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Question 1
Incorrect
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A 50-year-old farmer presents to his general practitioner (GP) with gradually progressive shortness of breath over the last year, along with an associated cough. He has no significant past medical history to note except for a previous back injury and is a non-smoker. He occasionally takes ibuprofen for back pain but is on no other medications. He has worked on farms since his twenties and acquired his own farm 10 years ago.
On examination, the patient has a temperature of 36.9oC and respiratory rate of 26. Examination of the chest reveals bilateral fine inspiratory crackles. His GP requests a chest X-ray, which shows bilateral reticulonodular shadowing.
Which one of the following is the most likely underlying cause of symptoms in this patient?Your Answer: Beryllium exposure
Correct Answer: Extrinsic allergic alveolitis
Explanation:Causes of Pulmonary Fibrosis: Extrinsic Allergic Alveolitis
Pulmonary fibrosis is a condition characterized by shortness of breath and reticulonodular shadowing on chest X-ray. It can be caused by various factors, including exposure to inorganic dusts like asbestosis and beryllium, organic dusts like mouldy hay and avian protein, certain drugs, systemic diseases, and more. In this scenario, the patient’s occupation as a farmer suggests a possible diagnosis of extrinsic allergic alveolitis or hypersensitivity pneumonitis, which is caused by exposure to avian proteins or Aspergillus in mouldy hay. It is important to note that occupational lung diseases may entitle the patient to compensation. Non-steroidal anti-inflammatory drugs, silicosis, crocidolite exposure, and beryllium exposure are less likely causes in this case.
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This question is part of the following fields:
- Respiratory
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Question 2
Incorrect
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A 72-year-old retired boiler maker presents to his General Practitioner with increasing shortness of breath and non-specific dull right-sided chest ache. He has a 35-pack-year history and has recently lost a little weight. On examination, there is evidence of a large right-sided pleural effusion.
Investigations:
Investigation
Result
Normal value
Sodium (Na+) 132 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 120 μmol/l 50–120 µmol/l
Haemoglobin 115 g/l 135–175 g/l
Platelets 170 × 109/l 150–400 × 109/l
Chest X-ray: large right-sided pleural effusion.
Pleural tap: pleural effusion contains occasional red blood cells, white blood cells and abnormal-looking cells which look of a sarcomatous type.
Which of the following statements fits best with the underlying condition?Your Answer: Smoking is likely to have played a significant role in the development of the effusion
Correct Answer: The vast majority of cases are associated with a history of asbestos exposure
Explanation:Understanding Mesothelioma: Causes, Treatment, and Prognosis
Mesothelioma is a type of cancer that has three major histological subtypes: sarcomatous, epithelial, and mixed. The vast majority of cases are associated with a history of direct exposure to asbestos, particularly in industries such as ship building, boiler manufacture, paper mill working, and insulation work. Patients often present with shortness of breath and chest pain on the affected side.
While smoking increases the risk of malignancy, it does not directly play a role in the development of malignant pleural effusion. Treatment often includes a combination of chemotherapy, radiotherapy, and surgery, but even with these approaches, the result is not curative. Median survival is short, with a life expectancy of around two years.
In early stages of cancer, radiation therapy combined with surgical treatment can be very effective, but in later stages, it is only effective in providing symptom relief. Radiation therapy alone will not be curative in 40% of cases. Understanding the causes, treatment options, and prognosis of mesothelioma is crucial for patients and their families.
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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 65-year-old woman presents to a spirometry clinic with a history of progressive dyspnea on exertion over the past six months, particularly when hurrying or walking uphill. What spirometry result would indicate a possible diagnosis of chronic obstructive pulmonary disease in this patient?
Your Answer: FEV1: > 80% predicted, FEV1/FVC ratio: > 0.70
Correct Answer:
Explanation:Interpreting Spirometry Results: Understanding FEV1 and FEV1/FVC Ratio
Spirometry is a common diagnostic test used to assess lung function. It measures the amount of air that can be exhaled forcefully and quickly after taking a deep breath. Two important measurements obtained from spirometry are the forced expiratory volume in 1 second (FEV1) and the ratio of FEV1 to forced vital capacity (FVC).
Identifying an obstructive disease pattern
In chronic obstructive pulmonary disease (COPD), the airways are obstructed, resulting in a reduced FEV1. However, the lung volume is relatively normal, and therefore the FVC will be near normal too. COPD is diagnosed as an FEV1 < 80% predicted and an FEV1/FVC < 0.70. Understanding the clinical scenario While an FEV1 < 30% predicted and an FEV1/FVC < 0.70 indicate an obstructive picture, it is important to refer to the clinical scenario. Shortness of breath on mild exertion, particularly walking up hills or when hurrying, is likely to relate to an FEV1 between 50-80%, defined by NICE as moderate airflow obstruction. Differentiating between obstructive and restrictive lung patterns An FVC < 80% expected value is indicative of a restrictive lung pattern. In COPD, the FVC is usually preserved or increased, hence the FEV1/FVC ratio decreases. An FEV1 of <0.30 indicates severe COPD, but it is not possible to have an FEV1/FVC ratio of > 0.70 with an FEV1 this low in COPD. It is important to note, however, that in patterns of restrictive lung disease, you can have a reduced FEV1 with a normal FEV1/FVC ratio.
