mantoux test results are negative. What is the probable diagnosis?

      Your Answer: Sarcoidosis

      Explanation:

      Understanding Sarcoidosis: A Multisystem Disorder

      Sarcoidosis is a condition that affects multiple systems in the body and is characterized by the presence of non-caseating granulomas. Although the exact cause of sarcoidosis is unknown, it is more commonly seen in young adults and people of African descent.

      The symptoms of sarcoidosis can vary depending on the severity of the condition. Acute symptoms may include erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, and polyarthralgia. On the other hand, insidious symptoms may include dyspnea, non-productive cough, malaise, and weight loss. In some cases, sarcoidosis can also cause skin lesions such as lupus pernio and hypercalcemia due to increased conversion of vitamin D to its active form.

      Sarcoidosis can also present as different syndromes. Lofgren’s syndrome is an acute form of the disease characterized by bilateral hilar lymphadenopathy, erythema nodosum, fever, and polyarthralgia. It usually has a good prognosis. Mikulicz syndrome, which is now considered outdated and unhelpful by many, is characterized by enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis, or lymphoma. Heerfordt’s syndrome, also known as uveoparotid fever, is characterized by parotid enlargement, fever, and uveitis secondary to sarcoidosis.

      In conclusion, sarcoidosis is a complex condition that affects multiple systems in the body. Understanding the different symptoms and syndromes associated with sarcoidosis can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Respiratory Medicine
      319.3
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  • Question 3 - A 68-year-old woman comes to the emergency department complaining of fatigue and difficulty...

    Correct

    • A 68-year-old woman comes to the emergency department complaining of fatigue and difficulty breathing for the past 2 days. She has a medical history of hypertension, a heart attack 3 years ago, heart failure, and a recent chest infection that was successfully treated with antibiotics. During the examination, the patient has bibasal crepitations and an elevated JVP. Her temperature is 37ºC, oxygen saturation is 95% on air, heart rate is 95 beats per minute, respiratory rate is 26 breaths per minute, and blood pressure is 129/86 mmHg.

      What is the most appropriate course of treatment?

      Your Answer: IV furosemide

      Explanation:

      The recommended treatment for acute pulmonary oedema in this patient is IV loop diuretic, specifically furosemide. This is because the patient is experiencing acute decompensated heart failure, which causes pulmonary oedema. IV loop diuretic has a prompt diuretic effect, reducing ventricular filling pressures and improving symptoms within 30 minutes.

      IV dobutamine is not necessary for this patient as they are not in shock and dobutamine is typically reserved for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock.

      IV morphine is not recommended for acute heart failure as it may increase morbidity in patients with acute pulmonary oedema.

      Oral furosemide is not the preferred route of administration for this patient as IV furosemide has a faster onset of diuresis.

      Heart failure requires acute management, with recommended treatments for all patients including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be necessary, with guidelines suggesting oxygen saturations be kept at 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may have a role in cases of concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect/contraindication. Patients with respiratory failure may require CPAP, while those with hypotension or cardiogenic shock may require inotropic agents like dobutamine or vasopressor agents like norepinephrine. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be necessary. Regular medication for heart failure should be continued, with beta-blockers only stopped in certain circumstances. Opiates should not be routinely offered to patients with acute heart failure due to potential increased morbidity.

      In summary, acute management of heart failure involves a range of treatments depending on the patient’s specific condition. It is important to carefully consider the potential side-effects and contraindications of each treatment, and to continue regular medication for heart failure where appropriate. Opiates should be used with caution, and only in cases where they are likely to reduce dyspnoea/distress without causing harm. With appropriate management, patients with acute heart failure can receive the care they need to improve their outcomes and quality of life.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 4 - A 45-year-old woman comes to the clinic with a complaint of dyspnoea on...

    Correct

    • A 45-year-old woman comes to the clinic with a complaint of dyspnoea on exertion and a non-productive cough that has been bothering her for the past 4 months. During the examination, the doctor notices clubbing and crepitations at the lung bases. Lung function tests reveal a decreased vital capacity and an elevated FEV1:FVC ratio. What is the most probable diagnosis?

      Your Answer: Fibrosing alveolitis

      Explanation:

      Understanding Cryptogenic Fibrosing Alveolitis

      Cryptogenic fibrosing alveolitis, also known as idiopathic pulmonary fibrosis, is a disorder that typically affects individuals between the ages of 50 and 70 years, with a slightly higher incidence in men than women. The condition is characterized by progressive breathlessness on exertion, dry cough, and a restrictive pattern on pulmonary function tests. While excessive sputum production is uncommon in the early stages, constitutional symptoms such as weight loss and lethargy may occur. Finger clubbing is a common finding in patients with cryptogenic fibrosing alveolitis.

