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  • Question 1 - You evaluate a 47-year-old man with a history of increasing shortness of breath...

    Incorrect

    • You evaluate a 47-year-old man with a history of increasing shortness of breath and a persistent dry cough. He has a smoking history of 25 pack-years.
      The recent lung function test findings are as follows:
      FEV1/FVC ratio = 85% predicted
      FVC = 60% predicted
      What is the MOST LIKELY diagnosis in this case?

      Your Answer: Bronchiectasis

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      This patient has a history of worsening breathlessness and lung function tests that show a pattern of restrictive lung disease. In restrictive lung disease, the ratio of FEV1 to FVC is usually normal, around 70% predicted, but the FVC is reduced to less than 80% predicted. Both the FVC and FEV1 can be reduced in this condition. The ratio can also be higher if the FVC is reduced to a greater extent. Out of the options provided, only idiopathic pulmonary fibrosis can cause a restrictive lung disease pattern. Smoking is a risk factor for developing idiopathic pulmonary fibrosis, especially if the person has smoked more than 20 packs of cigarettes per year.

    • This question is part of the following fields:

      • Respiratory
      83.6
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  • Question 2 - A 30-year-old woman comes in with a persistent cough and wheezing.
    Which ONE...

    Incorrect

    • A 30-year-old woman comes in with a persistent cough and wheezing.
      Which ONE clinical characteristic would indicate a possible diagnosis of severe acute asthma?

      Your Answer: Oxygen saturations of 90% on air

      Correct Answer: Heart rate of 115 bpm

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

    • This question is part of the following fields:

      • Respiratory
      67.2
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  • Question 3 - A 45-year-old man presents with acute severe asthma. You initiate management for the...

    Incorrect

    • A 45-year-old man presents with acute severe asthma. You initiate management for the patient, guided by the most recent BTS guidelines.

      According to the BTS guidelines, which of the following is NOT a suitable treatment?

      Your Answer: IV salbutamol if inhaled therapy cannot be used reliably

      Correct Answer: 1 hourly ipratropium bromide nebulisers

      Explanation:

      The BTS guidelines for managing acute asthma in adults provide the following recommendations:

      Oxygen:
      – It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.

      β2 agonists therapy:
      – High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
      – Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
      – For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
      – In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.

      Ipratropium bromide:
      – Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      Steroid therapy:
      – Steroids should be given in adequate doses for all cases of acute asthma attacks.
      – Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.

      Other therapies:
      – Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
      – A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
      – Routine prescription of antibiotics is not necessary for patients with acute asthma.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
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  • Question 4 - A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
    Which...

    Incorrect

    • A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
      Which of the following drug doses used in the treatment of acute adult asthma is incorrect?

      Your Answer: Ipratropium bromide 500 mcg via oxygen-driven nebuliser

      Correct Answer: Terbutaline 5mg via oxygen-driven nebuliser

      Explanation:

      The recommended drug doses for adult acute asthma are as follows:

      – Salbutamol: Administer 5 mg using an oxygen-driven nebulizer.
      – Ipratropium bromide: Deliver 500 mcg via an oxygen-driven nebulizer.
      – Prednisolone: Take orally at a dose of 40-50 mg.
      – Hydrocortisone: Administer 100 mg intravenously.
      – Magnesium sulphate: Infuse 1.2-2 g intravenously over a period of 20 minutes.

      Terbutaline can be used as an alternative to salbutamol, with a dose of 10 mg via an oxygen-driven nebulizer. Intravenous salbutamol may be considered (250 mcg IV slowly) only when inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation.

      According to the current ALS guidelines, IV aminophylline may be considered in severe or life-threatening asthma, following senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
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  • Question 5 - A 68-year-old male with a history of COPD presents to the emergency department...

    Correct

    • A 68-year-old male with a history of COPD presents to the emergency department complaining of worsening shortness of breath. The patient's family informs you that during the previous episode, the patient required BiPAP. What is one of the criteria for initiating BiPAP in COPD patients?

