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  • Question 1 - A 56-year-old man presents to you for medication review. He has a history...

    Correct

    • A 56-year-old man presents to you for medication review. He has a history of chronic obstructive pulmonary disease and experiences frequent infective exacerbations. His current medications include a salbutamol inhaler, azithromycin, and a beclomethasone-formoterol-glycopyrronium (Trimbow) inhaler. The patient admits to restarting smoking and reports having around 4 infective exacerbations annually.

      What would be the most suitable course of action for managing this patient?

      Your Answer: Stop azithromycin and refer to respiratory

      Explanation:

      If a patient with COPD continues to smoke, it is not advisable to provide them with azithromycin prophylaxis. Instead, they should be offered smoking cessation. The use of high-dose inhaled corticosteroids is no longer recommended due to the increased risk of infections such as pneumonia. Long-term oral corticosteroids should only be used at low doses and on the advice of the respiratory team. Beta-carotene supplements are not recommended for the management of COPD due to limited evidence of their effectiveness.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

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      • Respiratory Health
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  • Question 2 - Sarah, a 63-year-old woman, is seen accompanied by her daughter. Her daughter explains...

    Incorrect

    • Sarah, a 63-year-old woman, is seen accompanied by her daughter. Her daughter explains that Sarah lives alone and had problems getting to the clinic without assistance.

      Whilst out running errands together earlier today Sarah briefly passed out with what seems to be a fainting episode. She recovered quickly but her daughter is concerned as Sarah seems to be quite breathless on walking on the flat and has to keep stopping every 50 metres. Her face has also become rather puffy. Sarah has a history of chronic obstructive pulmonary disease and smokes 5 cigarettes per day.

      On examination you notice prominent veins over the upper chest and her face is mildly oedematous. There is a harsh fixed wheeze in the right upper lung.

      What is the most appropriate management plan?

      Your Answer: Arrange an urgent chest x ray

      Correct Answer: Prescribe a course of steroids and review in one day

      Explanation:

      Superior Vena Cava Obstruction (SVCO)

      Superior Vena Cava Obstruction (SVCO) is a condition where there is an obstruction of blood flow in the superior vena cava. This can be caused by external venous compression due to a tumour, enlarged lymph nodes, or other enlarged mediastinal structures. The most common cause of SVCO is malignancy, particularly lung cancer and lymphoma. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

      The typical features of SVCO include facial/upper body oedema, facial plethora, venous distention, and increased shortness of breath. Impaired venous return can cause symptoms of dizziness and even result in syncopal attacks. Headache due to pressure effect is also seen.

      Prompt recognition of SVCO on clinical grounds and immediate referral for specialist assessment is crucial. The presence of any stridor or laryngeal oedema makes SVCO a medical emergency. Treatment typically involves steroids and radiotherapy, with chemotherapy and stent insertion being indicated in some cases.

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  • Question 3 - A 23-year-old woman is barely responsive in the waiting area. What single feature...

    Incorrect

    • A 23-year-old woman is barely responsive in the waiting area. What single feature would indicate possible opioid overdose?

      Your Answer: Dilated pupils

      Correct Answer: Hypotension

      Explanation:

      Understanding Acute Opioid Toxicity

      Acute opioid toxicity is a serious condition that can result in drowsiness, nausea, vomiting, and respiratory depression. The severity of symptoms may be exacerbated if alcohol or other sedatives are also involved. Hypotension is a common occurrence, and both tachycardia and bradycardia may be observed. Hypoventilation can lead to hypoxia-induced cardiac arrhythmias, and pinpoint pupils may be present. Sweating is more commonly associated with acute opioid withdrawal. It is important to seek medical attention immediately if you suspect acute opioid toxicity.

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  • Question 4 - A 67-year-old man with a lengthy COPD history calls for guidance. He has...

    Correct

    • A 67-year-old man with a lengthy COPD history calls for guidance. He has been experiencing increased shortness of breath for the past two days and has been using his inhalers more frequently. He is coughing up clear sputum and has no fever, chest pain, or haemoptysis. He is uncertain whether to take his 'rescue' medications. What is the best advice to give him?

      Your Answer: Take a course of prednisolone

      Explanation:

      NICE suggests including an antibiotic only when the sputum shows signs of being purulent.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

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  • Question 5 - A 72-year-old male presents with worsening shortness of breath for the past week....

    Correct

    • A 72-year-old male presents with worsening shortness of breath for the past week. He has a history of COPD and smokes around 15 cigarettes a day. He has had a chronic cough for several years, which has not changed in character recently. On chest auscultation, he has reduced air entry throughout, diffuse wheeze, and no focal crepitations. His respiratory rate is 22 breaths/min, his temperature is 37.50ºC, and his oxygen saturations are 94% on air. His heart rate and blood pressure are within normal limits.

      What is the most appropriate course of action for this patient?

      Your Answer: Increase use of bronchodilator inhaler and prescribe a five day course of oral prednisolone

      Explanation:

      According to NICE guidelines, oral antibiotics should only be given to patients with acute exacerbation of COPD if they have purulent sputum or clinical signs of pneumonia. Since the patient in question doesn’t exhibit any signs of bacterial pneumonia, such as a change in cough or clinical signs of consolidation, NICE recommends a trial of steroids with increased inhaler use as the first line of treatment.

      Based on the information provided, the patient’s observations are reasonable, and hospital admission is not necessary. However, she should be monitored for any deterioration, and a tool like CURB65 can be used to guide decisions regarding hospital admission.