Conclusion
Interpreting spirometry results requires an understanding of FEV1 and FEV1/FVC ratio. Identifying an obstructive disease pattern, understanding the clinical scenario, and differentiating between obstructive and restrictive lung patterns are crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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A 63-year-old male smoker arrived in the Emergency Department by ambulance. He had become increasingly breathless at home, and despite receiving high-flow oxygen in the ambulance he is no better. He has a flapping tremor of his hands, a bounding pulse and palmar erythema.
What is the most likely cause of his symptoms?Your Answer:
Correct Answer: Hypercapnia
Explanation:Understanding Hypercapnia: A Possible Cause of Breathlessness and Flapping Tremor in COPD Patients
Hypercapnia is a condition that can occur in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure. It is caused by the retention of carbon dioxide (CO2) due to a relative loss of surface area for gas exchange within the lungs. This can lead to bronchospasm and inflammation, which can further exacerbate the problem. In some cases, patients with chronic hypoxia and hypercapnia may become dependent on hypoxia to drive respiration. If high concentrations of oxygen are given, this drive may be reduced or lost completely, leading to hypoventilation, reduced minute ventilation, accumulation of CO2, and subsequent respiratory acidosis (type 2 respiratory failure).
External signs of hypercapnia include reduced Glasgow Coma Scale (GCS) score, flapping tremor (asterixis), palmar erythema, and bounding pulses (due to CO2-induced vasodilation). While other conditions such as hepatic encephalopathy, Parkinson’s disease, delirium tremens, and hyperthyroidism can also cause tremors and other symptoms, they do not typically cause breathlessness or the specific type of tremor seen in hypercapnia.
It is important for healthcare professionals to recognize the signs and symptoms of hypercapnia in COPD patients, as prompt intervention can help prevent further complications and improve outcomes.
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This question is part of the following fields:
- Respiratory
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Question 5
Incorrect
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A 40-year-old Afro-Caribbean man comes to the clinic complaining of fever, dry cough and joint pains. Upon examination, his chest is clear. He has several tender, warm, erythematous nodules on both shins. A chest X-ray reveals prominent hila bilaterally. What is the most probable diagnosis?
Your Answer:
Correct Answer: Sarcoidosis
Explanation:The patient is displaying symptoms that are typical of acute sarcoidosis, including erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia. The patient’s ethnic background, being Afro-Caribbean, is also a factor as sarcoidosis is more prevalent in this population. It is important to take a thorough medical history as sarcoidosis can mimic other diseases. Mycoplasma pneumonia presents with flu-like symptoms followed by a dry cough and reticulonodular shadowing on chest X-ray. Pneumocystis jirovecii pneumonia causes breathlessness, fever, and perihilar shadowing on chest X-ray and is associated with severe immunodeficiency. Pulmonary TB causes cough, fever, weight loss, and erythema nodosum, with typical chest X-ray findings including apical shadowing or cavity, or multiple nodules. Pulmonary fibrosis presents with shortness of breath, a non-productive cough, and bilateral inspiratory crepitations on auscultation. However, the X-ray findings in this patient are not consistent with pulmonary fibrosis as reticulonodular shadowing would be expected.
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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 with chronic obstructive pulmonary disease (COPD) is brought to Accident and Emergency with difficulty breathing. On arrival, his saturations were 76% on air, pulse 118 bpm and blood pressure 112/72 mmHg. He was given nebulised bronchodilators and started on 6 litres of oxygen, which improved his saturations up to 96%. He is more comfortable now, but a bit confused.
What should be the next step in the management of this patient?Your Answer:
Correct Answer: Arterial blood gas
Explanation:Management of Acute Exacerbation of COPD: Considerations and Interventions
When managing a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD), it is important to consider various interventions based on the patient’s clinical presentation. In this case, the patient has increased oxygen saturations, which may be contributing to confusion. It is crucial to avoid over-administration of oxygen, as it may worsen breathing function. An arterial blood gas can guide oxygen therapy and help determine the appropriate treatment, such as reducing oxygen concentration or initiating steroid therapy.
IV aminophylline may be considered if nebulisers and steroids have not been effective, but it is not necessary in this case. Pulmonary function testing is not beneficial in immediate management. Intubation is not currently indicated, as the patient’s confusion is likely due to excessive oxygen administration.
Antibiotics may be necessary if there is evidence of infection, but in this case, an arterial blood gas is the most important step. Overall, management of acute exacerbation of COPD requires careful consideration of the patient’s clinical presentation and appropriate interventions based on their individual needs.
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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 55-year-old woman presents with 6 months of recurrent episodes of shortness of breath. She describes it as ‘coming on suddenly without warning’. They have woken her at night before. She describes the attacks as a ‘tightness’ in the chest and says that they are associated with tingling in her fingers. The episodes resolve in a few minutes by themselves. She is otherwise medically fit and well. She smokes 15 cigarettes per day and has a family history of asthma. Examination is normal, and the peak expiratory flow rate is normal for her age and height.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Panic attacks
Explanation:Differentiating between possible causes of acute shortness of breath: A medical analysis
When a patient presents with acute shortness of breath, it is important to consider a range of possible causes. In this case, the patient’s symptoms suggest panic attacks rather than left ventricular failure, acute asthma attacks, COPD, or anaemia.
Panic attacks are characterized by sudden onset and spontaneous resolution, numbness of extremities, and normal examination and peak flow measurement. They can be triggered or occur unexpectedly, and may be due to a disorder such as panic disorder or post-traumatic stress disorder, or secondary to medical problems such as thyroid disease. Treatment includes psychological therapies, breathing exercises, stress avoidance, and pharmacological therapies such as selective serotonin reuptake inhibitors.
