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Question 1
Incorrect
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A 50-year-old patient came in with worsening shortness of breath. A CT scan of the chest revealed a lesion in the right middle lobe of the lung. The radiologist described the findings as an area of ground-glass opacity surrounded by denser lung tissue.
What is the more common name for this sign?Your Answer: Halo sign
Correct Answer: Atoll sign
Explanation:Radiological Signs in Lung Imaging: Atoll, Halo, Kerley B, Signet Ring, and Tree-in-Bud
When examining CT scans of the lungs, radiologists look for specific patterns that can indicate various pathologies. One such pattern is the atoll sign, also known as the reversed halo sign. This sign is characterized by a region of ground-glass opacity surrounded by denser tissue, forming a crescent or annular shape that is at least 2 mm thick. It is often seen in cases of cryptogenic organizing pneumonia (COP), but can also be caused by tuberculosis or other infections.
Another important sign is the halo sign, which is seen in angioinvasive aspergillosis. This sign appears as a ground-glass opacity surrounding a pulmonary nodule or mass, indicating alveolar hemorrhage.
Kerley B lines are another pattern that can be seen on lung imaging, indicating pulmonary edema. These lines are caused by fluid accumulation in the interlobular septae at the periphery of the lung.
The signet ring sign is a pattern seen in bronchiectasis, where a dilated bronchus and accompanying pulmonary artery branch are visible in cross-section. This sign is characterized by a marked dilation of the bronchus, which is not seen in the normal population.
Finally, the tree-in-bud sign is a pattern seen in endobronchial tuberculosis or other endobronchial pathologies. This sign appears as multiple centrilobular nodules with a linear branching pattern, and can also be seen in cases of cystic fibrosis or viral pneumonia.
Overall, understanding these radiological signs can help clinicians diagnose and treat various lung pathologies.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 62-year-old teacher visits her GP as she has noticed that she is becoming increasingly breathless whilst walking. She has always enjoyed walking and usually walks 5 times a week. Over the past year she has noted that she can no longer manage the same distance that she has been accustomed to without getting breathless and needing to stop. She wonders if this is a normal part of ageing or if there could be an underlying medical problem.
Which of the following are consistent with normal ageing with respect to the respiratory system?Your Answer: Reduction of forced expiratory volume in 1 second (FEV1) by 20–30%
Explanation:Age-Related Changes in Respiratory Function and Abnormalities to Watch For
As we age, our respiratory system undergoes natural changes that can affect our lung function. By the age of 80, it is normal to experience a reduction in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) by about 25-30%. Peak expiratory flow rate (PEFR) also decreases by approximately 30% in both men and women. However, if these changes are accompanied by abnormal readings such as PaO2 levels below 8.0 kPa, PaCO2 levels above 6.5 kPa, or O2 saturation levels below 91% on air, it may indicate hypoxemia or hypercapnia, which are not consistent with normal aging. It is important to monitor these readings and seek medical attention if abnormalities are detected.
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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 54-year-old woman presents to the Emergency Department with sudden chest pain and difficulty breathing. She has a history of factor V Leiden mutation and has smoked 20 packs of cigarettes per year. Upon examination, the patient has a fever of 38.0 °C, blood pressure of 134/82 mmHg, heart rate of 101 bpm, respiratory rate of 28 breaths/minute, and oxygen saturation of 90% on room air. Both lungs are clear upon auscultation. Cardiac examination reveals a loud P2 and a new systolic murmur at the left lower sternal border. The patient also has a swollen and red right lower extremity. An electrocardiogram (ECG) taken in the Emergency Department was normal, and troponins were within the normal range.
Which of the following chest X-ray findings is consistent with the most likely underlying pathology in this patient?Your Answer: Rib-notching
Correct Answer: Wedge-shaped opacity in the right middle lobe
Explanation:Radiological Findings and Their Significance in Diagnosing Medical Conditions
Wedge-shaped opacity in the right middle lobe
A wedge-shaped opacity in the right middle lobe on a chest X-ray could indicate a pulmonary embolism, which is a blockage in a lung artery. This finding is particularly significant in patients with risk factors for clotting, such as a history of smoking or factor V Leiden mutation.
Diffuse bilateral patchy, cloudy opacities
Diffuse bilateral patchy, cloudy opacities on a chest X-ray could suggest acute respiratory distress syndrome or pneumonia. These conditions can cause inflammation and fluid buildup in the lungs, leading to the appearance of cloudy areas on the X-ray.
Rib-notching
Rib-notching is a radiological finding that can indicate coarctation of the aorta, a narrowing of the main artery that carries blood from the heart. Dilated vessels in the chest can obscure the ribs, leading to the appearance of notches on the X-ray.