      While haemoptysis is rare, it may suggest the development of lung malignancy, which occurs with an increased risk in patients with this condition. It is important to note that the risk of lung cancer does not exclude the possibility of cryptogenic fibrosing alveolitis. Chest pain is uncommon in this condition.

      There is no definitive treatment for cryptogenic fibrosing alveolitis, and the average survival from the time of diagnosis is 3 years. However, the course of the disease can be highly variable, and up to 20% of patients survive for more than 5 years from diagnosis.

      In summary, cryptogenic fibrosing alveolitis is a progressive lung disorder that presents with breathlessness on exertion, dry cough, and a restrictive pattern on pulmonary function tests. While there is no definitive treatment, early diagnosis and management can improve outcomes for patients.

    • This question is part of the following fields:

      • Respiratory Medicine
      93.6
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  • Question 5 - An 80-year-old man is admitted with a right lower lobe pneumonia. Along with...

    Correct

    • An 80-year-old man is admitted with a right lower lobe pneumonia. Along with consolidation, there seems to be a moderate-sized pleural effusion on the same side. A pleural fluid aspiration is performed under ultrasound guidance, and the fluid's appearance is clear, sent off for culture. While waiting for the culture results, what is the most crucial factor in deciding whether to place a chest tube?

      Your Answer: pH of the pleural fluid

      Explanation:

      According to the British Thoracic Society (BTS), chest tube placement in pleural infection is mainly indicated for patients with purulent or cloudy pleural fluid, positive Gram stain and/or culture results from non-purulent pleural fluid, and pleural fluid pH below 7.2. Among these indications, pleural fluid pH is considered the most valuable test.

      Investigating and Managing Pleural Effusion: BTS Guidelines

      Pleural effusion is a condition where fluid accumulates in the pleural space, the area between the lungs and the chest wall. To investigate and manage this condition, the British Thoracic Society (BTS) has provided guidelines.

      Imaging is an essential part of the investigation process, and the BTS recommends performing posterioranterior (PA) chest x-rays in all patients. Ultrasound is also recommended as it increases the likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations. Contrast CT is increasingly performed to investigate the underlying cause, particularly for exudative effusions.

      Pleural aspiration is another crucial step in the investigation process. The BTS recommends using ultrasound to reduce the complication rate. A 21G needle and 50ml syringe should be used, and fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology, and microbiology. Light’s criteria can help distinguish between a transudate and an exudate. Other characteristic pleural fluid findings include low glucose in rheumatoid arthritis and tuberculosis, raised amylase in pancreatitis and oesophageal perforation, and heavy blood staining in mesothelioma, pulmonary embolism, and tuberculosis.

      In cases of pleural infection, diagnostic pleural fluid sampling is required for all patients with a pleural effusion in association with sepsis or a pneumonic illness. If the fluid is purulent or turbid/cloudy, a chest tube should be placed to allow drainage. If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection, a chest tube should be placed.

      For managing recurrent pleural effusion, options include recurrent aspiration, pleurodesis, indwelling pleural catheter, and drug management to alleviate symptoms such as opioids to relieve dyspnoea. The BTS guidelines provide a comprehensive approach to investigating and managing pleural effusion.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 6 - An anxious, 30-year-old saleswoman presents with mild shortness of breath on exertion, which...

    Correct

    • An anxious, 30-year-old saleswoman presents with mild shortness of breath on exertion, which had come on gradually over several months. The symptom was intermittent and seemed to get worse in the evening. She has also been on treatment for depression over the last two months. On examination, she has minimal weakness of shoulder abductors and slight weakness of eye closure bilaterally. Deep tendon reflexes are present and symmetrical throughout and plantar responses are flexor. You now have the results of the investigations: FBC, U&E, LFT, TFT - normal; chest radiograph and lung function tests - normal; ECG - normal.
      Which of the following is the most likely diagnosis?
      Select the SINGLE most likely diagnosis.

      Your Answer: Myasthenia gravis

      Explanation:

      Understanding Myasthenia Gravis: Symptoms, Diagnosis, and Treatment

      Myasthenia gravis (MG) is a neuromuscular disorder that occurs when the body produces autoantibodies against the nicotinic acetylcholine receptor at the neuromuscular junction. This results in muscular weakness that is characterized by fatigability, meaning that the muscles become increasingly weaker during their use. MG primarily affects the muscles of the face, the extrinsic ocular muscles (causing diplopia), and the muscles involved in deglutition. Respiratory and proximal lower limb muscles may also be involved early in the disease, which can cause breathlessness and even sudden death.

      Diagnosing MG can be challenging, as weakness may not be apparent on a single examination. However, electrodiagnostic tests and detecting the autoantibodies can confirm the diagnosis. The Tensilon test, which involves injecting edrophonium chloride to reverse the symptoms of MG, is now used only when other tests are negative and clinical suspicion of MG is still high.