Left ventricular failure, on the other hand, would cause respiratory problems due to pulmonary congestion, leading to reduced pulmonary compliance and increased airway resistance. Examination of someone with left ventricular failure would reveal pulmonary crackles and possibly a small mitral regurgitation murmur. However, it is unlikely that a woman would experience acute episodes such as these due to heart failure.
Acute asthma attacks are typically triggered by inhaled allergens or other factors such as cold/dry air, stress, or upper respiratory tract infections. The absence of triggers in this case suggests that asthma is not the diagnosis.
COPD is a possible differential due to the patient’s smoking history, but it is unlikely to have worsened so acutely and resolved in a matter of minutes. The normal peak expiratory flow rate also suggests that COPD is not the cause.
Finally, anaemia would not account for acute episodes of shortness of breath, which are present normally on exertion in anaemic patients. Signs of anaemia such as pallor, tachycardia, cardiac dilation, or oedema are not mentioned in the patient’s history.
In conclusion, a careful analysis of the patient’s symptoms and medical history can help differentiate between possible causes of acute shortness of breath, leading to appropriate treatment and management.
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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 35-year-old woman of Chinese descent is referred to a Respiratory Physician by her General Practitioner due to a productive cough with mucopurulent sputum and occasional blood tinges. She has also been experiencing shortness of breath lately. Her medical history shows that she had a similar episode of shortness of breath and productive cough a year ago, and had multiple bouts of pneumonia during childhood. What is the most reliable test to confirm the probable diagnosis for this patient?
Your Answer:
Correct Answer: High-resolution computed tomography (HRCT) chest
Explanation:Diagnostic Tests for Bronchiectasis: Understanding Their Uses and Limitations
Bronchiectasis is a respiratory condition that can be challenging to diagnose. While there are several diagnostic tests available, each has its own uses and limitations. Here, we will discuss the most common tests used to diagnose bronchiectasis and their respective roles in clinical practice.
High-Resolution Computed Tomography (HRCT) Chest
HRCT chest is considered the gold-standard imaging test for diagnosing bronchiectasis. It can identify bronchial dilation with or without airway thickening, which are the main findings associated with this condition. However, more specific findings may also point to the underlying cause of bronchiectasis.Chest X-Ray
A chest X-ray is often the first imaging test ordered for patients with respiratory symptoms. While it can suggest a diagnosis of bronchiectasis, it is not the gold-standard diagnostic test.Autoimmune Panel
Autoimmune diseases such as rheumatoid arthritis, Sjögren syndrome, and inflammatory bowel disease can cause systemic inflammation in the lungs that underlies the pathology of bronchiectasis. While an autoimmune panel may be conducted if bronchiectasis is suspected, it is not very sensitive for this condition and is not the gold standard.Bronchoscopy
Bronchoscopy may be used in certain cases of bronchiectasis, particularly when there is localized bronchiectasis due to an obstruction. It can help identify the site of the obstruction and its potential cause, such as foreign-body aspiration or luminal-airway tumor.Pulse Oximetry
Pulse oximetry is a useful tool for assessing the severity of respiratory or cardiac disease. However, it is not specific for any particular underlying pathology and is unlikely to help make a diagnosis. It is primarily used to guide clinical management.In conclusion, while there are several diagnostic tests available for bronchiectasis, each has its own uses and limitations. HRCT chest is the gold-standard test, while other tests may be used to support a diagnosis or identify potential underlying causes. Understanding the role of each test can help clinicians make an accurate diagnosis and provide appropriate treatment.
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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 35-year-old call centre operator with a 6-year history of sarcoidosis presents with worsening shortness of breath during his visit to Respiratory Outpatients. This is his fifth episode of this nature since his diagnosis. In the past, he has responded well to tapered doses of oral steroids. What initial test would be most useful in evaluating his current pulmonary condition before prescribing steroids?
Your Answer:
Correct Answer: Pulmonary function tests with transfer factor
Explanation:Pulmonary Function Tests with Transfer Factor in Sarcoidosis: An Overview
Sarcoidosis is a complex inflammatory disease that can affect multiple organs, with respiratory manifestations being the most common. Pulmonary function tests with transfer factor are a useful tool in assessing the severity of sarcoidosis and monitoring response to treatment. The underlying pathological process in sarcoidosis is interstitial fibrosis, leading to a restrictive pattern on pulmonary function tests with reduced transfer factor. While steroids are often effective in treating sarcoidosis, monitoring transfer factor levels can help detect exacerbations and assess response to treatment. Other diagnostic tests, such as arterial blood gas, chest X-ray, serum ACE levels, and HRCT of the chest, may also be useful in certain situations but are not always necessary as an initial test. Overall, pulmonary function tests with transfer factor play a crucial role in the management of sarcoidosis.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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A 54-year-old smoker comes to the clinic with complaints of chest pain and cough. He reports experiencing more difficulty breathing and a sharp pain in his third and fourth ribs. Upon examination, a chest x-ray reveals an enlargement on the right side of his hilum. What is the most probable diagnosis?