Cardiomegaly
Cardiomegaly, or an enlarged heart, can be seen on a chest X-ray and may indicate heart failure. This condition occurs when the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body.
Lower lobe opacities with blunting of the costophrenic angle on PA chest film and opacities along the left lateral thorax on left lateral decubitus film
Lower lobe opacities with blunting of the costophrenic angle on a posterior-anterior chest X-ray and opacities along the left lateral thorax on a left lateral decubitus film can indicate pleural effusion. This condition occurs when fluid accumulates in the space between the lungs and the chest wall, causing the lung to collapse and leading to the appearance of cloudy areas on the X-ray. The location of the opacities can shift depending on the patient’s position.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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A 25-year-old man has suffered a left-sided pneumothorax. A chest drain has been inserted through the left fifth intercostal space at the mid-axillary line.
As well as the intercostal muscles, which other muscle is likely to have been pierced?Your Answer: Pectoralis major
Correct Answer: Serratus anterior
Explanation:Muscles and Chest Drains: Understanding the Anatomy
The human body is a complex system of muscles, bones, and organs that work together to keep us alive and functioning. When it comes to chest drains, understanding the anatomy of the surrounding muscles is crucial for successful placement and management. Let’s take a closer look at some of the key muscles involved.
Serratus Anterior
The serratus anterior muscle is located on the lateral chest and plays a vital role in protracting the scapula and contributing to rotation. It is likely to be pierced with most chest drains due to its position, with its lower four segments attaching to the fifth to eighth ribs anterior to the mid-axillary line.Latissimus Dorsi
The latissimus dorsi muscle is a back muscle involved in adduction, medial rotation, and extension of the shoulder. It is not pierced by a chest drain.External Oblique
The external oblique muscle is located in the anterior abdomen and is not involved with a chest drain.Pectoralis Major
The pectoralis major muscle is situated in the anterior chest and is not affected by a chest drain, as it does not overlie the fifth intercostal space at the mid-axillary line. It flexes, extends, medially rotates, and adducts the shoulder.Pectoralis Minor
The pectoralis minor muscle lies inferior to the pectoralis major on the anterior chest. It is a small muscle and is not usually pierced with a chest drain, as it does not overlie the fifth intercostal space at the mid-clavicular line.In conclusion, understanding the anatomy of the muscles surrounding the chest is essential for successful chest drain placement and management. Knowing which muscles are likely to be pierced and which are not can help healthcare professionals provide the best possible care for their patients.
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This question is part of the following fields:
- Respiratory
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Question 5
Correct
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What is the most effective tool for assessing a patient who is suspected of having occupational asthma?
Your Answer: Serial measurements of ventilatory function performed before, during, and after work
Explanation:Occupational Asthma
Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable airflow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases. To diagnose occupational asthma, several investigations are conducted, including serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. A consistent fall in peak flow values and increased intraday variability on working days, along with improvement on days away from work, confirms the diagnosis of occupational asthma. It is important to understand the causes and symptoms of occupational asthma to prevent and manage this condition effectively.
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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You have a telephone consultation with a 28-year-old male who wants to start trying to conceive. He has a history of asthma and takes salbutamol 100mcg as needed.
Which of the following would be most important to advise?Your Answer: Take folic acid 400 mcg once daily from before conception until 12 weeks of pregnancy
Correct Answer: Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy
Explanation:Women who are taking antiepileptic medication and are planning to conceive should be prescribed a daily dose of 5mg folic acid instead of the standard 400mcg. This high-dose folic acid should be taken from before conception until the 12th week of pregnancy to reduce the risk of neural tube defects. It is important to refer these women to specialist care, but they should continue to use effective contraception until they have had a full assessment. Despite the medication, it is still likely that they will have a normal pregnancy and healthy baby. If trying to conceive, women should start taking folic acid as soon as possible, rather than waiting for a positive pregnancy test.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 58-year-old woman presents with a history of recurrent cough, haemoptysis, and copious amounts of mucopurulent sputum for the past 10 years. Sputum analysis shows mixed flora with anaerobes present. During childhood, she experienced multiple episodes of pneumonia.
What is the probable diagnosis for this patient?Your Answer: Reactivation tuberculosis
Correct Answer: Bronchiectasis
Explanation:Recognizing Bronchiectasis: Symptoms and Indicators
Bronchiectasis is a respiratory condition that can be identified through several symptoms and indicators. One of the most common signs is the production of large amounts of sputum, which can be thick and difficult to cough up. Additionally, crackles may be heard when listening to the chest with a stethoscope. In some cases, finger clubbing may also be present. This occurs when the fingertips become enlarged and rounded, resembling drumsticks.