      Treatment of MG involves anticholinesterase medications, but many patients also benefit from thymectomy. It is important to note that a thymoma may be present in up to 15% of patients with MG.

      Other conditions, such as transient ischaemic attacks, angina, multiple sclerosis, and somatisation disorder, may cause weakness, but they do not typically present with the same symptoms as MG. Therefore, it is crucial to consider MG as a potential diagnosis when a patient presents with fatigable muscular weakness.

    • This question is part of the following fields:

      • Respiratory Medicine
      93.2
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  • Question 7 - A 55-year-old woman presents to her GP complaining of persistent coloured sputum for...

    Incorrect

    • A 55-year-old woman presents to her GP complaining of persistent coloured sputum for the past 2 years. She has a history of frequent chest infections. On examination, bilateral basal crepitations were heard.
      Which of the following is the most probable diagnosis?

      Your Answer: Chronic obstructive pulmonary disease (COPD)

      Correct Answer: Bronchiectasis

      Explanation:

      Differentiating Bronchiectasis from Other Respiratory Conditions

      Bronchiectasis is a condition characterized by permanent dilatation of the bronchi and bronchioles due to chronic infection. Patients with bronchiectasis typically present with a persistent cough, copious purulent sputum, and occasional haemoptysis. Bilateral crackles are often found during examination. It is important to differentiate bronchiectasis from other respiratory conditions such as COPD, aspergilloma, extrinsic allergic alveolitis, and idiopathic pulmonary fibrosis. While patients with COPD may have sputum production and chronic dyspnoea, they are likely to have quiet breath sounds or wheeze. Aspergilloma, on the other hand, is usually asymptomatic with little sputum production, but may cause cough, haemoptysis, lethargy, and weight loss. Extrinsic allergic alveolitis results from a hypersensitivity reaction to fungal spores or avian proteins, causing a dry, non-productive cough. Idiopathic pulmonary fibrosis, which causes a dry cough, exertional dyspnoea, weight loss, and arthralgia, is also different from bronchiectasis. Therefore, a thorough evaluation of symptoms and examination is necessary to accurately diagnose bronchiectasis and differentiate it from other respiratory conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 8 - A 70-year-old man presented to the clinic with proximal muscle weakness and a...

    Correct

    • A 70-year-old man presented to the clinic with proximal muscle weakness and a cough lasting eight weeks. He also reported pain in the small joints of his hands and small haemorrhages in the nailfolds. On examination, there was no lymphadenopathy or clubbing, but bibasal crackles were heard. A chest radiograph revealed diffuse reticular infiltrates, and lung function tests showed a restrictive pattern. What is the most likely underlying cause of his interstitial lung disease?

      Your Answer: Polymyositis

      Explanation:

      Differential Diagnosis of Polymyositis: A Comparison with Other Connective Tissue Diseases

      Polymyositis is a systemic connective tissue disease that causes inflammation of the striated muscle and skin in the case of dermatomyositis. Patients typically present with muscle weakness, pain in the small joints of the fingers, and dermatitis. The disease is associated with HLA-B8 and HLA-DR3, and underlying malignancy is present in at least 5-8% of cases. Here, we compare polymyositis with other connective tissue diseases to aid in differential diagnosis.

      Rheumatoid arthritis (RA) is another systemic inflammatory disease that affects mainly the joints, in particular, the proximal interphalangeal joints, in a symmetrical fashion. Pulmonary fibrosis is a known complication of RA, and muscular weakness is also a possible feature. However, in RA, joint-related symptoms are typically more prominent than muscle weakness, making polymyositis a more likely diagnosis in cases of predominant muscle weakness.

      Cryptogenic fibrosing alveolitis, also known as idiopathic pulmonary fibrosis, presents with diffuse reticular infiltrates on chest radiographs and a restrictive pattern on lung function tests. However, the history of proximal muscle weakness and pain in the small joints of the hands does not fit with this diagnosis and suggests polymyositis instead.

      Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple systems in the body. While SLE would be in the differential diagnosis for polymyositis, the prominent proximal muscle weakness and the fact that the patient is a man (SLE affects women in 90% of cases) make polymyositis a more likely diagnosis.

      Ankylosing spondylitis (AS) is an inflammatory rheumatic disease that primarily affects the axial joints and entheses. AS can be associated with pulmonary fibrosis and produces a restrictive pattern on spirometry. However, the more prominent complaint of proximal muscle weakness and the involvement of the small joints of the hands make AS a less likely diagnosis in cases of predominant muscle weakness.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 9 - A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic...

    Correct

    • A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic obstructive pulmonary disease.
      Which of the following is the most appropriate investigation to confirm diagnosis?