      If there are specific markers of infection clinically, such as focal consolidation or purulent sputum, a combination of amoxicillin and prednisolone may be indicated. It is important for patients with COPD to continue using their inhalers, especially when they are unwell.

      Acute exacerbations of COPD are a common reason for hospitalization in developed countries. The most common causes of these exacerbations are bacterial infections, such as Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis, as well as respiratory viruses, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

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

      For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators, such as beta adrenergic agonists and muscarinic antagonists, should also be used. Steroid therapy and IV theophylline may be considered, and non-invasive ventilation may be used for patients with type 2 respiratory failure. BiPAP is typically used with initial settings of EPAP at 4-5 cm H2O and IPAP at 10-15 cm H2O.

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  • Question 6 - You encounter a 28-year-old man who has asthma. He informs you that he...

    Incorrect

    • You encounter a 28-year-old man who has asthma. He informs you that he has visited you today because one of the partners is unwilling to modify his inhaler treatment until he quits smoking. He is presently using a salbutamol inhaler as needed, but he is experiencing frequent wheezing episodes and has developed a cough at night. What is the best course of action?

      Your Answer:

      Correct Answer: Alter his inhaler treatment and speak to the doctor concerned

      Explanation:

      It is important to note that a patient’s decision to continue smoking should not be a reason to deny them treatment for their asthma. As a healthcare professional, it is your responsibility to bring this to the attention of the doctor involved and discuss the situation with them. This will also give the doctor an opportunity to explain their perspective on the matter. It is not recommended to bring this up during a practice meeting as it may come across as confrontational.

      Simply changing the patient’s inhaler treatment will not address the issue of treatment being withheld. It is not acceptable to refuse to adjust their inhalers until they agree to seek smoking cessation treatment, as this can be seen as blackmail. Additionally, removing the patient from the practice list for not quitting smoking is not an appropriate course of action.

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      • Respiratory Health
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  • Question 7 - A 62-year-old man presents with a three day history of hearing a noise...

    Incorrect

    • A 62-year-old man presents with a three day history of hearing a noise when he breathes. He has been feeling fatigued and has had a dry cough for a week, but upon further questioning he admits to coughing up blood and losing weight for several months. He is a heavy smoker of over 20 cigarettes per day for 45 years and has COPD with a high degree of reversibility, for which he is taking full doses of his bronchodilator inhalers. Initially, he thought he was developing a throat infection, but now the noise has become quite loud and he is experiencing shortness of breath. Upon examination, there is reduced air entry in the left lung and obvious stridor present. His oxygen saturation on air is 88%. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Arrange an urgent chest x ray

      Explanation:

      Understanding Stridor and its Association with Lung Cancer

      Stridor is a respiratory sound characterized by a loud, harsh, and high-pitched noise. It is usually heard during inspiration and is caused by a partial obstruction of the airway, particularly in the trachea, larynx, or pharynx. In severe cases of upper airway obstruction, stridor may also occur during expiration, indicating tracheal or bronchial obstruction within the thoracic cavity.

      Lung cancer is one of the conditions that can cause stridor, particularly small cell carcinomas that grow rapidly and metastasize to mediastinal lymph nodes early in the disease’s course. Patients with lung cancer may present with large intra-thoracic tumors, making it difficult to distinguish the primary tumor from lymph node metastases. The pressure on mediastinal structures can cause various symptoms, including hoarseness, hemi-diaphragm paralysis, dysphagia, and stridor due to compression of the major airways. Understanding the association between stridor and lung cancer can help in the early detection and management of the disease.

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  • Question 8 - You see a 55-year-old lady with shortness of breath on exertion and a...

    Incorrect

    • You see a 55-year-old lady with shortness of breath on exertion and a chronic non-productive cough. She quit smoking 5 years ago and reports no weight loss. On examination, you note clubbing and fine bilateral crackles.

      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Chronic obstructive pulmonary disease

      Explanation:

      Consider Pulmonary Fibrosis in Patients with Persistent Breathlessness and Clubbing

      It is crucial to consider a diagnosis of pulmonary fibrosis in patients who present with persistent breathlessness, dry cough, bilateral inspiratory crackles, and clubbing of the fingers. While COPD may be a possibility, it would not explain the presence of clubbing. Heart failure typically presents with other features such as orthopnoea, peripheral oedema, and a raised JVP. Bronchiectasis usually has a productive cough, and a pulmonary embolism typically presents more acutely with chest pain and without clubbing or bi-basal crackles. Therefore, it is essential to consider pulmonary fibrosis as a potential diagnosis in patients with these symptoms. Proper diagnosis and treatment can help improve patient outcomes and quality of life.

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  • Question 9 - Your next patient is a 32-year-old teacher who has come for their annual...

    Incorrect

    • Your next patient is a 32-year-old teacher who has come for their annual review. Until around two years ago they used just a salbutamol inhaler as required. Following a series of exacerbations, they were started on a corticosteroid inhaler and currently takes Clenil (beclomethasone dipropionate) 400mcg bd. The patient reports that their asthma control has been 'good' for the past six months or so. They have had to use their asthma inhaler twice over the past six months, both times after going for a long jog. Their peak flow today is 520 l/min which is 90% of the best value recorded 5 years ago but up from the 510 l/min recorded 12 months ago. Their inhaler technique is good. What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Decrease the Clenil dose to 200mcg bd

      Explanation:

      If asthma is well controlled, it is advisable to reduce the treatment, as per the guidelines of the British Thoracic Society.