It is important to note that bronchiectasis can be caused by a variety of factors, including childhood pneumonia or previous tuberculosis. These conditions can lead to damage in the airways, which can result in bronchiectasis.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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A 35-year-old woman had a productive cough due to upper respiratory tract infection two weeks ago. She experienced a burning sensation in her chest during coughing. About a week ago, she coughed up a teaspoonful of yellow sputum with flecks of blood. The next morning, she had a small amount of blood-tinged sputum but has not had any subsequent haemoptysis. Her cough is resolving, and she is starting to feel better. She has no history of respiratory problems and has never smoked cigarettes. On examination, there are no abnormalities found in her chest, heart, or abdomen. Her chest x-ray is normal.
What would be your recommendation at this point?Your Answer: Observation only
Explanation:Acute Bronchitis
Acute bronchitis is a type of respiratory tract infection that causes inflammation in the bronchial tubes. This condition is usually caused by viral infections, with up to 95% of cases being attributed to viruses such as adenovirus, coronavirus, and influenzae viruses A and B. While antibiotics are often prescribed for acute bronchitis, there is little evidence to suggest that they provide significant relief or shorten the duration of the illness.
Other viruses that can cause acute bronchitis include parainfluenza virus, respiratory syncytial virus, coxsackievirus A21, rhinovirus, and viruses that cause rubella and measles. It is important to note that in cases where there is no evidence of bronchoconstriction or bacterial infection, and the patient is not experiencing respiratory distress, observation is advised.
Overall, the causes and symptoms of acute bronchitis can help individuals take the necessary steps to manage their condition and prevent its spread to others.
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This question is part of the following fields:
- Respiratory
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Question 9
Correct
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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: 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 10
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: Flecainide
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 11
Incorrect
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A trauma call is initiated in the Emergency Department after a young cyclist is brought in following a road traffic collision. The cyclist was riding on a dual carriageway when a car collided with them side-on, causing them to land in the middle of the road with severe injuries, shortness of breath, and chest pain. A bystander called an ambulance which transported the young patient to the Emergency Department. The anaesthetist on the trauma team assesses the patient and diagnoses them with a tension pneumothorax. The anaesthetist then inserts a grey cannula into the patient's second intercostal space in the mid-clavicular line. Within a few minutes, the patient expresses relief at being able to breathe more easily.
What signs would the anaesthetist have observed during the examination?Your Answer: Ipsilateral tracheal deviation, reduced chest expansion, increased resonance on percussion, absent breath sounds
Correct Answer: Contralateral tracheal deviation, reduced chest expansion, increased resonance on percussion, absent breath sounds
Explanation:Understanding Tension Pneumothorax: Symptoms and Treatment
Tension pneumothorax is a medical emergency that occurs when air enters the pleural space but cannot exit, causing the pressure in the pleural space to increase and the lung to collapse. This condition can be diagnosed clinically by observing contralateral tracheal deviation, reduced chest expansion, increased resonance on percussion, and absent breath sounds. Treatment involves inserting a wide-bore cannula to release the trapped air. Delay in treatment can be fatal, so diagnosis should not be delayed by investigations such as chest X-rays. Other respiratory conditions may present with different symptoms, such as normal trachea, reduced chest expansion, reduced resonance on percussion, and normal vesicular breath sounds. Tracheal tug is a sign of severe respiratory distress in paediatrics, while ipsilateral tracheal deviation is not a symptom of tension pneumothorax. Understanding the symptoms of tension pneumothorax is crucial for prompt diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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An 85-year-old man with chronic COPD presents for a review of his home oxygen therapy. The following results are from his arterial blood gas (ABG):
pH 7.37 (normal range 7.35–7.45)
pa(O2) 7.6 (normal range 10–14 kPa)
pa(CO2) 8 (normal range 4.0–6.0 kPa)
HCO3 37 (normal range 22–26 mmol)
base excess +6 (normal range −2 to +2 mmol).
Which of the following best describe this man’s blood gas result?Your Answer: Partial compensation for respiratory acidosis secondary to chronic respiratory disease
Correct Answer: Compensation for respiratory acidosis secondary to chronic respiratory disease
Explanation:Understanding ABGs: A Five-Step Approach and Mnemonic
Arterial blood gas (ABG) analysis is a crucial tool in assessing a patient’s respiratory and metabolic status. The Resuscitation Council (UK) recommends a five-step approach to interpreting ABGs:
1. Assess the patient.
2. Assess their oxygenation (pa(O2) should be >10 kPa).
3. Determine if the patient is acidotic (pH < 7.35) or alkalotic (pH > 7.45).
4. Assess respiratory status by determining if their pa(CO2) is high or low.
5. Assess metabolic status by determining if their bicarbonate (HCO3) is high or low.To aid in understanding ABGs, the mnemonic ROME can be used:
– Respiratory = Opposite: A low pH and high pa(CO2) indicate respiratory acidosis, while a high pH and low pa(CO2) indicate respiratory alkalosis.