Your Answer:
Correct Answer: Bronchogenic carcinoma
Explanation:Diagnosis of Bronchogenic Carcinoma
The patient’s heavy smoking history, recent onset of cough, and bony pain strongly suggest bronchogenic carcinoma. The appearance of the chest X-ray further supports this diagnosis. While COPD can also cause cough and dyspnea, it is typically accompanied by audible wheezing and the presence of a hilar mass is inconsistent with this diagnosis. Neither tuberculosis nor lung collapse are indicated by the patient’s history or radiographic findings. Hyperparathyroidism is not a consideration unless hypercalcemia is present. Overall, the evidence points towards a diagnosis of bronchogenic carcinoma.
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This question is part of the following fields:
- Respiratory
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Question 11
Incorrect
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A 62-year-old female patient complains of breathlessness and weight loss over the past three months. She is a smoker who consumes 10 cigarettes per day. During the examination, you observe clubbing of the fingers and a few crackles in the chest. What is the probable diagnosis?
Your Answer:
Correct Answer: Pulmonary fibrosis
Explanation:Respiratory Causes of Clubbing
Clubbing is a condition where the fingertips and nails become enlarged and rounded. It is often associated with respiratory and cardiovascular diseases. One of the respiratory causes of clubbing is pulmonary fibrosis, which is characterized by weight loss and breathlessness. Other respiratory causes include bronchiectasis, empyema, bronchial carcinoma, and mesothelioma. These conditions can also lead to weight loss and breathlessness, making it important to seek medical attention if these symptoms are present. On the other hand, cardiovascular causes of clubbing include cyanotic congenital heart disease and infective endocarditis. It is important to identify the underlying cause of clubbing in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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A 56-year-old woman presents to the Emergency Department with a 2-week history of productive cough with green sputum and a one day history of palpitations. She also had some rigors and fever. On examination:
Result Normal
Respiratory rate (RR) 26 breaths/min 12–18 breaths/min
Sats 96% on air 94–98%
Blood pressure (BP) 92/48 mmHg <120/80 mmHg
Heart rate (HR) 130 bpm 60–100 beats/min
Some bronchial breathing at left lung base, heart sounds normal however with an irregularly irregular pulse. electrocardiogram (ECG) showed fast atrial fibrillation (AF). She was previously fit and well.
Which of the following is the most appropriate initial management?Your Answer:
Correct Answer: Intravenous fluids
Explanation:Treatment for AF in a Patient with Sepsis
In a patient with sepsis secondary to pneumonia, the new onset of AF is likely due to the sepsis. Therefore, the priority is to urgently treat the sepsis with intravenous fluids and broad-spectrum antibiotics. If the AF persists after the sepsis is treated, other options for AF treatment can be considered. Bisoprolol and digoxin are not the first-line treatments for AF in this case. Oral antibiotics are not recommended for septic patients. Flecainide may be considered if the AF persists after the sepsis is treated.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses concern about feeling excessively tired during the day and experiencing frequent episodes of sleepiness.
Her husband reports that she snores heavily at night and sometimes stops breathing. Additionally, her work performance has been declining, and she is at risk of losing her job.
What is the most suitable initial step in managing this patient's condition?Your Answer:
Correct Answer: Continuous Positive Airways Pressure (CPAP)
Explanation:Obstructive Sleep Apnoea and its Treatment
The presence of heavy snoring, apnoea attacks at night, and daytime somnolence suggests the possibility of obstructive sleep apnoea. The recommended treatment for this condition is continuous positive airway pressure (CPAP), which helps maintain airway patency during sleep. In addition to CPAP, weight loss and smoking cessation are also helpful measures. Surgery is not necessary for this condition.
Long-term oxygen therapy is indicated for individuals with chronic hypoxia associated with chronic respiratory disease to prevent the development of pulmonary hypertension. However, bronchodilators are not useful in this case. It is important to seek medical attention if any of these symptoms are present to receive proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 14
Incorrect
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A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?
Your Answer:
Correct Answer: Suboptimal therapy
Explanation:Differentiating Between Respiratory Conditions: A Guide
When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.
Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.
Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.
Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.
Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 45-year-old male patient complains of worsening breathlessness and weight loss over the past two months. During examination, scattered wheezing, coughing, and fever are observed. A chest x-ray reveals pneumonic shadowing, and there are several tender subcutaneous nodules and a purpuric rash. What is the most probable diagnosis?
Your Answer:
Correct Answer: Churg-Strauss syndrome
Explanation:Churg-Strauss Syndrome: A Granulomatous Vasculitis
Churg-Strauss syndrome is a type of granulomatous vasculitis that is more commonly seen in males. The classic presentation of this syndrome includes asthma, rhinitis, and eosinophilia vasculitis. The condition is characterized by pulmonary eosinophilic infiltration, with the lungs, peripheral veins, and skin being the most commonly affected areas. Chest x-rays typically show transient patchy pneumonic shadows, while the skin may exhibit tender subcutaneous nodules and purpuric lesions. In addition, perinuclear anti-neutrophil cytoplasmic antibody (pANCA) is usually positive.
While sarcoidosis may present with similar symptoms, wheezing is not typically seen, and bilateral hilar lymphadenopathy is the typical x-ray feature. On the other hand, granulomatosis with polyangiitis may also be a possibility, but ENT symptoms are expected, and wheezing is not typical. Overall, Churg-Strauss syndrome should be considered in patients presenting with asthma, rhinitis, and eosinophilia vasculitis, along with the characteristic pulmonary and skin manifestations.