      Stepping Down Asthma Treatment: BTS Guidelines

      The British Thoracic Society (BTS) recommends that asthma treatment should be reviewed every three months to consider stepping down treatment. However, the guidelines do not suggest a strict move from one step to another but rather advise taking into account the duration of treatment, side-effects, and patient preference. When reducing the dose of inhaled steroids, the BTS suggests doing so by 25-50% at a time.

      Patients with stable asthma may only require a formal review once a year. However, if a patient has recently had an escalation of asthma treatment, they are likely to be reviewed more frequently. It is important to follow the BTS guidelines to ensure that patients receive the appropriate level of treatment for their asthma and to avoid unnecessary side-effects.

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  • Question 10 - A 49-year-old teacher comes to the clinic complaining of cough and pleuritic chest...

    Incorrect

    • A 49-year-old teacher comes to the clinic complaining of cough and pleuritic chest pain that has been going on for 4 days. The patient has no significant medical history. During the physical examination, the patient's temperature is 38.1ºC, blood pressure is 122/78 mmHg, respiratory rate is 20/min, and pulse is 80/min. Upon auscultation of the chest, bronchial breathing is heard in the right base and the same area is dull to percussion. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Oral amoxicillin

      Explanation:

      Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. Antibiotic therapy should be considered based on the patient’s CRP level. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Management of low-severity pneumonia typically involves a 5-day course of amoxicillin, while moderate to high-severity pneumonia may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution and the need for a repeat chest x-ray at 6 weeks.

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  • Question 11 - A 68 year old woman with chronic asthma has been using a lot...

    Incorrect

    • A 68 year old woman with chronic asthma has been using a lot of salbutamol including via a nebuliser. She has a tremor, headache and tachycardia.
      Select from the list the single most likely biochemical finding.

      Your Answer:

      Correct Answer: Hypokalaemia

      Explanation:

      Cautionary Measures for β2-Adrenergic Agonist Treatment

      β2-adrenergic agonist treatment may lead to potentially serious hypokalaemia, especially in severe asthma cases. This effect can be intensified by theophylline, corticosteroids, diuretics, and hypoxia. Therefore, it is crucial to monitor plasma-potassium concentration in severe asthma patients. People with diabetes should also exercise caution when using β2 agonists, particularly when given intravenously, as it may increase the risk of ketoacidosis. These cautionary measures are necessary to ensure the safe and effective use of β2-adrenergic agonist treatment.

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  • Question 12 - A 68-year-old woman with a recent diagnosis of chronic obstructive pulmonary disease (COPD)...

    Incorrect

    • A 68-year-old woman with a recent diagnosis of chronic obstructive pulmonary disease (COPD) is seen.

      Her spirometry shows an FEV1 of 42% predicted with an FEV1:FVC ratio of 64%. Her current treatment consists of a short-acting beta agonist (SABA) used as required which was started when a clinical diagnosis was made two to three months ago prior to her having had the spirometry performed. A chest x Ray was normal and she gave up cigarettes a few weeks ago. Her home peak flow measurments show a 30% diurnal variation.

      On reviewing her symptoms she needs to use the SABA at least four times a day and despite this still feels persistently breathless. In addition, she tells you that over the last few years she gets attacks of 'bronchitis' two to three times a year. You can see from her notes that she has received at least two courses of antibiotics each year for the last three years for acute episodes of productive cough and shortness of breath.

      Which of the following is the next most appropriate step in her pharmacological management?

      Your Answer:

      Correct Answer: Add in a LABA and ICS in a combination inhaler

      Explanation:

      Management of COPD with Persistent Breathlessness

      Patients with COPD who experience persistent breathlessness despite regular SABA use require additional inhaled treatment to improve symptom control and prevent exacerbations. Spirometry results confirming an obstructive picture, frequent exacerbations, and an FEV1 of less than 50% are useful in determining the next step in management.

      The two options for add-on inhaled treatment are a LABA+ICS combination inhaler or a LAMA. The choice depends on the presence of asthmatic features, such as a previous diagnosis of asthma or atopy, a higher eosinophil count, substantial variation on FEV1 over time, or a substantial diurnal variation in peak flow. If asthmatic features are present, a LABA & ICS combination inhaler is preferred.

      Adding a regular ICS on its own has no role in the COPD treatment ladder, while a regular SAMA can be used instead of a SABA but is not an option for add-in treatment. Adding a LABA may improve symptoms, but the combination of ICS/LABA is more beneficial for patients with a history of frequent exacerbations.

      In addition to inhaled treatment, it may be necessary to issue an emergency supply of antibiotics and oral steroids for patients with persistent breathlessness and frequent exacerbations. For more information on managing stable COPD, refer to the NICE Visual Summary guide and NICE NG115 guidelines.

      Overall, the management of COPD with persistent breathlessness requires a tailored approach based on individual patient characteristics and the presence of asthmatic features.

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  • Question 13 - One of your elderly patients with COPD is about to commence long-term oxygen...

    Incorrect

    • One of your elderly patients with COPD is about to commence long-term oxygen therapy. What is the most suitable method to administer this oxygen?

      Your Answer:

      Correct Answer: Oxygen concentrator supplied via Home Oxygen Order Form

      Explanation:

      The prescription for oxygen is now done through the Home Oxygen Order Form instead of the FP10. Private companies are now responsible for providing the oxygen supply instead of the local pharmacy.