      Your Answer: Patient on maximal medical therapy

      Explanation:

      Before starting BiPAP, it is important for patients with COPD to have already started maximum medical therapy. This includes receiving supplemental oxygen, using nebulizers with salbutamol and ipratropium, taking steroids and antibiotics if necessary, and potentially receiving IV bronchodilators. Additionally, patients should meet the blood gas requirements of having a pH level below 7.35 and a pCO2 level above 6 Kpa. Another criteria for initiating NIV is having a respiratory rate higher than 23.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

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      • Respiratory
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  • Question 6 - A 72 year old female who is a known heavy smoker visits the...

    Incorrect

    • A 72 year old female who is a known heavy smoker visits the emergency department. She has experienced a worsening productive cough for the past week and feels breathless. An arterial blood gas is obtained and the results are as follows:

      Parameter Result
      pH 7.31
      pO2 9.1 kPa
      pCO2 6.5 kPa
      Bicarbonate 32 mmol/l
      Base Excess +4

      Which of the following options most accurately characterizes this blood gas result?

      Your Answer: Metabolic alkalosis with respiratory compensation

      Correct Answer: Respiratory acidosis with metabolic compensation

      Explanation:

      The typical pH range for blood is 7.35-7.45. The blood gases indicate a condition called respiratory acidosis, which is partially corrected by metabolic processes. This condition may also be referred to as type 2 respiratory failure, characterized by low oxygen levels and high carbon dioxide levels in the blood.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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      • Respiratory
      63.9
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  • Question 7 - A 6-year-old girl is brought in by her parents with wheezing and difficulty...

    Correct

    • A 6-year-old girl is brought in by her parents with wheezing and difficulty breathing. Over the past few days, she has been feeling sick and has had a decreased appetite. Her parents have noticed that she seems to struggle with breathing, especially when she is playing or exerting herself. Her oxygen levels are at 90% on room air, but all her other vital signs are normal. A chest X-ray is taken, which is shows left lung appears overinflated and hyperlucent, with concomitant rib flaring and a depressed ipsilateral hemidiaphragm. What is the MOST likely diagnosis for this patient?

      Your Answer: Inhaled foreign body

      Explanation:

      This child’s medical history and chest X-ray findings are indicative of an inhaled foreign object. Upon careful examination, it is evident that the left lung appears more transparent than the right lung, and the foreign body is lodged in the left tracheobronchial tree.

      Airway foreign bodies in children can be life-threatening, and it is important to consider this diagnosis when young children experience unexplained difficulty breathing and wheezing. Unfortunately, there is often a delay in diagnosing this condition.

      Foreign objects typically get stuck in the right tracheobronchial tree because the right main bronchus is wider, shorter, and more vertically positioned compared to the left main bronchus. However, they can become lodged anywhere in the tracheobronchial tree.

      While there is often a history of choking prior to the symptoms, this is not always the case. Any history of running with objects in the mouth or being in close proximity to small objects that can be placed in the mouth can provide important clues. In the absence of a choking history, clinical features may include paroxysmal coughing, unexplained difficulty breathing, changes in voice, poor appetite, irritability, decreased breath sounds on one side, and localized wheezing.

      To aid in diagnosis, a chest X-ray should be taken during expiration as it can accentuate any differences between the two lungs. The following findings may be observed: the normal lung may appear smaller and denser than the affected lung, the affected lung may appear excessively transparent and overinflated, and a radio-opaque foreign object may be visible. However, it is important to note that approximately 35% of patients may have a normal chest X-ray.

      Bronchoscopy is considered the gold-standard test for diagnosing tracheobronchial foreign bodies. This procedure not only confirms the presence of a foreign object but also allows for potential retrieval.

      Possible complications of this condition include pneumonia, atelectasis (collapsed lung), bronchospasm (constriction of the airways), pneumothorax (collapsed lung due to air leakage), broncho-oesophageal fistula (abnormal connection between the bronchial tubes and the esophagus), and bronchiectasis (permanent dilation of the bronchial tubes).

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      • Respiratory
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  • Question 8 - Following the passing of a young patient treated for an extended cardiac arrest...

    Incorrect

    • Following the passing of a young patient treated for an extended cardiac arrest after a near-drowning incident, your supervisor requests that you arrange a training session for the junior physicians. Which of the following statements accurately reflects the management of near-drowning patients?