– Metabolic = Equivalent: A high pH and high HCO3 indicate metabolic alkalosis, while a low pH and low HCO3 indicate metabolic acidosis.Compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a normal pH, high pa(CO2), and high HCO3, indicating renal compensation. In contrast, compensation for respiratory alkalosis secondary to chronic respiratory disease would show a low pa(CO2) and a high pH.
Partial compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a high pa(CO2) and a high HCO3, with a normal pH indicating full compensation and a mildly altered pH indicating partial compensation. Compensation for metabolic acidosis secondary to chronic respiratory disease is not applicable, as this condition would present with low HCO3 levels.
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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 65 year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. There was an associated dry cough, but no fever. Examination revealed scattered wheezes and some expiratory high-pitched sounds. C-reactive protein (CRP) level was normal. Mantoux test was negative. Spirometry revealed the following report:
FEV1 51%
FVC 88%
FEV1/FVC 58%
What is the most likely diagnosis?Your Answer: Acute respiratory distress syndrome (ARDS)
Correct Answer: Bronchiolitis obliterans (BO)
Explanation:Respiratory Disorders: Bronchiolitis Obliterans, ARDS, Pneumocystis Pneumonia, COPD Exacerbation, and Idiopathic Pulmonary Hypertension
Bronchiolitis obliterans (BO) is a respiratory disorder that may occur after bone marrow, heart, or lung transplant. It presents with an obstructive pattern on spirometry, low DLCO, and hypoxia. CT scan shows air trapping, and chest X-ray may show interstitial infiltrates with hyperinflation. BO may also occur in connective tissue diseases, such as rheumatoid arthritis, and idiopathic variety called cryptogenic organising pneumonia (COP). In contrast, acute respiratory distress syndrome (ARDS) patients deteriorate quickly, and pneumocystis pneumonia usually presents with normal clinical findings. Infective exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a productive cough and raised CRP, while idiopathic pulmonary hypertension has a restrictive pattern and inspiratory fine crepitations.
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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 38-year-old man from Somalia presents at your general practice surgery as a temporary resident. He has noticed some lumps on the back of his neck recently. He reports having a productive cough for the last 3 months, but no haemoptysis. He has lost 3 kg in weight in the last month. He is a non-smoker and lives with six others in a flat. His chest X-ray shows several large calcified, cavitating lesions bilaterally.
What is the GOLD standard investigation for active disease, given the likely diagnosis?Your Answer: Tuberculin skin test
Correct Answer: Sputum culture
Explanation:The patient in question has several risk factors for tuberculosis (TB), including being from an ethnic minority and living in overcrowded accommodation. The presence of symptoms and chest X-ray findings of bilateral large calcified, cavitating lesions strongly suggest a diagnosis of TB. The gold standard investigation for TB is to send at least three spontaneous sputum samples for culture and microscopy, including one early morning sample. Treatment should be initiated without waiting for culture results if clinical symptoms and signs of TB are present. Treatment involves a 6-month course of antibiotics, with the first 2 months consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampicin. Even if culture results are negative, the full course of antibiotics should be completed. Public health must be notified of the diagnosis for contact tracing and surveillance. Pulmonary function testing is useful for assessing the severity of lung disease but is not used in the diagnosis of TB. Tissue biopsy is not recommended as the gold standard investigation for TB, but may be useful in some cases of extrapulmonary TB. The tuberculin skin test is used to determine if a patient has ever been exposed to TB, but is not the gold standard investigation for active TB. Interferon-γ release assays measure a person’s immune reactivity to TB and can suggest the likelihood of M tuberculosis infection.
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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 55-year-old man was in a car accident and was taken to the Emergency Department where a chest tube was inserted to drain fluid. The thoracic wall is composed of several structures, including the skin, external intercostal muscle, internal intercostal muscle, innermost intercostal muscle, parietal pleura, and visceral pleura. What is the correct order of structures that the tube would pass through during the procedure?
Your Answer: 4-5-1-3-2
Correct Answer: 2-5-1-3-4
Explanation:Correct Order of Structures Traversed in Chest Drain Insertion
When inserting a chest drain, it is important to know the correct order of structures that will be traversed. The order is as follows: skin, external intercostal muscle, internal intercostal muscle, innermost intercostal muscle, and parietal pleura.