      Your Answer: Spirometry

      Explanation:

      Investigations for COPD: Spirometry is Key

      COPD is a chronic obstructive airway disease that is diagnosed through a combination of clinical history, signs, and investigations. While several investigations may be used to support a diagnosis of COPD, spirometry is the most useful and important tool. A spirometer is used to measure functional lung volumes, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1:FVC ratio provides an estimate of the severity of airflow obstruction, with a normal ratio being 75-80%. In patients with COPD, the ratio is typically <0.7 and FEV1 <80% predicted. Spirometry is essential for establishing a baseline for disease severity, monitoring disease progression, and assessing the effects of treatment. Other investigations, such as echocardiography, chest radiography, ECG, and peak flow, may be used to exclude other pathologies or assess comorbidities, but spirometry remains the key investigation for diagnosing and managing COPD.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 10 - 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 11 - A 55-year-old woman presents to the hypertension clinic for review. She has a...

    Correct

    • A 55-year-old woman presents to the hypertension clinic for review. She has a past medical history of depression and gout. The patient was initiated on lisinopril for hypertension two months ago, with gradual titration of the dose and monitoring of her urea and electrolytes. During today's visit, she reports a dry cough that has been progressively worsening over the past four weeks. The cough is described as really annoying and is causing sleep disturbance. The patient is a non-smoker, and a chest x-ray performed six weeks ago during an Emergency Department visit was normal. What is the most appropriate course of action regarding her antihypertensive medications?

      Your Answer: Switch her to an angiotensin II receptor blocker

      Explanation:

      A dry cough is a common side effect experienced by patients who begin taking an ACE inhibitor. However, in this case, the patient has been suffering from this symptom for four weeks and it is affecting her sleep. Therefore, it is advisable to switch her to an angiotensin II receptor blocker.

      Angiotensin II receptor blockers are a type of medication that is commonly used when patients cannot tolerate ACE inhibitors due to the development of a cough. Examples of these blockers include candesartan, losartan, and irbesartan. However, caution should be exercised when using them in patients with renovascular disease. Side-effects may include hypotension and hyperkalaemia.

      The mechanism of action for angiotensin II receptor blockers is to block the effects of angiotensin II at the AT1 receptor. These blockers have been shown to reduce the progression of renal disease in patients with diabetic nephropathy. Additionally, there is evidence to suggest that losartan can reduce the mortality rates associated with CVA and IHD in hypertensive patients.

      Overall, angiotensin II receptor blockers are a viable alternative to ACE inhibitors for patients who cannot tolerate the latter. They have a proven track record of reducing the progression of renal disease and improving mortality rates in hypertensive patients. However, as with any medication, caution should be exercised when using them in patients with certain medical conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
      129.9
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  • Question 12 - A 63-year-old man visits his doctor with a persistent cough that has lasted...

    Correct

    • A 63-year-old man visits his doctor with a persistent cough that has lasted for 5 weeks. He reports coughing up smelly, green phlegm and experiencing night sweats, left-sided chest pain, and occasional fevers. He denies any weight loss. During the examination, the lower left lung is dull to percussion with low-pitched bronchial breath sounds, and he has a temperature of 38.2°C. The patient has not traveled recently or had any contact with sick individuals. The doctor notes that he was treated for pneumonia 7 weeks ago. What is the most probable cause of this patient's presentation?

      Your Answer: Lung abscess

      Explanation:

      The most likely diagnosis for this patient is lung abscess, as they are presenting with a subacute productive cough, foul-smelling sputum, and night sweats. The duration of a cough can be categorized as acute, subacute, or chronic, and this patient falls under the subacute category. The patient’s recent history of aspiration pneumonia and examination findings, such as dullness on percussion, bronchial breath sounds, and fever, support the diagnosis of lung abscess.

      Lung cancer is not the most likely diagnosis for this patient, as they do not have weight loss and have other findings that point towards lung abscess. Pulmonary fibrosis is also unlikely, as it is rare to have unilateral pulmonary fibrosis, and the patient’s examination findings do not support this diagnosis. Recurrent pneumonia is a good differential, but the presence of bronchial breath sounds and night sweats make lung abscess a more likely diagnosis.

      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 13 - 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: Beclomethasone

      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
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  • Question 14 - A 50-year-old man comes to see his GP complaining of chest tightness and...

    Correct

    • A 50-year-old man comes to see his GP complaining of chest tightness and shortness of breath on exertion for the past month. He reports that the symptoms subside after resting for 5 minutes. The patient has a medical history of asthma, hypertension, and obesity.
      During the examination, the patient's temperature is 37.2ºC, heart rate is 86 bpm, blood pressure is 132/75 mmHg, and the ECG is normal.
      What is the most appropriate prophylactic medication for this likely diagnosis?