      Long-Term Oxygen Therapy for COPD Patients

      Long-term oxygen therapy (LTOT) is recommended for patients with chronic obstructive pulmonary disease (COPD) who have severe or very severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, or oxygen saturations less than or equal to 92% on room air. LTOT involves breathing supplementary oxygen for at least 15 hours a day using oxygen concentrators.

      To assess patients for LTOT, arterial blood gases are measured on two occasions at least three weeks apart in patients with stable COPD on optimal management. Patients with a pO2 of less than 7.3 kPa or those with a pO2 of 7.3-8 kPa and secondary polycythaemia, peripheral oedema, or pulmonary hypertension should be offered LTOT. However, LTOT should not be offered to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.

      Before offering LTOT, a structured risk assessment should be carried out to evaluate the risks of falls from tripping over the equipment, the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e-cigarettes).

      Overall, LTOT is an important treatment option for COPD patients with severe or very severe airflow obstruction or other related symptoms.

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  • Question 14 - A 65-year-old man presents with haemoptysis and a cough for four weeks. Has...

    Incorrect

    • A 65-year-old man presents with haemoptysis and a cough for four weeks. Has been a publican for 35 years. He is a lifelong non-smoker and drinks around 20 units of alcohol per week.

      He did not worry too much about his symptoms because he is a non-smoker, the amount of blood was very small and he also has a cold with a productive cough.

      He has no abnormality in his chest on examination.

      What is the most appropriate management?

      Your Answer:

      Correct Answer: Arrange urgent admission to hospital

      Explanation:

      Lung Cancer and Passive Smoking

      According to NICE NG12 guidelines, individuals with chest X-ray findings that suggest lung cancer or those aged 40 and over with unexplained haemoptysis should be referred for an appointment within two weeks. While smoking is the leading cause of lung cancer, a small but significant proportion of cases are not linked to smoking. The International Agency for Research on Cancer (IARC) evaluates evidence on the carcinogenic risk to humans of various exposures, including tobacco, alcohol, infections, radiation, occupational exposures, and medications. The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) evaluates evidence for other exposures, such as diet, overweight and obesity, and physical exercise.

      Living with someone who smokes increases the risk of lung cancer in non-smokers by about a quarter. Exposure to passive smoke in the home is estimated to cause around 11,000 deaths every year in the UK from lung cancer, stroke, and ischaemic heart disease. This patient, who is not a smoker, has worked for many years in an environment where he would have been exposed to significant levels of smoke over a prolonged period (passive smoking), which is a risk factor for lung cancer. It is important to note that the smoking ban in public places was only introduced in the UK over the period 2006 to 2007, so individuals like this patient would have been exposed to passive smoke for many years before this time.

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  • Question 15 - A 68-year-old gentleman presents for review. His notes indicate that he was recently...

    Incorrect

    • A 68-year-old gentleman presents for review. His notes indicate that he was recently treated with furosemide for heart failure after presenting with gradually increasing shortness of breath and bibasal crepitations. Despite taking the medication for the last week, he reports feeling no better and has marked exertional breathlessness. On examination, he is centrally cyanosed with finger clubbing and fine bibasal inspiratory crepitations. There is no evidence of peripheral edema. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Identifying the Correct Diagnosis for Breathlessness

      A variety of conditions can cause breathlessness, making it difficult to arrive at a correct diagnosis. For instance, someone with shortness of breath and bibasal crepitations may be misdiagnosed with heart failure. However, a normal ECG and BNP can rule out cardiac failure.

      To identify the correct diagnosis, a thorough clinical examination is necessary. In this case, the presence of finger clubbing narrows the options down to bronchiectasis, carcinoma, and pulmonary fibrosis. The additional features of cyanosis and bibasal fine crepitations strongly suggest that pulmonary fibrosis is the underlying diagnosis.

      By carefully considering all the symptoms and conducting a comprehensive examination, healthcare professionals can accurately diagnose and treat patients with breathlessness.

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  • Question 16 - A 28-year old patient with well-controlled asthma presents to his general practitioner with...

    Incorrect

    • A 28-year old patient with well-controlled asthma presents to his general practitioner with a one-week history of a cough productive of green sputum. He is slightly more short of breath than usual but not needing to use any more of his salbutamol. He feels feverish but doesn't describe any chest pains. He takes oral Aminophylline and inhaled beclomethasone dipropionate for his asthma and uses salbutamol as needed. He is allergic to penicillin.

      On examination, he is talking in full sentences and his peak flow is 80% of his predicted. His temperature is 37.8 degrees and oxygen saturations are 98% in air. His pulse is 86 and he has right basal crackles on his chest but no wheeze.

      Which of the following antibiotics would you prescribe for him?

      Your Answer:

      Correct Answer: Ciprofloxacin

      Explanation:

      Process of Elimination in Tricky Questions

      When faced with a tricky question, it is important to stay calm and think through the options. One useful technique is the process of elimination. For example, in a question about the best antibiotic for a patient with a penicillin allergy who is taking aminophylline, you can immediately eliminate options that contain penicillin. Macrolides and ciprofloxacin can interact with aminophylline, increasing its plasma concentration, so you can eliminate those options as well. By process of elimination, you can arrive at the best answer, which in this case is doxycycline. Practicing this approach can help you tackle tricky questions and improve your performance in exams. Remember to take your time, read the question carefully, and eliminate options that do not fit the criteria.

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  • Question 17 - A 35-year-old female attends your clinic on a Monday afternoon with a complaint...