The external intercostal muscles are encountered first in chest drain insertion before the internal and innermost intercostal muscles, as suggested by their names. The skin is the first structure to be traversed by the tube. The parietal pleura lines the inner surface of the thoracic cavity and is the outer boundary of the pleural cavity. The chest drain tip should enter the pleural cavity which is bound by the parietal and visceral pleura. The parietal pleura is therefore encountered before reaching the visceral pleura. The visceral pleura should not be penetrated in chest drain insertion.
Knowing the correct order of structures to be traversed during chest drain insertion is crucial to ensure the procedure is done safely and effectively.
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This question is part of the following fields:
- Respiratory
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Question 16
Incorrect
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You are the Foundation Year 2 doctor on a general practice (GP) attachment when a 65-year-old man presents, complaining of malaise, cough and breathlessness. He says these symptoms have been present for 2 days, and he has brought up some yellow-coloured sputum on a few occasions. He reports no pain and no palpitations and is coping at home, although he has taken 2 days off work. He has no long-standing conditions but smokes five cigarettes a day and has done so for the last 15 years. He has no known allergies. On examination, he is alert and orientated, and has a respiratory rate of 22 breaths per minute, a blood pressure of 126/84 mmHg and a temperature of 38.1 °C. There is bronchial breathing and crepitations on auscultation, particularly on the right-hand side of the chest, and heart sounds are normal.
What would be the most appropriate management for this patient?Your Answer: 5-day course of flucloxacillin
Correct Answer: 5-day course of amoxicillin
Explanation:Treatment and Management of Community-Acquired Pneumonia
Community-acquired pneumonia is a common respiratory infection that can be effectively managed in the community with appropriate treatment and management. The severity of the infection can be assessed using the CRB-65 score, which takes into account confusion, respiratory rate, blood pressure, and age. A score of zero indicates low severity and suggests that oral antibiotics and community treatment should suffice. However, admission to hospital may be necessary in certain cases.
The first-choice antibiotic for community-acquired pneumonia is amoxicillin, although a macrolide may be considered in patients with penicillin allergy. Flucloxacillin may be added if there is suspicion of a staphylococcal infection or associated influenzae.
It is important to provide safety-netting advice to patients, advising them to return if symptoms worsen or do not improve on antibiotics. Additionally, the absence of wheeze on auscultation and no history of respiratory disease suggests that a salbutamol inhaler is not necessary.
While the CURB-65 score is commonly used, the CRB-65 score is more practical in community settings as it does not require laboratory analysis. Overall, prompt and appropriate treatment and management can effectively manage community-acquired pneumonia in the community.
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This question is part of the following fields:
- Respiratory
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Question 17
Correct
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A 10-year-old boy is brought to the Emergency Department after aspirating a peanut an hour earlier. He has a non-productive cough and shortness of breath. On arrival in the Emergency Department, he is tachypnoeic and has an oxygen saturation of 90% on room air. A chest X-ray demonstrates a complete whiteout of the right lung and the trachea is seen deviated to the right of the midline.
Which of the following processes is most likely causing the findings seen on the chest X-ray?Your Answer: Atelectasis
Explanation:Differentiating Acute Aspiration from Other Pulmonary Conditions
When a patient presents with acute aspiration, it is important to differentiate it from other pulmonary conditions. The most likely process in acute aspiration is atelectasis due to bronchial obstruction. This occurs when the main stem bronchus is blocked, preventing gas from entering the affected lung and causing it to collapse. A chest X-ray will show complete whiteout of the hemithorax and ipsilateral tension on the mediastinum, leading to shifting of the trachea towards the affected lung.
Pneumonia is less likely to develop so acutely and typically presents with productive cough and fever. Pneumothorax, on the other hand, would not cause a whiteout of the hemithorax and would instead show a line in the lung space with decreased lung markings peripherally. Pleural effusion could cause similar symptoms but would cause a contralateral mediastinal shift and is often associated with other systemic conditions. Pulmonary edema, which often occurs in the context of left heart failure, presents with cough and shortness of breath, but patients will have crackles on auscultation and are unlikely to have a mediastinal shift on chest X-ray.
Therefore, understanding the differences between these conditions is crucial in accurately diagnosing and treating acute aspiration.
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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 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: Haemosiderin-laden macrophages
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 19
Incorrect
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A 68-year-old woman with a long history of rheumatoid arthritis presents to her general practitioner complaining of a chronic cough, weight loss and haemoptysis. She smokes ten cigarettes a day. You understand that she has begun anti-tumour necrosis factor (TNF) antibody treatment around 9 months earlier. On examination, her rheumatoid appears quiescent at present.