      Your Answer: Prescribe sublingual glyceryl trinitrate

      Explanation:

      To prevent angina attacks, the first-line treatment is either a beta-blocker or a calcium channel blocker. This patient is displaying symptoms of stable angina, which includes shortness of breath and chest tightness that occurs during exercise and is relieved by rest. The ECG results are normal, ruling out any serious conditions like myocardial infarction. According to NICE guidelines, all patients with stable angina should receive aspirin and a statin, unless there are contraindications. Additionally, sublingual glyceryl trinitrate spray (GTN) should be given to stop acute angina attacks. However, GTN spray does not prevent future attacks, so prophylactic medication should also be prescribed.

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 15 - Both restrictive lung disease and obstructive lung disease may affect a particular pulmonary...

    Correct

    • Both restrictive lung disease and obstructive lung disease may affect a particular pulmonary function test to a similar extent. Which test is this? Please select only one option from the list provided.

      Your Answer: Tidal volume

      Explanation:

      Pulmonary Function Tests: Understanding Tidal Volume, Total Lung Capacity, Residual Volume, FEV1/FVC Ratio, and FEV1

      Pulmonary function tests (PFTs) are a group of tests that measure how well the lungs are functioning. There are several parameters that are measured during PFTs, including tidal volume (TV), total lung capacity (TLC), residual volume (RV), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio, and forced expiratory volume in 1 second (FEV1).

      Tidal volume refers to the amount of gas inspired or expired with each breath. It can be reduced in both obstructive and restrictive lung disease, but the underlying mechanism causing the reduction is different. In obstructive lung disease, there is airflow limitation, while in restrictive lung disease, there is reduced lung volume or inability to fully expand the thoracic cage.

      Total lung capacity is the volume of air in the lungs after a maximal inspiration. It is increased in obstructive lung disease due to air trapping, but is reduced in restrictive lung disease.

      Residual volume is the volume of air remaining in the lungs after a maximal expiration. It cannot be measured with spirometry, but it is increased in obstructive lung disease due to air trapping.

      The FEV1/FVC ratio is a measure of how much air a person can forcefully exhale in one second compared to the total amount of air they can exhale. A ratio of less than 70% is indicative of obstructive lung disease, while a ratio greater than 70% is indicative of restrictive lung disease.

      FEV1 is the amount of air a person can forcefully exhale in one second. It is characteristically reduced in obstructive lung disease, but normal in restrictive lung disease because there is no airflow limitation.

      Understanding these parameters can help healthcare professionals diagnose and manage lung diseases.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 16 - A 62-year-old woman is referred to the medical team from the orthopaedic ward....

    Correct

    • A 62-year-old woman is referred to the medical team from the orthopaedic ward. She underwent a right total-hip replacement six days ago. She is known to have mild COPD and is on regular inhaled steroids and a short-acting b2 agonist. She now complains of left-sided chest pain and is also dyspnoeic. Your clinical diagnosis is pulmonary embolism (PE).
      Which of the following is usually NOT a feature of PE in this patient?

      Your Answer: Bradycardia

      Explanation:

      Symptoms and Signs of Pulmonary Embolism

      Pulmonary embolism (PE) is a serious condition that can be life-threatening. It is important to recognize the symptoms and signs of PE to ensure prompt diagnosis and treatment. Here are some of the common symptoms and signs of PE:

      Dyspnoea: This is the most common symptom of PE, present in about 75% of patients. Dyspnoea can occur at rest or on exertion.

      Tachypnoea: This is defined as a respiratory rate of more than 20 breaths per minute and is present in about 55% of patients with PE.

      Tachycardia: This is present in about 25% of cases of PE. It is important to note that a transition from tachycardia to bradycardia may suggest the development of right ventricular strain and potentially cardiogenic shock.

      New-onset atrial fibrillation: This is a less common feature of PE, occurring in less than 10% of cases. Atrial flutter, atrial fibrillation, and premature beats should alert the doctor to possible right-heart strain.

      Bradycardia: This is not a classic feature of PE. However, if a patient with PE transitions from tachycardia to bradycardia, it may suggest the development of right ventricular strain and potentially cardiogenic shock.

      In summary, dyspnoea, tachypnoea, tachycardia, and new-onset atrial fibrillation are some of the common symptoms and signs of PE. It is important to have a high level of suspicion for PE, especially in high-risk patients, to ensure prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 17 - 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.

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      • Respiratory Medicine
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  • Question 18 - A 67-year-old man with worsening dyspnea is suspected to have idiopathic pulmonary fibrosis....

    Correct

    • A 67-year-old man with worsening dyspnea is suspected to have idiopathic pulmonary fibrosis. What is the preferred diagnostic test to confirm the diagnosis?