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This question is part of the following fields:
- Respiratory
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Question 16
Incorrect
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A 70-year old man is being evaluated by the respiratory team for progressive cough and shortness of breath over the last 10 months. He has no history of smoking and is typically healthy. The only notable change in his lifestyle is that he recently started breeding pigeons after retiring. Upon examination, the patient is diagnosed with interstitial pneumonia.
What is the most frequently linked organism with interstitial pneumonia?Your Answer:
Correct Answer: Mycoplasma
Explanation:Types of Bacterial Pneumonia and Their Patterns in the Lung
Bacterial pneumonia can be caused by various organisms, each with their own unique patterns in the lung. Mycoplasma, viruses like RSV and CMV, and fungal infections like histoplasmosis typically cause interstitial patterns in the lung. Haemophilus influenzae, Staphylococcus, Pneumococcus, Escherichia coli, and Klebsiella all typically have the same alveolar pattern, with Klebsiella often causing an aggressive, necrotizing lobar pneumonia. Streptococcus pneumoniae is the most common cause of typical bacterial pneumonia, while Staphylococcus aureus pneumonia is typically of the alveolar type and seen in intravenous drug users or patients with underlying debilitating conditions. Mycoplasma pneumonia may also have extra-pulmonary manifestations. These conditions are sometimes referred to as atypical pneumonia.
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This question is part of the following fields:
- Respiratory
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Question 17
Incorrect
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A 75-year-old woman presents to a respiratory outpatient clinic with a dry cough and shortness of breath that has been ongoing for 6 months. Despite being a non-smoker, her husband is a pigeon breeder. Upon examination, she has an SpO2 of 95% on room air and clubbing is present. Chest examination reveals symmetrical and bilateral reduced chest expansion with fine end-inspiratory crepitations. A chest radiograph shows increased interstitial markings in the lower zones of both lungs. High-resolution computed tomography (HRCT) confirms these findings and also shows bibasal honeycombing. There is no lymphadenopathy present on CT. What is the most likely diagnosis?
Your Answer:
Correct Answer: Idiopathic pulmonary fibrosis (usual interstitial pneumonia)
Explanation:Differential Diagnosis for Interstitial Lung Disease: A Case Study
Interstitial lung disease (ILD) is a group of lung disorders that affect the interstitium, the tissue and space surrounding the air sacs in the lungs. Idiopathic pulmonary fibrosis (IPF) is the most common type of ILD, characterized by chronic inflammation of the lung interstitium with lower zone predominance. This article discusses the differential diagnosis for ILD, using a case study of a patient presenting with subacute dry cough, exertional dyspnea, and general malaise and fatigue.
Idiopathic Pulmonary Fibrosis (IPF)
IPF is characterized by chronic inflammation of the lung interstitium with lower zone predominance. Patients present with subacute dry cough, exertional dyspnea, and general malaise and fatigue. Clinical examination reveals fine end-inspiratory crepitations throughout the chest with lower zone predominance. Radiological findings include reduced lung volumes and bilateral increased interstitial markings with lower zone predominance on chest X-ray (CXR), and honeycombing and microcyst formation in the lung bases on high-resolution CT (HRCT). Lung transplantation is the only definitive treatment, while steroids are not indicated.Tuberculosis
Tuberculosis presents with chronic cough, haemoptysis, fever, and night sweats. Imaging shows cavitating lesions ± lymphadenopathy.Bronchiectasis
Bronchiectasis presents with productive cough, recurrent chest infections, and haemoptysis. CXR findings are often non-specific, but dilated, thick-walled (ectatic) bronchi are easily seen on HRCT.Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)
Hypersensitivity pneumonitis may be caused by airborne irritants to lung parenchyma, such as pigeon breeding. Changes are classically found in lung apices, making it less likely than IPF/UIP.Sarcoidosis
End-stage sarcoidosis may present with lung fibrosis, but this does not spare the apices and typically affects the middle and upper zones of the lung.In conclusion, the differential diagnosis for ILD includes IPF, tuberculosis, bronchiectasis, hypersensitivity pneumonitis, and sarcoidosis. Accurate diagnosis is crucial for appropriate treatment and management of these conditions.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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A 67-year-old woman presents with right-sided pleural effusion. Thoracentesis is performed and the pleural fluid analysis reveals the following results:
Pleural fluid Pleural fluid analysis Serum Normal value
Protein 2.5 g/dl 7.3 g/dl 6-7.8 g/dl
Lactate dehydrogenase (LDH) 145 IU/l 350 IU/l 100-250 IU/l
What is the probable diagnosis for this patient?Your Answer:
Correct Answer: Heart failure
Explanation:Causes of Transudative and Exudative Pleural Effusions
Pleural effusion is the accumulation of fluid in the pleural space, which can be classified as transudative or exudative based on Light’s criteria. The most common cause of transudative pleural effusion is congestive heart failure, which can also cause bilateral or unilateral effusions. Other causes of transudative effusions include cirrhosis and nephrotic syndrome. Exudative pleural effusions are typically caused by pneumonia, malignancy, or pleural infections. Nephrotic syndrome can also cause transudative effusions, while breast cancer and viral pleuritis are associated with exudative effusions. Proper identification of the underlying cause is crucial for appropriate management of pleural effusions.
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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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A 45-year-old woman with known asthma presents to the Emergency Department with severe breathlessness and wheeze.