Investigations:
Investigation Result Normal value
Chest X-ray Calcified hilar lymph nodes,
possible left upper lobe fibrosis
Haemoglobin 109 g/l 115–155 g/l
White cell count (WCC) 11.1 × 109/l 4–11 × 109/l
Platelets 295 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 61 mm/h 0–10mm in the 1st hour
C-reactive protein (CRP) 55 mg/l 0–10 mg/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
Creatinine 100 μmol/l 50–120 µmol/l
Which of the following diagnoses fits best with this clinical picture?Your Answer: Rheumatoid lung disease
Correct Answer: Active pulmonary tuberculosis
Explanation:Differential diagnosis of calcified lymph nodes and upper lobe fibrosis in a patient with rheumatoid arthritis
A patient with rheumatoid arthritis presents with calcified lymph nodes and upper lobe fibrosis on a chest X-ray. Several possible causes need to be considered, including active pulmonary tuberculosis, lymphoma, rheumatoid lung disease, bronchial carcinoma, and invasive aspergillosis. While anti-TNF antibody medication for rheumatoid arthritis may increase the risk of tuberculosis and aspergillosis, it is important to rule out other potential etiologies based on clinical examination, imaging studies, and laboratory tests. The presence of soft, fluffy, and ill-defined lesions on chest X-ray may suggest active tuberculosis, while the absence of upper lobe fibrosis may argue against lymphoma or radiotherapy-induced fibrosis. Pulmonary nodules and lung fibrosis at the lung bases are more typical of rheumatoid lung disease, but calcified nodes with upper lobe fibrosis are unusual. Bronchial carcinoma may be a concern given the patient’s age and smoking history, but typically lymph nodes are not calcified. Invasive aspergillosis is more likely in immunosuppressed patients and can be detected by a CT scan and a serum galactomannan test. A comprehensive differential diagnosis can guide further evaluation and management of this complex case.
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This question is part of the following fields:
- Respiratory
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Question 20
Correct
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A 65-year-old lady is admitted with severe pneumonia and, while on the ward, develops a warm, erythematosus, tender and oedematous left leg. A few days later, her breathing, which was improving with antibiotic treatment, suddenly deteriorated.
Which one of the following is the best diagnostic test for this patient?Your Answer: Computed tomography (CT) pulmonary angiogram
Explanation:The Best Imaging Method for Dual Pathology: Resolving Pneumonia and Pulmonary Embolus
Computed tomography (CT) pulmonary angiography is the best imaging method for a patient with dual pathology of resolving pneumonia and a pulmonary embolus secondary to a deep vein thrombosis. This method uses intravenous contrast to image the pulmonary vessels and can detect a filling defect within the bright pulmonary arteries, indicating a pulmonary embolism.
A V/Q scan, which looks for a perfusion mismatch, may indicate a pulmonary embolism, but would not be appropriate in this case due to the underlying pneumonia making interpretation difficult.
A D-dimer test should be performed, but it is non-specific and may be raised due to the pneumonia. It should be used together with the Wells criteria to consider imaging.
A chest X-ray should be performed to ensure there is no worsening pneumonia or pneumothorax, but in this case, a pulmonary embolism is the most likely diagnosis and therefore CTPA is required.
An arterial blood gas measurement can identify hypoxia and hypocapnia associated with an increased respiratory rate, but this is not specific to a pulmonary embolism and many pulmonary diseases can cause this arterial blood gas picture.
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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 32-year-old office worker attends Asthma Clinic for her annual asthma review. She takes a steroid inhaler twice daily, which seems to control her asthma well. Occasionally, she needs to use her salbutamol inhaler, particularly if she has been exposed to allergens.
What is the primary mechanism of action of the drug salbutamol in the treatment of asthma?Your Answer: β2-adrenoceptor antagonist
Correct Answer: β2-adrenoceptor agonist
Explanation:Pharmacological Management of Asthma: Understanding the Role of Different Drugs
Asthma is a chronic inflammatory condition of the airways that causes reversible airway obstruction. The pathogenesis of asthma involves the release of inflammatory mediators due to IgE-mediated degranulation of mast cells. Pharmacological management of asthma involves the use of different drugs that target specific receptors and pathways involved in the pathogenesis of asthma.
β2-adrenoceptor agonists are selective drugs that stimulate β2-adrenoceptors found in bronchial smooth muscle, leading to relaxation of the airways and increased calibre. Salbutamol is a commonly used short-acting β2-adrenoceptor agonist, while salmeterol is a longer-acting drug used in more severe asthma.