      Your Answer: High-resolution CT scan

      Explanation:

      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.

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      • Respiratory Medicine
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  • Question 19 - A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough,...

    Correct

    • A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially when climbing stairs. She reports intermittent fevers of up to 39°C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and serum ANA is negative. On examination there are red nodules over her lower legs.
      Which of the following is the most likely diagnosis?

      Your Answer: Sarcoidosis

      Explanation:

      Sarcoidosis is a condition where non-caseating granulomata develop in at least two organs, causing systemic inflammation. It is most common in African-Caribbean women and often affects the lungs, causing symptoms such as dry cough, dyspnea, and weight loss. Erythema nodosum is also frequently seen in patients with sarcoidosis. Histoplasmosis, Goodpasture’s syndrome, adenocarcinoma of the lung, and systemic lupus erythematosus are all possible differential diagnoses, but the absence of specific features makes sarcoidosis more likely in this case.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 20 - As part of the yearly evaluation, you are assessing a 70-year-old man who...

    Correct

    • As part of the yearly evaluation, you are assessing a 70-year-old man who has been diagnosed with chronic obstructive pulmonary disease (COPD). In the previous year, he experienced three COPD exacerbations, one of which required hospitalization. During the current visit, his chest sounds clear, and his oxygen saturation level is 94% while breathing room air. As per NICE guidelines, what treatment options should you suggest to him?

      Your Answer: A home supply of prednisolone and an antibiotic

      Explanation:

      According to the 2010 NICE guidelines, patients who experience frequent exacerbations of COPD should be provided with a home supply of corticosteroids and antibiotics. It is important to advise the patient to inform you if they need to use these medications and to assess if any further action is necessary. Antibiotics should only be taken if the patient is producing purulent sputum while coughing.

      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
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  • Question 21 - 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.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 22 - A 32-year-old woman comes to the clinic complaining of sudden breathlessness and pain...

    Correct

    • A 32-year-old woman comes to the clinic complaining of sudden breathlessness and pain on the left side of her chest for the past 24 hours. She is generally healthy and takes the combined oral contraceptive pill.
      What is the highest scoring factor in the Wells' scoring system for suspected pulmonary embolism (PE)?

      Your Answer: Clinical signs and symptoms of a deep-vein thrombosis (DVT)

      Explanation:

      Understanding the Two-Level PE Wells Score: Clinical Signs and Symptoms of DVT

      The Two-Level PE Wells Score is a tool used to assess the likelihood of a patient having a pulmonary embolism (PE). One of the key factors in this score is the presence of clinical signs and symptoms of a deep-vein thrombosis (DVT), which includes leg swelling and pain on palpation of the deep veins. This carries three points in the score, and is a crucial factor in determining the likelihood of a PE.

      Other factors in the score include an alternative diagnosis being less likely than a PE, heart rate over 100 beats/min, immobilization or recent surgery, previous DVT/PE, haemoptysis, and malignancy. Each of these factors carries a certain number of points, and a score of over 4 points indicates a high likelihood of a PE, while a score of 4 points or less indicates a lower likelihood.

      Overall, understanding the Two-Level PE Wells Score and the clinical signs and symptoms of DVT is important in accurately assessing the likelihood of a patient having a PE and determining the appropriate course of treatment.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 23 - An 80-year-old man with terminal lung cancer is evaluated by the palliative care...

    Incorrect

    • An 80-year-old man with terminal lung cancer is evaluated by the palliative care team to determine his analgesic requirements. He is currently on a regimen of 30 mg slow-release morphine twice daily, which effectively manages his pain. However, he is experiencing difficulty swallowing both tablet and liquid forms of the medication. The palliative team suggests transitioning him to subcutaneous morphine. What is the appropriate daily dosage for him?

      Your Answer: 60mg

      Correct Answer: 30mg

      Explanation:

      Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.

      Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.

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      • Respiratory Medicine
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  • Question 24 - A 50-year-old female comes to an after-hours general practitioner complaining of worsening fever,...

    Correct

    • A 50-year-old female comes to an after-hours general practitioner complaining of worsening fever, chest pain that worsens when inhaling, and a productive cough with blood-streaked sputum. She reports that she had symptoms of a dry cough, myalgia, and lethargy a week ago, but this week her symptoms have changed to those she is presenting with today. Her chest x-ray shows a cavitating lesion with a thin wall on the right side and an associated pleural effusion. What is the probable causative organism?

      Your Answer: Staphylococcus aureus

      Explanation:

      Causes of Pneumonia

      Pneumonia is a respiratory infection that can be caused by various infectious agents. Community acquired pneumonia (CAP) is the most common type of pneumonia and is caused by different microorganisms. The most common cause of CAP is Streptococcus pneumoniae, which accounts for around 80% of cases. Other infectious agents that can cause CAP include Haemophilus influenzae, Staphylococcus aureus, atypical pneumonias caused by Mycoplasma pneumoniae, and viruses.