    Incorrect

    • A 35-year-old female attends your clinic on a Monday afternoon with a complaint of a worsening cough that produces green sputum and a sore throat that has been present for 2 days. She denies experiencing any other symptoms. Upon examination, there is a mild wheeze but no focal respiratory signs. The patient's observations, peak flow, and the rest of her examination are normal. She is currently taking salbutamol and beclomethasone inhalers for asthma and has an intrauterine system for contraception.

      What is the most appropriate course of action for managing this patient?

      Your Answer:

      Correct Answer: Prescribe oral doxycycline

      Explanation:

      For this patient with pre-existing asthma, an immediate or delayed antibiotic prescription should be considered due to the higher risk of complications. The first-line antibiotic for acute bronchitis is oral doxycycline, unless the patient is pregnant or a child. As this patient has normal observations and no focal respiratory signs, same-day admission is not necessary, and treatment can be provided in the community without intravenous antibiotics or oxygen.

      Reassuring the patient and prescribing carbocisteine is not recommended as mucolytics are not effective for managing acute cough caused by acute bronchitis. Administering IM amoxicillin is also not appropriate as doxycycline is the recommended first-choice antibiotic for this condition, and IM is an invasive route that is unnecessary for this patient who can swallow.

      Understanding Acute Bronchitis

      Acute bronchitis is a chest infection that is typically self-limiting and caused by inflammation of the trachea and major bronchi. This results in swollen airways and the production of sputum. The condition usually resolves within three weeks, but some patients may experience a cough for longer. Viral infections are the leading cause of acute bronchitis, with most cases occurring in the autumn or winter.

      Symptoms of acute bronchitis include a sudden onset of cough, sore throat, runny nose, and wheezing. While most patients have a normal chest examination, some may experience a low-grade fever or wheezing. It is important to differentiate acute bronchitis from pneumonia, which may present with sputum, wheezing, and breathlessness.

      Acute bronchitis is typically diagnosed based on clinical presentation, but CRP testing may be used to guide antibiotic therapy. Management of acute bronchitis includes analgesia, good fluid intake, and consideration of antibiotic therapy for patients who are systemically unwell, have pre-existing co-morbidities, or have a CRP level indicating the need for antibiotics. Doxycycline is the first-line antibiotic recommended by NICE Clinical Knowledge Summaries/BNF, but it cannot be used in children or pregnant women. Alternatives include amoxicillin.

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  • Question 18 - A 55-year-old smoker visits his GP clinic.

    As per the NICE guidelines for...

    Incorrect

    • A 55-year-old smoker visits his GP clinic.

      As per the NICE guidelines for identifying and referring suspected cancer (NG12), which of the following symptoms would necessitate an urgent chest x-ray?

      Your Answer:

      Correct Answer: Suspected rib fracture

      Explanation:

      Referral and Assessment Guidelines for Lung Cancer

      Persistent haemoptysis, superior vena caval obstruction, and stridor are all red flags for possible lung cancer and require immediate referral to a cancer specialist. In addition, NICE NG12 recommends an urgent chest X-ray within two weeks for individuals aged 40 and over who have unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, especially if they have a history of smoking. For those with persistent or recurrent chest infections, finger clubbing, supraclavicular or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis, an urgent chest X-ray should also be considered. Early detection and referral can improve outcomes for individuals with lung cancer.

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  • Question 19 - You are conducting an annual COPD review for Mrs. Patel. You quickly refer...

    Incorrect

    • You are conducting an annual COPD review for Mrs. Patel. You quickly refer to the latest NICE guidelines.

      Which of the following factors in her medical history would warrant the prescription of prophylactic antibiotics?

      Your Answer:

      Correct Answer: He has had 5 exacerbations in the past year

      Explanation:

      Patients with COPD who experience frequent exacerbations and meet specific criteria are recommended to undergo azithromycin prophylaxis. According to NICE guidelines, this treatment should be considered for non-smokers, patients who have already undergone pulmonary rehabilitation and are on the maximum inhaled therapy, and those who have had more than four exacerbations resulting in hospitalization with sputum production. Before starting the antibiotics, patients should undergo a CT scan to eliminate other lung pathologies.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

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  • Question 20 - Can you interpret the post-bronchodilator spirometry results of a 54-year-old woman who has...

    Incorrect

    • Can you interpret the post-bronchodilator spirometry results of a 54-year-old woman who has been experiencing gradual shortness-of-breath?

      FEV1/FVC 0.60
      FEV1% predicted 60%

      Your Answer:

      Correct Answer: COPD (stage 2 - moderate)

      Explanation:

      Investigating and Diagnosing COPD

      To diagnose COPD, NICE recommends considering patients over 35 years of age who are smokers or ex-smokers and have symptoms such as chronic cough, exertional breathlessness, or regular sputum production. The following investigations are recommended: post-bronchodilator spirometry to demonstrate airflow obstruction, chest x-ray to exclude lung cancer and identify hyperinflation, bullae, or flat hemidiaphragm, full blood count to exclude secondary polycythaemia, and BMI calculation. The severity of COPD is categorized using the FEV1, with Stage 1 being mild and Stage 4 being very severe. Measuring peak expiratory flow is of limited value in COPD as it may underestimate the degree of airflow obstruction. It is important to note that the grading system has changed following the 2010 NICE guidelines, with Stage 1 now including patients with an FEV1 greater than 80% predicted but a post-bronchodilator FEV1/FVC ratio less than 70%.

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  • Question 21 - A 65-year-old man presents with a firm swelling at the base of his...