      Your Answer: Patients with reduced GCS and hypothermia at presentation should be rewarmed with target core temperature of 36.5ºC to 37.5ºC

      Correct Answer: Patients should be extricated from the water in the horizontal position

      Explanation:

      When rescuing drowning patients, it is important to extricate them from the water in a horizontal position whenever possible. This is because the pressure of the water on the body when submerged increases the flow of blood back to the heart, which in turn increases cardiac output. However, when the patient is removed from the water, this pressure effect is lost, which can lead to a sudden drop in blood pressure and circulatory collapse due to the loss of peripheral resistance and pooling of blood in the veins. By extricating the patient in a horizontal position, we can help counteract this effect.

      It is worth noting that the amount of water in the lungs after drowning is typically small, usually less than 4 milliliters per kilogram of body weight. Therefore, attempting to drain the water from the lungs is ineffective and not recommended.

      In cases of fresh water drowning, pneumonia may occur due to unusual pathogens such as aeromonas spp, burkholderia pseudomallei, chromobacterium spp, pseudomonas species, and leptospirosis.

      If the patient experiences bronchospasm, nebulized bronchodilators can be used as a treatment.

      To prevent secondary brain injury, it is important to prevent hyperthermia. This can be achieved by maintaining the patient’s core body temperature below 36 degrees Celsius during the rewarming process.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

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      • Respiratory
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  • Question 9 - A 25-year-old woman comes in with a sudden worsening of her asthma symptoms....

    Incorrect

    • A 25-year-old woman comes in with a sudden worsening of her asthma symptoms. Her heart rate is 115 bpm, respiratory rate 28/min, and her oxygen levels are at 89% when breathing normally. She is feeling fatigued, and her breathing is weak. When listening to her chest, there are no sounds heard.
      Which of the following medication dosages could be given as part of her treatment?

      Your Answer: Salbutamol 5 mg via air-driven nebuliser

      Correct Answer: Aminophylline 5 mg/kg IV loading dose over 20 minutes

      Explanation:

      This patient is displaying symptoms of life-threatening asthma, and the only available option for treatment with the correct dosage is an aminophylline loading dose.

      The signs of acute severe asthma in adults include a peak expiratory flow (PEF) of 33-50% of the best or predicted value, a respiratory rate of over 25 breaths per minute, a heart rate of over 110 beats per minute, and an inability to complete sentences in one breath.

      On the other hand, life-threatening asthma is characterized by a PEF of less than 33% of the best or predicted value, a blood oxygen saturation level (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kPA, a normal partial pressure of carbon dioxide (PaCO2) within the range of 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, and hypotension.

      The recommended drug doses for adult acute asthma are as follows: 5 mg of salbutamol delivered through an oxygen-driven nebulizer, 500 mcg of ipratropium bromide via an oxygen-driven nebulizer, 40-50 mg of prednisolone taken orally, 100 mg of hydrocortisone administered intravenously, and 1.2-2 g of magnesium sulfate given intravenously over a period of 20 minutes. Intravenous salbutamol may be considered (250 mcg administered slowly) only when inhaled therapy is not possible, such as in a patient receiving bag-mask ventilation.

      According to the current ALS guidelines, IV aminophylline can be considered in cases of severe or life-threatening asthma, following consultation with a senior medical professional. If used, a loading dose of 5 mg/kg should be administered over 20 minutes, followed by a continuous infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      49.9
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  • Question 10 - A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell...

    Incorrect

    • A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell and has experienced recent weight loss. Additionally, she has developed a rash. Her medical history includes a diagnosis of asthma last year and allergic rhinitis. On examination, she has a normal body temperature, her blood pressure is 180/95, and she has a purpuric rash primarily on her legs. During chest examination, a few scattered wheezes are heard.

      Recently, she had a blood test, and the results are as follows:
      - Hemoglobin (Hb): 10.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 23.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 8.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Lymphocytes: 2.1 x 109/l (normal range: 1.3-3.5 x 109/l)
      - Eosinophils: 15.7 x 109/l (normal range: 0.04-0.44 x 109/l)
      - C-reactive protein (CRP): 107 mg/l (normal range: <5 mg/l)
      - Sodium (Na): 142 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.6 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 255 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 14.8 mmol/l (normal range: 2.5-7.5 mmol/l)

      What is the SINGLE most likely diagnosis?