α1-adrenoceptor antagonists, which mediate smooth muscle contraction in blood vessels, are not used in the treatment of asthma. β1-adrenoceptor agonists, found primarily in cardiac tissue, are not used in asthma management either, as they increase heart rate and contractility.
β2-adrenoceptor antagonists, also known as β blockers, cause constriction of the airways and should be avoided in asthma due to the risk of bronchoconstriction. Muscarinic antagonists, such as ipratropium, are useful adjuncts in asthma management as they block the muscarinic receptors in bronchial smooth muscle, leading to relaxation of the airways.
Other drugs used in asthma management include steroids (oral or inhaled), leukotriene receptor antagonists (such as montelukast), xanthines (such as theophylline), and sodium cromoglycate. Understanding the role of different drugs in asthma management is crucial for effective treatment and prevention of exacerbations.
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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 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: Intravenous (IV) aminophylline
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 23
Correct
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A 35-year-old male patient presented to the Emergency department with sudden onset chest pain and shortness of breath that had been ongoing for six hours. The symptoms appeared out of nowhere while he was watching TV, and lying flat made the breathlessness worse. The patient denied any recent history of infection, cough, fever, leg pain, swelling, or travel.
Upon examination, the patient was apyrexial and showed no signs of cyanosis. Respiratory examination revealed reduced breath sounds and hyperresonance in the right lung.
What is the most likely diagnosis?Your Answer: Primary spontaneous pneumothorax
Explanation:Diagnosis and Management of a Primary Spontaneous Pneumothorax
Given the sudden onset of shortness of breath and reduced breath sounds from the right lung, the most likely diagnosis for this patient is a right-sided primary spontaneous pneumothorax (PSP). Primary pneumothoraces occur in patients without chronic lung disease, while secondary pneumothoraces occur in patients with existing lung disease. To rule out a pulmonary embolism, a D-dimer test should be performed. A positive D-dimer does not necessarily mean a diagnosis of pulmonary embolism, but a negative result can rule it out. If the D-dimer is positive, imaging would be the next step in management.
A 12-lead ECG should also be performed to check for any ischaemic or infarcted changes, although there is no clinical suspicion of acute coronary syndrome in this patient. Bornholm disease, a viral infection causing myalgia and severe pleuritic chest pain, is unlikely given the examination findings. An asthma attack would present similarly, but there is no history to suggest this condition in this patient.
In summary, a primary spontaneous pneumothorax is the most likely diagnosis for this patient. A D-dimer test should be performed to rule out a pulmonary embolism, and a 12-lead ECG should be done to check for any ischaemic or infarcted changes. Bornholm disease and asthma are unlikely diagnoses.
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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 42-year-old man with advanced lung disease due to cystic fibrosis (CF) is being evaluated for a possible lung transplant. What respiratory pathogen commonly found in CF patients would make him ineligible for transplantation if present?
Your Answer: Methicillin-resistant Staphylococcus aureus (MRSA)
Correct Answer: Burkholderia cenocepacia
Explanation:Common Respiratory Pathogens in Cystic Fibrosis and Their Impact on Lung Transplantation
Cystic fibrosis (CF) is a genetic disorder that affects the respiratory and digestive systems. Patients with CF are prone to chronic respiratory infections, which can lead to accelerated lung function decline and poor outcomes following lung transplantation. Here are some common respiratory pathogens in CF and their impact on lung transplantation:
Burkholderia cenocepacia: This Gram-negative bacterium is associated with poor outcomes following lung transplantation and renders a patient ineligible for transplantation in the UK.
Methicillin-resistant Staphylococcus aureus (MRSA): This Gram-positive bacterium is resistant to many antibiotics but is not usually a contraindication to lung transplantation. Attempts at eradicating the organism from the airways should be made.
Pseudomonas aeruginosa: This Gram-negative bacterium is the dominant respiratory pathogen in adults with CF and can cause accelerated lung function decline. However, it is not a contraindication to transplantation.
Aspergillus fumigatus: This fungus is commonly isolated from sputum cultures of CF patients and may be associated with allergic bronchopulmonary aspergillosis. Its presence does not necessarily mandate treatment and is not a contraindication to transplantation.
Haemophilus influenzae: This Gram-negative bacterium is commonly seen in CF, particularly in children. It is not associated with accelerated lung function decline and is not a contraindication to transplantation.
In summary, respiratory infections are a common complication of CF and can impact the success of lung transplantation. It is important for healthcare providers to monitor and manage these infections to optimize patient outcomes.
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This question is part of the following fields:
- Respiratory
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Question 25
Correct
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A 54-year-old man who is a long-term cigarette smoker presents with nocturnal dry cough of 4 weeks’ duration. He has recently gone through a stressful life situation due to divorce and bankruptcy. He mentions a history of atopic diseases in his family. His symptom improves with omeprazole, one tablet daily taken in the morning.