    Incorrect

    • A 65-year-old man presents with a firm swelling at the base of his neck on the right hand side, just above the clavicle. He noticed it about two weeks ago. It is not painful. He is an ex-smoker who stopped smoking three years ago (before that he smoked 10 roll-up cigarettes per day for 35 years). On further questioning he has noticed a loss of appetite and weight loss of 8 lbs.

      On examination he is apyrexial and has a firm non-mobile lymph node 3 cm in diameter in the right supraclavicular fossa. There are no abnormalities on examination of the respiratory system and there is no organomegaly on abdominal examination.

      What is the most appropriate management strategy?

      Your Answer:

      Correct Answer: Routine referral to an ear nose and throat specialist

      Explanation:

      Supraclavicular Lymph Node Enlargement and Malignancy

      The right supraclavicular lymph node drains the mid-section of the chest, oesophagus, and lungs. An enlarged and fixed node in this area can indicate malignancy, with the lungs being a common primary site. While glandular fever is a possibility, it is less common in this age group, and the patient is presenting with several alarm symptoms.

      Empirically treating with antibiotics is not recommended, as there are no signs of an infected sebaceous cyst, the patient is not feverish, and there is no identified focus for infection. According to NICE guidance, patients with cervical or supraclavicular lymphadenopathy should undergo an urgent chest x-ray.

      The NPSA’s thematic review of delayed cancer diagnosis found that 23% of lung cancer cases had diagnostic delays, although not all of these were directly attributable to general practitioners’ actions. Therefore, it is crucial to investigate any supraclavicular lymph node enlargement promptly to rule out malignancy and ensure timely treatment.

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  • Question 22 - A 27-year-old woman who is 16 weeks pregnant arrives at the Emergency Department...

    Incorrect

    • A 27-year-old woman who is 16 weeks pregnant arrives at the Emergency Department with a worsening of her asthma symptoms. After receiving nebulised salbutamol, she stabilises and you are requested to assess her before discharge. She reports using only a salbutamol inhaler (100 mcg) as needed and identifies grass pollen as the most common trigger. Her current peak flow is 380 l/min (predicted 440 l/min) and her inhaler technique is satisfactory. What is the most suitable course of action?

      Your Answer:

      Correct Answer: Add inhaled beclomethasone 200mcg bd

      Explanation:

      During pregnancy, it is safe to use short-acting/long-acting beta 2-agonists, inhaled and oral corticosteroids as recommended by the British Thoracic Society (BTS) guidelines, even if the patient has asthma that is not well-controlled with a SABA.

      The management of asthma in adults has been updated by NICE in 2017, following the 2016 British Thoracic Society (BTS) guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist, not a LABA. NICE doesn’t follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. It should be noted that NICE doesn’t recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance.

      The steps for managing asthma in adults are as follows: for newly-diagnosed asthma, a short-acting beta agonist (SABA) is recommended. If the patient is not controlled on the previous step or has symptoms >= 3/week or night-time waking, a SABA + low-dose inhaled corticosteroid (ICS) is recommended. For step 3, a SABA + low-dose ICS + leukotriene receptor antagonist (LTRA) is recommended. Step 4 involves a SABA + low-dose ICS + long-acting beta agonist (LABA), and LTRA should be continued depending on the patient’s response. Step 5 involves a SABA +/- LTRA, and switching ICS/LABA for a maintenance and reliever therapy (MART) that includes a low-dose ICS. Step 6 involves a SABA +/- LTRA + medium-dose ICS MART, or changing back to a fixed-dose of a moderate-dose ICS and a separate LABA. Step 7 involves a SABA +/- LTRA + one of the following options: increasing ICS to high-dose (only as part of a fixed-dose regime, not as a MART), a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline), or seeking advice from a healthcare professional with expertise in asthma.

      It is important to note that the definitions of what constitutes a low, moderate, or high-dose ICS have changed. For adults, <= 400 micrograms budesonide or equivalent is considered a low dose, 400 micrograms - 800 micrograms budesonide or equivalent is a moderate dose, and > 800 micrograms budes

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  • Question 23 - A 67-year-old man visits his GP for a check-up on his chronic obstructive...

    Incorrect

    • A 67-year-old man visits his GP for a check-up on his chronic obstructive pulmonary disease (COPD), despite not experiencing any exacerbations in the past year. During the appointment, the GP orders some routine blood tests.

      What alterations could be observed on the full blood count as a chronic effect of this man's condition?

      Your Answer:

      Correct Answer: Increased concentration of haematocrit

      Explanation:

      Polycythaemia can be a long-term complication of COPD that may be detected through a full blood count. This condition is caused by chronic hypoxia, which triggers the kidneys to produce more erythropoietin and increase haemoglobin levels. Thrombocytopenia, on the other hand, is a reduction in platelet count that can be caused by various factors such as medication side effects, vitamin deficiencies, or disseminated intravascular coagulation. Conversely, thrombocythemia, or an elevated platelet count, can be caused by inflammation, malignancy, or infection. Leukopenia, or a decrease in white blood cells, can be a result of acute infection or serious conditions like HIV or cancer. Finally, anaemia, or a decrease in haemoglobin concentration, can be caused by deficiencies in iron, vitamin B12, or folic acid.

      Understanding COPD: Symptoms and Diagnosis

      Chronic obstructive pulmonary disease (COPD) is a common medical condition that includes chronic bronchitis and emphysema. Smoking is the leading cause of COPD, and patients with mild disease may only need occasional use of a bronchodilator, while severe cases may result in frequent hospital admissions due to exacerbations. Symptoms of COPD include a productive cough, dyspnea, wheezing, and in severe cases, right-sided heart failure leading to peripheral edema.