      Klebsiella pneumoniae is another microorganism that can cause pneumonia, but it is typically found in alcoholics. Streptococcus pneumoniae, also known as pneumococcus, is the most common cause of community-acquired pneumonia. It is characterized by a rapid onset, high fever, pleuritic chest pain, and herpes labialis (cold sores).

      In summary, pneumonia can be caused by various infectious agents, with Streptococcus pneumoniae being the most common cause of community-acquired pneumonia. It is important to identify the causative agent to provide appropriate treatment and prevent complications.

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      • Respiratory Medicine
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  • Question 25 - A 67-year-old man presents to the Emergency Department with pleuritic chest pain that...

    Correct

    • A 67-year-old man presents to the Emergency Department with pleuritic chest pain that started two hours ago. He has a history of lung cancer with bony metastases and has recently started treatment with erlotinib.

      His vital signs are as follows: temperature 37.2ºC; oxygen saturation 92% on room air; respiratory rate 20 breaths per minute; heart rate 98 beats per minute; blood pressure 140/86 mmHg.

      A chest X-ray is performed, which shows no abnormalities. He is started on supplemental oxygen therapy, and a CT pulmonary angiogram (CTPA) is ordered.

      While waiting for the CTPA results, what is the most appropriate next step in management?

      Your Answer: Commence rivaroxaban

      Explanation:

      The recommended initial management for patients with suspected pulmonary embolism (PE) is to ensure they are haemodynamically stable before starting anticoagulation. According to the latest NICE Guidelines (2020), a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban should be started unless there are contraindications. In this case, the patient is stable and can be started on rivaroxaban. It is important to note that starting prophylactic dose LMWH is not appropriate for suspected PE, and commencing warfarin at loading dose is also not recommended due to its delayed anticoagulant effects. Thrombolytic agents such as alteplase are only appropriate for haemodynamically unstable patients. Dabigatran is an alternative option for patients who cannot take apixaban or rivaroxaban, but it too requires a bridging dose of LMWH.

      Management of Pulmonary Embolism: NICE Guidelines

      Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.

      Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.

      In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.

      Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 26 - A 67-year-old man presents to you with complaints of increasing shortness of breath....

    Correct

    • A 67-year-old man presents to you with complaints of increasing shortness of breath. He reports having to use 3 or 4 pillows to sleep at night and feeling more breathless after climbing just one flight of stairs. His medical history includes a previous myocardial infarction and high cholesterol. During examination, you observe bibasal crepitations and notice swelling in his ankles. What is the most suitable next investigation to perform?

      Your Answer: B-type Natriuretic Peptide (BNP)

      Explanation:

      According to the updated 2018 NICE guidelines, the initial test for patients with suspected chronic heart failure should be an NT-proBNP test, regardless of their history of myocardial infarction. Additionally, all patients should undergo a 12-lead ECG. While a CT chest is typically not necessary, a chest x-ray may be performed to rule out other potential conditions.

      Chronic heart failure is a condition that requires proper diagnosis and management. In 2018, NICE updated their guidelines on the diagnosis and management of this condition. Previously, the first-line investigation was determined by whether the patient had previously had a myocardial infarction or not. However, this is no longer the case. All patients should now have an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation.

      Interpreting the NT-proBNP blood test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks. B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis.

      There are different levels of BNP, and each level indicates a different severity of the condition. High levels of BNP are greater than 400 pg/ml (116 pmol/litre) for BNP and greater than 2000 pg/ml (236 pmol/litre) for NTproBNP. Raised levels of BNP are between 100-400 pg/ml (29-116 pmol/litre) for BNP and between 400-2000 pg/ml (47-236 pmol/litre) for NTproBNP. Normal levels of BNP are less than 100 pg/ml (29 pmol/litre) for BNP and less than 400 pg/ml (47 pmol/litre) for NTproBNP.

      It is important to note that several factors can alter the BNP level. Factors that increase BNP levels include left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR < 60 ml/min, sepsis, COPD, diabetes, and age > 70. On the other hand, factors that decrease BNP levels include diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists.

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      • Respiratory Medicine
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  • Question 27 - A 45-year-old woman presents with a 3-day history of cough, fever and left-sided...

    Incorrect

    • A 45-year-old woman presents with a 3-day history of cough, fever and left-sided pleuritic pain. On examination she has a temperature of 38.5 °C, a respiratory rate of 37/min, a blood pressure of 110/80 mm/Hg and a pulse rate of 110/min. Oxygen saturations are 95%. She has basal crepitations and dullness to percussion at the left lung base.
      Which of the following is the most likely diagnosis?