What is the most likely diagnosis?Your Answer: Gastro-oesophageal reflux disease
Explanation:Differential Diagnosis of Nocturnal Cough: Gastro-oesophageal Reflux Disease as the Likely Cause
Nocturnal cough can have various causes, including asthma, sinusitis with post-nasal drip, congestive heart failure, and gastro-oesophageal reflux disease (GERD). In this case, the patient’s cough improved after taking omeprazole, a proton pump inhibitor, which suggests GERD as the likely cause of his symptoms. The mechanism of cough in GERD is related to a vagal reflex triggered by oesophageal irritation, which is exacerbated by stress and lying flat. Peptic ulcer disease, asthma, psychogenic cough, and chronic bronchitis are less likely causes based on the absence of relevant symptoms or response to treatment. Therefore, GERD should be considered in the differential diagnosis of nocturnal cough, especially in patients with risk factors such as smoking and obesity.
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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 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: Right-sided pneumonia
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 27
Incorrect
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A 14-year-old male is brought in with acute severe asthma. During examination, it is noted that his peripheral pulse volume decreases during inspiration. What is the most probable reason for this clinical finding?
Your Answer: A falling heart rate on inspiration
Correct Answer: Reduced left atrial filling pressure on inspiration
Explanation:Pulsus Paradoxus
Pulsus paradoxus is a medical condition where there is an abnormal drop in blood pressure during inhalation. This occurs when the right heart responds directly to changes in intrathoracic pressure, while the filling of the left heart depends on the pulmonary vascular volume. In cases of severe airflow limitation, such as acute asthma, high respiratory rates can cause sudden negative intrathoracic pressure during inhalation. This enhances the normal fall in blood pressure, leading to pulsus paradoxus.
It is important to understand the underlying mechanisms of pulsus paradoxus to properly diagnose and treat the condition. By recognizing the relationship between intrathoracic pressure and blood pressure, healthcare professionals can provide appropriate interventions to manage the symptoms and prevent complications. With proper management, patients with pulsus paradoxus can lead healthy and fulfilling lives.
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This question is part of the following fields:
- Respiratory
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Question 28
Correct
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A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough, and low-grade fever. He has a medical history of hypertension and was hospitalized six months ago for an acute inferior myocardial infarction complicated by left ventricular failure and arrhythmia. His chest x-ray reveals diffuse interstitial pneumonia, and further investigations show an ESR of 110 mm/h, FEV1 of 90%, FVC of 70%, and KCO of 60%. What is the most likely cause of these findings?
Your Answer: Amiodarone
Explanation:Side Effects of Amiodarone
Amiodarone is a medication that is known to cause several side effects. Among these, pneumonitis and pulmonary fibrosis are the most common. These conditions are characterized by a progressively-worsening dry cough, pleuritic chest pain, dyspnoea, and malaise. Other side effects of amiodarone include neutropenia, hepatitis, phototoxicity, slate-grey skin discolouration, hypothyroidism, hyperthyroidism, arrhythmias, corneal deposits, peripheral neuropathy, and myopathy. It is important to be aware of these potential side effects when taking amiodarone, and to seek medical attention if any of these symptoms occur. Proper monitoring and management can help to minimize the risk of serious complications.
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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 50-year-old man visits the Respiratory Outpatients Department complaining of a dry cough and increasing breathlessness. During the examination, the doctor observes finger clubbing, central cyanosis, and fine end-inspiratory crackles upon auscultation. The chest X-ray shows reticular shadows and peripheral honeycombing, while respiratory function tests indicate a restrictive pattern with reduced lung volumes but a normal forced expiratory volume in 1 second (FEV1): forced vital capacity (FVC) ratio. The patient's pulmonary fibrosis is attributed to which of the following medications?
Your Answer: Spironolactone
Correct Answer: Bleomycin
Explanation:Drug-Induced Pulmonary Fibrosis: Causes and Investigations
Pulmonary fibrosis is a condition characterized by scarring of the lungs, which can be caused by various diseases and drugs. One drug that has been linked to pulmonary fibrosis is bleomycin, while other causes include pneumoconiosis, occupational lung diseases, and certain medications. To aid in diagnosis, chest X-rays, high-resolution computed tomography (CT), and lung function tests may be performed. Treatment involves addressing the underlying cause. However, drugs such as aspirin, ramipril, spironolactone, and simvastatin have not been associated with pulmonary fibrosis. It is important to be aware of the potential risks of certain medications and to monitor for any adverse effects.
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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 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: Emphysema
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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