Which of the following is the most concerning finding on examination and initial investigations?Your Answer:
Correct Answer: PaCO2 5.5 kPa
Explanation:Assessing the Severity of an Acute Asthma Exacerbation
When assessing the severity of an acute asthma exacerbation, several factors must be considered. A PaCO2 level of 5.5 kPa in an acutely exacerbating asthmatic is a worrying sign and is a marker of a life-threatening exacerbation. A respiratory rate of 30 breaths per minute or higher is a sign of acute severe asthma, while poor respiratory effort is a sign of life-threatening asthma. Peak expiratory flow rate (PEFR) can also be used to help assess the severity of an acute exacerbation of asthma. A PEFR of 33-35% best or predicted is a sign of acute severe asthma, while a PEFR < 33% best or predicted is a sign of life-threatening asthma. A heart rate of 140 bpm or higher is a feature of acute severe asthma, while arrhythmia and/or hypotension are signs of life-threatening asthma. Inability to complete sentences in one breath is a sign of acute severe asthma, while an altered conscious level is a sign of life-threatening asthma. By considering these factors, healthcare professionals can accurately assess the severity of an acute asthma exacerbation and provide appropriate treatment.
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This question is part of the following fields:
- Respiratory
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Question 20
Incorrect
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What is the most effective method for diagnosing sleep apnoea syndrome?
Your Answer:
Correct Answer: Polygraphic sleep studies
Explanation:Sleep Apnoea
Sleep apnoea is a condition where breathing stops during sleep, causing frequent interruptions in sleep and restlessness. This leads to daytime drowsiness and irritability. Snoring is often associated with this condition. To diagnose sleep apnoea, a polygraphic recording of sleep is taken, which shows periods of at least 30 instances where breathing stops for 10 or more seconds in seven hours of sleep. These periods are also associated with a decrease in arterial oxygen saturation. the symptoms and diagnosis of sleep apnoea is important for proper treatment and management of the condition.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A 46-year-old man, who had been working abroad in the hard metal industry, presented with progressive dyspnoea. A chest X-ray showed diffuse interstitial fibrosis bilaterally. What is the typical cellular component found in a bronchoalveolar lavage (BAL) of this patient?
Your Answer:
Correct Answer: Giant cells
Explanation:Understanding Giant Cell Interstitial Pneumonia in Hard Metal Lung Disease
Hard metal lung disease is a condition that affects individuals working in the hard metal industry, particularly those exposed to cobalt dust. Prolonged exposure can lead to fibrosis and the development of giant cell interstitial pneumonia (GIP), characterized by bizarre multinucleated giant cells in the alveoli. These cannibalistic cells are formed by alveolar macrophages and type II pneumocytes and can contain ingested macrophages. While cobalt exposure can also cause other respiratory conditions, GIP is a rare but serious complication that may require lung transplantation in severe cases. Understanding the significance of different cell types found in bronchoalveolar lavage can aid in the diagnosis and management of this disease.
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This question is part of the following fields:
- Respiratory
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Question 22
Incorrect
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A 50-year-old woman presents to her General Practitioner with increasing shortness of breath. She has also suffered from dull right iliac fossa pain over the past few months. Past history of note includes tuberculosis at the age of 23 and rheumatoid arthritis. On examination, her right chest is dull to percussion, consistent with a pleural effusion, and her abdomen appears swollen with a positive fluid thrill test. She may have a right adnexal mass.
Investigations:
Investigation
Result
Normal value
Chest X-ray Large right-sided pleural effusion
Haemoglobin 115 g/l 115–155 g/l
White cell count (WCC) 6.8 × 109/l 4–11 × 109/l
Platelets 335 × 109/l 150–400 × 109/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 5.4 mmol/l 3.5–5.0 mmol/l
Creatinine 175 μmol/l 50–120 µmol/l
Bilirubin 28 μmol/l 2–17 µmol/l
Alanine aminotransferase 25 IU/l 5–30 IU/l
Albumin 40 g/l 35–55 g/l
CA-125 250 u/ml 0–35 u/ml
Pleural aspirate: occasional normal pleural cells, no white cells, protein 24 g/l.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Meig’s syndrome
Explanation:Possible Causes of Pleural Effusion: Meig’s Syndrome, Ovarian Carcinoma, Reactivation of Tuberculosis, Rheumatoid Arthritis, and Cardiac Failure
Pleural effusion is a condition where fluid accumulates in the pleural space, the area between the lungs and the chest wall. There are various possible causes of pleural effusion, including Meig’s syndrome, ovarian carcinoma, reactivation of tuberculosis, rheumatoid arthritis, and cardiac failure.
Meig’s syndrome is characterized by the association of a benign ovarian tumor and a transudate pleural effusion. The pleural effusion resolves when the tumor is removed, although a raised CA-125 is commonly found.
Ovarian carcinoma with lung secondaries is another possible cause of pleural effusion. However, if no malignant cells are found on thoracocentesis, this diagnosis becomes less likely.
Reactivation of tuberculosis may also lead to pleural effusion, but this would be accompanied by other symptoms such as weight loss, night sweats, and fever.
Rheumatoid arthritis can produce an exudative pleural effusion, but this presentation is different from the transudate seen in Meig’s syndrome. In addition, white cells would be present due to the inflammatory response.
Finally, cardiac failure can result in bilateral pleural effusions.
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This question is part of the following fields:
- Respiratory
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Question 23
Incorrect
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A 78-year-old man with known alcohol dependence presents to the Emergency Department with a few weeks of productive cough, weight loss, fever and haemoptysis. He is a heavy smoker, consuming 30 cigarettes per day. On a chest X-ray, multiple nodules 1-3 mm in size are visible throughout both lung fields. What is the best treatment option to effectively address the underlying cause of this man's symptoms?