      To diagnose COPD, doctors may recommend post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to check for hyperinflation, bullae, and flat hemidiaphragm, and to exclude lung cancer. A full blood count may also be necessary to exclude secondary polycythemia, and body mass index (BMI) calculation is important. The severity of COPD is categorized using the FEV1, with a ratio of less than 70% indicating airflow obstruction. The grading system has changed following the 2010 NICE guidelines, with Stage 1 – mild now including patients with an FEV1 greater than 80% predicted but with a post-bronchodilator FEV1/FVC ratio of less than 0.7. Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.

      In summary, COPD is a common condition caused by smoking that can result in a range of symptoms and severity. Diagnosis involves various tests to check for airflow obstruction, exclude lung cancer, and determine the severity of the disease.

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  • Question 24 - A 65 year old man presents with a productive cough that has lasted...

    Incorrect

    • A 65 year old man presents with a productive cough that has lasted for three days. He has been experiencing increasing shortness of breath over the past two days and reports feeling weak and lethargic. He also has a fever and rigors. His wife brought him to the community Emergency Medical Unit (EMU) as she was concerned about his rapid deterioration.

      Upon examination, his heart rate is 125 beats per minute, respiratory rate is 32 breaths per minute, Sa02 is 90% on room air, temperature is 38.9º, and blood pressure is 130/84 mmHg. He appears distressed but is not confused.

      Initial investigations reveal a hemoglobin level of 134 g/l, platelets of 550 * 109/l, and a white blood cell count of 18 * 109/l. His electrolyte levels are within normal range, with a sodium level of 141 mmol/l and a potassium level of 3.7 mmol/l. His urea level is 9.2 mmol/l and creatinine level is 130 µmol/l. A chest X-ray shows left lower zone consolidation.

      What is his CURB-65 score based on the given information?

      Your Answer:

      Correct Answer: 3

      Explanation:

      The patient is currently in a room with normal air temperature, measuring 38.9º. Their blood pressure is 130/84 mmHg and they appear to be distressed, but not confused. Initial tests indicate that their hemoglobin level is 134 g/l and their platelet count is currently unknown.

      Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. Antibiotic therapy should be considered based on the patient’s CRP level. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Management of low-severity pneumonia typically involves a 5-day course of amoxicillin, while moderate to high-severity pneumonia may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution and the need for a repeat chest x-ray at 6 weeks.

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  • Question 25 - A 24-year-old construction worker presents to your clinic as a temporary patient. He...

    Incorrect

    • A 24-year-old construction worker presents to your clinic as a temporary patient. He reports experiencing fever, malaise, and a dry cough that has gradually worsened over the past two weeks. Several other workers who are residing in the same dormitory as him have also fallen ill. On examination, he appears relatively healthy, but you note mild pharyngitis and scattered wheezing and crackles upon chest auscultation. Additionally, he has a rash that you suspect is erythema multiforme. What would be the most appropriate antibiotic for this patient?

      Your Answer:

      Correct Answer: Cefalexin

      Explanation:

      Mycoplasma Infection and Treatment

      The history of epidemic pneumonia, slow onset of symptoms, and erythema multiforme suggest the possibility of mycoplasma infection. In mycoplasma, the appearance on CXR is often worse than clinical examination, and the presence of cold agglutins or rising mycoplasma serology can confirm the diagnosis. Treatment with clarithromycin or erythromycin for 7-14 days is recommended, with doxycycline as an alternative and quinolones as an option.

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  • Question 26 - A 22-year-old male college student comes to the clinic complaining of shortness of...

    Incorrect

    • A 22-year-old male college student comes to the clinic complaining of shortness of breath during physical activity that has been going on for two months. He denies any other symptoms and is a non-smoker. On examination, there are no abnormalities, and his full blood count and chest x-ray are normal. What is the most useful test to confirm the suspected diagnosis?

      Your Answer:

      Correct Answer: Refer for arterial blood studies before and after exercise

      Explanation:

      Confirming Exercise-Induced Asthma

      This patient is showing signs of exercise-induced asthma. To confirm this diagnosis, the most appropriate investigation would be spirometry before and after exercise. This is because exercise is the trigger for his asthma symptoms, and spirometry can measure any changes in lung function before and after physical activity. By comparing the results, doctors can determine if the patient has exercise-induced asthma and develop an appropriate treatment plan. It is important to confirm the diagnosis to ensure the patient receives the correct treatment and can continue to participate in physical activity safely.

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  • Question 27 - You are working in the out-patient respiratory clinic where a 65-year-old male patient...

    Incorrect

    • You are working in the out-patient respiratory clinic where a 65-year-old male patient attends for follow-up. He has a diagnosis of COPD (FEV1/FVC= 0.68, FEV1=46% predicted) and currently smokes 30 cigarettes per day. He has noted progressive ankle swelling over last year but has not suffered any exacerbations in this time. He currently takes a tiotropium inhaler as well as a combination inhaler of salmeterol/fluticasone with a salbutamol inhaler when required, his inhaler technique has been assessed as good. In the clinic, his arterial blood gas results on air give a pO2 of 7.3kPa and 7.8kPa respectively from today and from clinic two months ago. He continues to smoke despite being offered smoking cessation therapy.

      The patient would like to be considered for home oxygen therapy. According to current NICE guidelines, what advice should you give him?