      Your Answer: Allergic bronchopulmonary aspergillosis

      Correct Answer: Churg-Strauss syndrome

      Explanation:

      This individual has presented with haemoptysis and a purpuric rash, alongside a history of asthma and allergic rhinitis. Blood tests have revealed elevated inflammatory markers, pronounced eosinophilia, and acute renal failure. The most likely diagnosis in this case is Churg-Strauss syndrome.

      Churg-Strauss syndrome is a rare autoimmune vasculitis that affects small and medium-sized blood vessels. The American College of Rheumatology has established six criteria for diagnosing Churg-Strauss syndrome. The presence of at least four of these criteria is highly indicative of the condition:

      1. Asthma (wheezing, expiratory rhonchi)
      2. Eosinophilia of more than 10% in peripheral blood
      3. Paranasal sinusitis
      4. Pulmonary infiltrates (which may be transient)
      5. Histological confirmation of vasculitis with extravascular eosinophils
      6. Mononeuritis multiplex or polyneuropathy

      Churg-Strauss syndrome can affect various organ systems, with the most common clinical features including:

      – Constitutional symptoms: fever, fatigue, weight loss, and arthralgia
      – Respiratory symptoms: asthma, haemoptysis, allergic rhinitis, and sinusitis
      – Cardiovascular symptoms: heart failure, myocarditis, and myocardial infarction
      – Gastrointestinal symptoms: gastrointestinal bleeding, bowel ischaemia, and appendicitis
      – Dermatological symptoms: purpura, livedo reticularis, and skin nodules
      – Renal symptoms: glomerulonephritis, renal failure, and hypertension
      – Neurological symptoms: mononeuritis multiplex

      Investigations often reveal eosinophilia, anaemia, elevated CRP and ESR, elevated creatinine, and elevated serum IgE levels. Approximately 70% of patients test positive for p-ANCA.

      The mainstay of treatment for Churg-Strauss syndrome is high-dose steroids. In cases with life-threatening complications, cyclophosphamide and azathioprine are often administered.

      Polyarteritis nodosa is another vasculitic disorder that affects small and medium-sized blood vessels. It can impact the gastrointestinal tract, kidneys, skin, and joints, but it is not typically associated with rhinitis or asthma.

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      • Respiratory
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  • Question 11 - A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing...

    Incorrect

    • A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing and chest pain that worsens with deep breaths. The results of his arterial blood gas (ABG) on room air are as follows:

      pH: 7.48
      pO2: 7.4 kPa
      PCO2: 3.1 kPa
      HCO3-: 24.5 mmol/l

      Which ONE statement about his ABG is correct?

      Your Answer:

      Correct Answer: He has a respiratory alkalosis

      Explanation:

      Arterial blood gas (ABG) interpretation is crucial in evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analysers, they generally fall within the following ranges: pH of 7.35 – 7.45, pO2 of 10 – 14 kPa, PCO2 of 4.5 – 6 kPa, HCO3- of 22 – 26 mmol/l, and base excess of -2 – 2 mmol/l.

      In this particular case, the patient’s medical history raises concerns about a potential diagnosis of pulmonary embolism. The relevant ABG findings are as follows: significant hypoxia (indicating type 1 respiratory failure), elevated pH (alkalaemia), low PCO2, and normal bicarbonate levels. These findings suggest that the patient is experiencing primary respiratory alkalosis.

      By analyzing the ABG results, healthcare professionals can gain valuable insights into a patient’s respiratory function and acid-base status, aiding in the diagnosis and management of various conditions.

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  • Question 12 - A 70-year-old nursing home resident is brought to the Emergency Department because she...

    Incorrect

    • A 70-year-old nursing home resident is brought to the Emergency Department because she has rapidly declined in the past 24 hours. She appears extremely ill and has a temperature of 39.3°C. She has a history of stroke, is typically confined to bed, and struggles with communication. During the examination, she exhibits rapid heart rate, rapid breathing, and coarse crackles in the right middle and lower areas.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Aspiration pneumonia

      Explanation:

      This patient presents with clinical features that are indicative of a right middle/lower lobe pneumonia. Considering her past medical history of a stroke and the specific location of the chest signs, it is highly probable that she is suffering from aspiration pneumonia.