      Your Answer: Pneumothorax

      Correct Answer: Bronchopneumonia

      Explanation:

      Differential Diagnosis for a Patient with Cough and Fever: Bronchopneumonia vs. Other Conditions

      Bronchopneumonia is a common condition that presents with a cough and fever, along with other symptoms such as sputum production, dyspnea, and pleuritic pain. Examination findings may include decreased breath sounds and focal chest signs. A chest radiograph can confirm the diagnosis. In primary care, a CRB-65 score is used to assess mortality risk and determine where to treat the patient: one point each for acute confusion, respiratory rate (RR) ≥30/min, systolic blood pressure (BP) <90 mmHg or diastolic BP <60 mmHg, age >65 years).
      CRB-65 score Mortality risk (%) – Where to treat
      0 <1 At home
      1-2 1-10 Hospital advised, particularly score of 2
      3-4 >10 Hospital advised, may require stay in intensive therapy unit (ITU).

      Other conditions that may present with similar symptoms include pneumothorax, pulmonary embolism, malignant mesothelioma, and tuberculosis. However, these conditions have distinct features that differentiate them from bronchopneumonia. For example, pneumothorax involves partial or full collapse of a lung, while pulmonary embolism results from obstruction of one or more of the pulmonary arteries. Malignant mesothelioma is a cancer that affects the pleura and peritoneum, and tuberculosis usually presents with a persistent productive cough, weight loss, night sweats, fevers, lymphadenopathy, and general malaise.

      It is important to consider these differentials when evaluating a patient with cough and fever, and to use appropriate diagnostic tools to confirm the diagnosis and determine the best course of treatment.

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      • Respiratory Medicine
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  • Question 28 - A 58-year-old man with chronic obstructive pulmonary disease (COPD) experiences an exacerbation of...

    Incorrect

    • 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: Trimethoprim

      Correct 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.

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      • Respiratory Medicine
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  • Question 29 - A 68-year-old male presents to the general practitioner with progressive dyspnoea, chronic cough...

    Incorrect

    • A 68-year-old male presents to the general practitioner with progressive dyspnoea, chronic cough and wheeze. He has a 50-pack-year smoking history and a past medical history of atopy and is currently taking a salbutamol inhaler. Spirometry shows a forced expiratory volume over 1 second (FEV1) of 55% predicted and an FEV1/forced vital capacity (FVC) ratio of 0.49. The patient also keeps a peak flow diary, which shows a diurnal variation in readings.
      What is the most appropriate next step in managing this patient?

      Your Answer: Ipratropium and beclomethasone bronchodilator therapy

      Correct Answer: Salmeterol and beclomethasone bronchodilator therapy

      Explanation:

      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.

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      • Respiratory Medicine
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  • Question 30 - A 35-year-old man presents to his General Practitioner with difficulty breathing during physical...

    Incorrect

    • A 35-year-old man presents to his General Practitioner with difficulty breathing during physical activity and feeling excessively tired. Upon further inquiry, he reports experiencing frequent respiratory infections. The doctor suspects a diagnosis of alpha-1-antitrypsin deficiency (AATD).
      What test should be arranged to confirm this diagnosis?

      Your Answer: Genetic testing for alpha-1-antitrypsin levels

      Correct Answer: Blood test for alpha-1-antitrypsin levels

      Explanation:

      Diagnostic Tests for Alpha-1-Antitrypsin Deficiency

      Alpha-1-antitrypsin deficiency (AATD) is a genetic disorder that can lead to chronic obstructive pulmonary disease (COPD) at a young age, especially in non-smokers with a family history of the condition. Here are some diagnostic tests that can help identify AATD:

      Blood Test: A simple blood test can measure the levels of alpha-1-antitrypsin in the blood. Low levels of this protein can indicate AATD, especially in patients with symptoms of COPD or a family history of the condition.

      CT Chest: A computed tomography (CT) scan of the chest can reveal the extent and pattern of emphysema in the lungs, which is a common complication of AATD. However, a CT scan alone cannot diagnose AATD.

      Chest X-Ray: A chest X-ray (CXR) can also show signs of emphysema or bronchiectasis in patients with AATD, but it is not a definitive test for the condition.

      Genetic Testing: Once AATD has been diagnosed, genetic testing can identify the specific variant of the condition that a patient has. However, genetic testing is not useful as an initial diagnostic test without first confirming low levels of alpha-1-antitrypsin in the blood.

      Pulmonary Function Testing: This test measures lung function and can help assess the severity of lung disease in patients with AATD. However, it is not a diagnostic test for the condition.

      In conclusion, a combination of these diagnostic tests can help identify AATD in patients with symptoms of COPD, a family history of the condition, or low levels of alpha-1-antitrypsin in the blood.

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      • Respiratory Medicine
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