      Your Answer:

      Correct Answer: Home oxygen is contraindicated as she is a current smoker

      Explanation:

      What are the indications for long-term oxygen therapy (LTOT) in COPD patients?

      In COPD patients, LTOT is typically indicated when their PaO2 is less than 7.3kPa when stable. However, this threshold is increased to less than 8kPa if they have secondary polycythemia, pulmonary hypertension, or peripheral edema. Arterial oxygen concentration should be assessed when stable and with at least two readings taken at least three weeks apart. To achieve the greatest effect, supplementary oxygen should be used for more than 20 hours per day, but a minimum of 15 hours per day is required.

      Maintenance oral corticosteroid use is not routinely recommended and should only be considered when it is not possible to fully wean steroids between exacerbations.

      As per the 2018 NICE update to the COPD guidelines, LTOT is no longer recommended for current smokers.

      Long-Term Oxygen Therapy for COPD Patients

      Long-term oxygen therapy (LTOT) is recommended for patients with chronic obstructive pulmonary disease (COPD) who have severe or very severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, or oxygen saturations less than or equal to 92% on room air. LTOT involves breathing supplementary oxygen for at least 15 hours a day using oxygen concentrators.

      To assess patients for LTOT, arterial blood gases are measured on two occasions at least three weeks apart in patients with stable COPD on optimal management. Patients with a pO2 of less than 7.3 kPa or those with a pO2 of 7.3-8 kPa and secondary polycythaemia, peripheral oedema, or pulmonary hypertension should be offered LTOT. However, LTOT should not be offered to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.

      Before offering LTOT, a structured risk assessment should be carried out to evaluate the risks of falls from tripping over the equipment, the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e-cigarettes).

      Overall, LTOT is an important treatment option for COPD patients with severe or very severe airflow obstruction or other related symptoms.

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  • Question 28 - A 72-year-old man comes to the clinic with symptoms of a respiratory tract...

    Incorrect

    • A 72-year-old man comes to the clinic with symptoms of a respiratory tract infection, including cough, shortness of breath, confusion, and diarrhea. He has recently returned from a long-term stay at a hotel in Spain. During the examination, you note a temperature of 39.2°C and signs of consolidation in the right lower lobe. Blood tests reveal an elevated white count and a sodium level of 128. What is the most appropriate statement regarding this man's pneumonia?

      Your Answer:

      Correct Answer: Long-term lung damage is common

      Explanation:

      Legionnaires Disease: Symptoms, Causes, and Treatment

      Legionnaires disease is a severe form of pneumonia caused by Legionella pneumophila, a Gram-negative bacillus. The disease is usually acquired from infected water supplies in cooling towers and air conditioning units. Although it is difficult to acquire, with a low attack rate of 5%, elderly individuals, smokers, and those with pre-existing chest disease are at a higher risk of developing the condition.

      The symptoms of Legionnaires disease are similar to those of the flu, including high fever (usually above 40°C), myalgias, and confusion. Treatment involves the use of ciprofloxacin or macrolides, and recovery is usually complete. However, if left untreated, the mortality rate can be as high as 15-20%.

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  • Question 29 - A 23-year-old female presents with episodic wheezing and shortness of breath for the...

    Incorrect

    • A 23-year-old female presents with episodic wheezing and shortness of breath for the past 5 months. She has smoked for the past 7 years and has a history of eczema. Examination of her chest is unremarkable. Spirometry is arranged and is reported as normal.

      What would be the most suitable course of action now?

      Your Answer:

      Correct Answer: Fractional exhaled nitric oxide + spirometry/bronchodilator reversibility test

      Explanation:

      It is recommended that individuals who are suspected to have asthma undergo both FeNO testing and spirometry with reversibility.

      Asthma diagnosis has been updated by NICE guidelines in 2017, which emphasizes the use of objective tests rather than subjective/clinical judgments. The guidance recommends the use of fractional exhaled nitric oxide (FeNO) test, which measures the level of nitric oxide produced by inflammatory cells, particularly eosinophils. Other established objective tests such as spirometry and peak flow variability are still important. All patients aged five and above should have objective tests to confirm the diagnosis. For patients aged 17 and above, spirometry with a bronchodilator reversibility (BDR) test and FeNO test should be performed. For children aged 5-16, spirometry with a BDR test and FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative BDR test. For patients under five years old, diagnosis should be made based on clinical judgment. The specific points about the tests include a FeNO level of >= 40 ppb for adults and >= 35 ppb for children considered positive, and a FEV1/FVC ratio less than 70% or below the lower limit of normal considered obstructive for spirometry. A positive reversibility test is indicated by an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more for adults, and an improvement in FEV1 of 12% or more for children.

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  • Question 30 - You assess a 68-year-old man with chronic obstructive pulmonary disease (COPD) and observe...

    Incorrect

    • You assess a 68-year-old man with chronic obstructive pulmonary disease (COPD) and observe signs of cor pulmonale with notable pedal edema. His FEV1 is 43%, and during his recent hospitalization, his pO2 on room air was 7.5 kPa. What intervention would be the most effective in improving this patient's survival?

      Your Answer:

      Correct Answer: Long-term oxygen therapy

      Explanation:

      One of the few interventions that has been proven to increase survival in COPD after quitting smoking is long-term oxygen therapy (LTOT). Patients with a pO2 level below 7.3 kPa should be offered LTOT, as well as those with a pO2 level between 7.3 – 8 kPa who have secondary polycythemia, nocturnal hypoxemia, peripheral edema, or pulmonary hypertension.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory Health (3/5) 60%
Passmed