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  • Question 13 - A 35-year-old woman with no significant medical history complains of chest pain on...

    Incorrect

    • A 35-year-old woman with no significant medical history complains of chest pain on the right side and difficulty breathing. She does not take any medications regularly and has no known allergies to drugs. She has been a heavy smoker for the past six years.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Pneumothorax

      Explanation:

      The risk of primary spontaneous pneumothorax is associated with smoking tobacco and increases as the duration of exposure and daily consumption rise. The changes caused by smoking in the small airways may contribute to the development of local emphysema, leading to the formation of bullae. In this case, the patient does not have any clinical features or significant risk factors for the other conditions mentioned. Therefore, primary spontaneous pneumothorax is the most probable diagnosis.

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      • Respiratory
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  • Question 14 - A 45-year-old man presents with a severe exacerbation of his COPD. He has...

    Incorrect

    • A 45-year-old man presents with a severe exacerbation of his COPD. He has been given a loading dose of aminophylline and you now intend to establish a maintenance infusion. He weighs 70 kg.
      What is the appropriate maintenance infusion rate for him?

      Your Answer:

      Correct Answer: 30 mg/hour

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a 60 kg patient, the appropriate infusion rate would be 30 mg/hour. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

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      • Respiratory
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  • Question 15 - A 23 year old male is brought to the emergency department (ED) by...

    Incorrect

    • A 23 year old male is brought to the emergency department (ED) by ambulance after being hit by a car while riding his bike. The patient appears restless. His vital signs are as follows:

      Blood Pressure: 86/54 mmHg
      Pulse Rate: 138 bpm
      Respiration Rate: 32 rpm
      SpO2: 94% on 15l oxygen

      During the examination, you observe tracheal deviation towards the left, absent breath sounds on the right side, and hyper-resonant percussion note on the right side.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Right sided tension pneumothorax

      Explanation:

      One of the clinical features of a tension pneumothorax is the deviation of the trachea away from the side where the pneumothorax is located. This particular feature is typically observed in cases of right-sided tension pneumothorax.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

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  • Question 16 - You assess a patient who came in with chest discomfort and difficulty breathing....

    Incorrect

    • You assess a patient who came in with chest discomfort and difficulty breathing. They have been diagnosed with a spontaneous pneumothorax and their initial attempt at pleural aspiration was unsuccessful. The pneumothorax is still significant in size, and the patient continues to experience breathlessness. You get ready to insert a Seldinger chest drain into the 'safe triangle'.
      What is the lower boundary of the 'safe triangle'?

      Your Answer:

      Correct Answer: 5th intercostal space

      Explanation:

      The British Thoracic Society (BTS) advises that chest drains should be inserted within the safe triangle to minimize the risk of harm to underlying structures and prevent damage to muscle and breast tissue, which can result in unsightly scarring. The safe triangle is defined by the base of the axilla, the lateral border of the latissimus dorsi, the lateral border of the pectoralis major, and the 5th intercostal space.

      There are several potential complications associated with the insertion of small-bore chest drains. These include puncture of the intercostal artery, accidental perforation of organs due to over-introduction of the dilator into the chest cavity, hospital-acquired pleural infection caused by a non-aseptic technique, inadequate stay suture that may lead to the chest tube falling out, and tube blockage, which may occur more frequently compared to larger bore Argyle drains.

      For more information on this topic, please refer to the British Thoracic Society pleural disease guidelines.

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  • Question 17 - A 72 year old male presents to the emergency department complaining of shortness...

    Incorrect

    • A 72 year old male presents to the emergency department complaining of shortness of breath. The patient has had a tracheostomy for several years after being on a ventilator for an extended period of time due to a severe head injury. You provide high flow oxygen and remove the inner tube of the tracheostomy. However, there is no improvement in the patient's condition. What would be the most suitable course of action for managing this patient?