Your Answer:
Correct Answer: Anti-tuberculous (TB) chemotherapy
Explanation:Choosing the Right Treatment: Evaluating Options for a Patient with Suspected TB
A patient presents with a subacute history of fever, productive cough, weight loss, and haemoptysis, along with a chest X-ray description compatible with miliary TB. Given the patient’s risk factors for TB, such as alcohol dependence and smoking, anti-TB chemotherapy is the most appropriate response, despite the possibility of lung cancer. IV antibiotics may be used until sputum staining and culture results are available, but systemic chemotherapy would likely lead to overwhelming infection and death. Tranexamic acid may be useful for significant haemoptysis, but it will not treat the underlying diagnosis. acyclovir is not indicated, as the patient does not have a history of rash, and a diagnosis of miliary TB is more likely than varicella pneumonia. Careful evaluation of the patient’s history and symptoms is crucial in choosing the right treatment.
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This question is part of the following fields:
- Respiratory
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Question 24
Incorrect
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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:
Correct 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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Question 25
Incorrect
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A 28-year-old man with a history of cystic fibrosis is experiencing deteriorating respiratory symptoms and is subsequently diagnosed with aspergillus infection. What is a common pulmonary manifestation of Aspergillus infection?
Your Answer:
Correct Answer: Allergic asthma
Explanation:Pulmonary Manifestations of Aspergillosis
Aspergillosis is a fungal infection caused by Aspergillus. It can affect various organs in the body, including the lungs. The pulmonary manifestations of aspergillosis include allergic reactions, bronchocentric granulomatosis, necrotising aspergillosis, extrinsic allergic alveolitis, aspergilloma, and bronchial stump infection.
Allergic reactions can manifest as allergic asthma or allergic bronchopulmonary aspergillosis (ABPA). Patients may experience recurrent wheezing, fever, and transient opacities on chest X-ray. In later stages, bronchiectasis may develop.
Bronchocentric granulomatosis is characterised by granuloma of bronchial mucosa with eosinophilic infiltrates. Chest X-ray shows a focal upper lobe lesion, and there may be haemoptysis.
Necrotising aspergillosis is usually found in immunocompromised patients. Chest X-ray shows spreading infiltrates, and there is invasion of blood vessels.
Extrinsic allergic alveolitis, also known as hypersensitivity pneumonitis, may occur in certain professions like malt workers. Four to 8 hours after exposure, there is an allergic reaction characterised by fever, chill, malaise, and dyspnoea. Serum IgE concentrations are normal.
Aspergilloma is saprophytic colonisation in pre-existing cavities. Haemoptysis is the most frequent symptom. Chest X-ray shows Monod’s sign, and gravitational change of position of the mass can be demonstrated.
Bronchial stump infection is usually found in post-surgery cases when silk suture is used. If nylon suture is used, this problem is eliminated. This can also occur in lung transplants at the site of anastomosis of bronchi.
Understanding the Pulmonary Manifestations of Aspergillosis
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This question is part of the following fields:
- Respiratory
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Question 26
Incorrect
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A 56-year-old man has just been admitted to the medical ward. Two days ago, he returned from a business trip and his history suggests he may have caught an atypical pneumonia. While examining the patient’s chest clinically, you try to determine whether the pneumonia is affecting one lobe in particular or is affecting the whole lung.
On the right side of the patient’s chest, which one of the following surface landmarks would be most likely to mark the boundary between the middle and lower lobes?Your Answer:
Correct Answer: Sixth rib
Explanation:Surface Landmarks for Lung Lobes and Abdominal Planes
The human body has several surface landmarks that can be used to locate important anatomical structures. In the case of the lungs, the position of the lobes can be estimated using the oblique and horizontal fissures. The sixth rib is the most likely surface landmark to mark the boundary between the right middle and lower lobes, while the fourth costal cartilage indicates the level of the horizontal fissure separating the superior from the middle lobes of the right lung.
In the abdomen, the tip of the ninth costal cartilage is a useful landmark as it marks the position of the transpyloric plane. This imaginary axial plane is important as it is where many anatomical structures, such as the pylorus of the stomach and the neck of the pancreas, are located. Additionally, the horizontal line passing through the centre of the nipple, known as the mammillary line, can also be used as a surface landmark for certain procedures.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a sudden ‘pop’ followed by the onset of pain and shortness of breath.
Upon examination, the patient appears to be struggling to breathe with a respiratory rate of 40 breaths per minute. Diminished breath sounds are heard on the right side of the chest during auscultation.
Diagnostic tests reveal a PaO2 of 8.2 kPa (normal range: 10.5-13.5 kPa) and a PaCO2 of 3.3 kPa (normal range: 4.6-6.0 kPa). A chest X-ray shows a 60% right-sided pneumothorax.
What is the most appropriate course of treatment for this patient?Your Answer:
Correct Answer: 14F chest drain insertion over a Seldinger wire
Explanation:Safe and Effective Chest Drain Insertion Techniques for Pneumothorax Management
Pneumothorax, the presence of air in the pleural cavity, can cause significant respiratory distress and requires prompt management. Chest drain insertion is a common procedure used to treat pneumothorax, but the technique used depends on the size and cause of the pneumothorax. Here are some safe and effective chest drain insertion techniques for managing pneumothorax:
1. Narrow-bore chest drain insertion over a Seldinger wire: This technique is appropriate for large spontaneous pneumothorax without trauma. It involves inserting a narrow-bore chest drain over a Seldinger wire, which is a minimally invasive technique that reduces the risk of complications.
2. Portex chest drain insertion: Portex chest drains are a safer alternative to surgical chest drains in traumatic cases. This technique involves inserting a less traumatic chest drain that is easier to manage and less likely to cause complications.
3. Avoid chest drain insertion using a trochar: Chest drain insertion using a trochar is a dangerous technique that can cause significant pressure damage to surrounding tissues. It should be avoided.
4. Avoid repeated air aspiration: Although needle aspiration is a management option for symptomatic pneumothorax, repeated air aspiration is not recommended. It can cause complications and is less effective than chest drain insertion.
In conclusion, chest drain insertion is an effective technique for managing pneumothorax, but the technique used should be appropriate for the size and cause of the pneumothorax. Narrow-bore chest drain insertion over a Seldinger wire and Portex chest drain insertion are safer alternatives to more invasive techniques. Chest drain insertion using a trochar and repeated air aspiration should be avoided.
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This question is part of the following fields:
- Respiratory
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Question 28
Incorrect
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A 72-year-old man is diagnosed with right-sided pleural effusion. The aspirated sample reveals a protein level of 15g/l. What could be the potential reason for the pleural effusion?
Your Answer:
Correct Answer: Renal failure
Explanation:Differentiating between transudate and exudate effusions in various medical conditions
Effusions can occur in various medical conditions, and it is important to differentiate between transudate and exudate effusions to determine the underlying cause. A transudate effusion is caused by increased capillary hydrostatic pressure or decreased oncotic pressure, while an exudate effusion is caused by increased capillary permeability.
In the case of renal failure, the patient has a transudative effusion as the effusion protein is less than 25 g/l. Inflammation from SLE would cause an exudate effusion, while pancreatitis and right-sided mesothelioma would also cause exudative effusions. Right-sided pneumonia would result in an exudate effusion as well.
Therefore, understanding the type of effusion can provide valuable information in diagnosing and treating various medical conditions.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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A 72-year-old woman is discovered outside in the early hours of the morning after falling to the ground. She is confused and uncertain of what happened and is admitted to the hospital. An abbreviated mental test (AMT) is conducted, and she scores 4/10. During the examination, crackles are heard at the base of her left lung.
Blood tests reveal:
Investigation Result Normal value
C-reactive protein (CRP) 89 mg/l < 10 mg/l
White cell count (WCC) 15 × 109/l 4–11 × 109/l
Neutrophils 11.4 × 109/l 5–7.58 × 109/l
The remainder of her blood tests, including full blood count (FBC), urea and electrolytes (U&Es), and liver function test (LFT), were normal.
Observations:
Investigation Result Normal value
Respiratory rate 32 breaths/min 12–18 breaths/min
Oxygen saturation 90% on air
Heart rate (HR) 88 beats/min 60–100 beats/min
Blood pressure (BP) 105/68 mmHg Hypertension: >120/80 mmHg*
Hypotension: <90/60 mmHg*
Temperature 39.1°C 1–37.2°C
*Normal ranges should be based on the individual's clinical picture. The values are provided as estimates.
Based on her CURB 65 score, what is the most appropriate management for this patient?Your Answer:
Correct Answer: Admit the patient and consider ITU
Explanation:Understanding the CURB Score and Appropriate Patient Management
The CURB score is a tool used to assess the severity of community-acquired pneumonia and determine the appropriate level of care for the patient. A score of 0-1 indicates that the patient can be discharged home, a score of 2 suggests hospital treatment, and a score of 3 or more warrants consideration for intensive care unit (ITU) admission.
In the case of a patient with a CURB score of 3, such as a 68-year-old with a respiratory rate of >30 breaths/min and confusion (AMT score of 4), ITU admission should be considered. Admitting the patient to a general ward or discharging them home with advice to see their GP the following day would not be appropriate.
It is important for healthcare professionals to understand and utilize the CURB score to ensure appropriate management of patients with community-acquired pneumonia.
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This question is part of the following fields:
- Respiratory
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Question 30
Incorrect
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A 25-year-old male graduate student comes to the clinic complaining of shortness of breath during physical activity for the past two months. He denies any other symptoms and is a non-smoker. Upon examination, there are no abnormalities found, and his full blood count and chest x-ray are normal. What diagnostic test would be most useful in confirming the suspected diagnosis?
Your Answer:
Correct Answer: Spirometry before and after exercise
Explanation:Confirming Exercise-Induced Asthma Diagnosis
To confirm the suspected diagnosis of exercise-induced asthma, the most appropriate investigation would be spirometry before and after exercise. This patient is likely to have exercise-induced asthma, which means that his asthma symptoms are triggered by physical activity. Spirometry is a lung function test that measures how much air a person can inhale and exhale. By performing spirometry before and after exercise, doctors can compare the results and determine if there is a significant decrease in lung function after physical activity. If there is a significant decrease, it confirms the diagnosis of exercise-induced asthma. This test is important because it helps doctors develop an appropriate treatment plan for the patient. With the right treatment, patients with exercise-induced asthma can still participate in physical activity and lead a healthy lifestyle.
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This question is part of the following fields:
- Respiratory
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