      Your Answer:

      Correct Answer: Pass suction catheter

      Explanation:

      If a patient with breathing difficulty does not show improvement after removing the inner tracheostomy tube, it is recommended to use a suction catheter to remove any secretions. This can help clear any blockage caused by secretions or debris in or near the tube. If this does not improve the situation, the next step would be to deflate the cuff. If deflating the cuff stabilizes or improves the patient’s condition, it suggests that air can flow around the tube within the airway, indicating that the tracheostomy tube may be obstructed or displaced.

      Further Reading:

      Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

      When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

      Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

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  • Question 18 - A 6-month-old boy has been brought to the hospital for evaluation of a...

    Incorrect

    • A 6-month-old boy has been brought to the hospital for evaluation of a severe respiratory infection. The medical team suspects a diagnosis of pertussis (whooping cough).
      What is the MOST SUITABLE investigation for this case?

      Your Answer:

      Correct Answer: PCR testing

      Explanation:

      Whooping cough, also known as pertussis, is a respiratory infection caused by the bacteria Bordetella pertussis. It is transmitted through respiratory droplets and has an incubation period of about 7-21 days. This disease is highly contagious and can be transmitted to around 90% of close household contacts.

      The clinical course of whooping cough can be divided into two stages. The first stage is called the catarrhal stage, which resembles a mild respiratory infection with symptoms like low-grade fever and a runny nose. A cough may be present, but it is usually mild compared to the second stage. The catarrhal stage typically lasts for about a week.

      The second stage is known as the paroxysmal stage. During this phase, the cough becomes more severe as the catarrhal symptoms start to subside. The coughing occurs in spasms, often preceded by an inspiratory whoop sound, followed by a series of rapid coughs. Vomiting may occur, and patients may develop subconjunctival hemorrhages and petechiae. Patients generally feel well between coughing spasms, and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over time. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) provides recommendations for testing whooping cough based on the patient’s age, time since onset of illness, and severity of symptoms. For infants under 12 months of age who are hospitalized, PCR testing is recommended. Non-hospitalized infants within two weeks of symptom onset should undergo culture testing of a nasopharyngeal swab or aspirate. Non-hospitalized infants presenting over two weeks after symptom onset should be tested for anti-pertussis toxin IgG antibody levels using serology.

      For children over 12 months of age and adults, culture testing of a nasopharyngeal swab or aspirate is recommended within two weeks of symptom onset. Children aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after symptom onset should undergo oral fluid testing for anti-pertussis toxin IgG antibody levels. Children under 5 or adults over

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  • Question 19 - You are managing a 65-year-old patient who has presented with confusion, shortness of...

    Incorrect

    • You are managing a 65-year-old patient who has presented with confusion, shortness of breath, and a productive cough. A diagnosis of pneumonia and sepsis is made. You ask the nurse to administer oxygen to the patient. What target parameter would you use to guide oxygen therapy in this patient who does not have a known history of respiratory disease?

      Your Answer:

      Correct Answer: SpO2 >94%

      Explanation:

      In this case, the most appropriate target parameter to guide oxygen therapy would be an SpO2 (oxygen saturation) level of greater than 94%.

      Further Reading:

      There are multiple definitions of sepsis, leading to confusion among healthcare professionals. The Sepsis 3 definition describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sepsis 2 definition includes infection plus two or more SIRS criteria. The NICE definition states that sepsis is a clinical syndrome triggered by the presence of infection in the blood, activating the body’s immune and coagulation systems. The Sepsis Trust defines sepsis as a dysregulated host response to infection mediated by the immune system, resulting in organ dysfunction, shock, and potentially death.

      The confusion surrounding sepsis terminology is further compounded by the different versions of sepsis definitions, known as Sepsis 1, Sepsis 2, and Sepsis 3. The UK organizations RCEM and NICE have not fully adopted the changes introduced in Sepsis 3, causing additional confusion. While Sepsis 3 introduces the use of SOFA scores and abandons SIRS criteria, NICE and the Sepsis Trust have rejected the use of SOFA scores and continue to rely on SIRS criteria. This discrepancy creates challenges for emergency department doctors in both exams and daily clinical practice.

      To provide some clarity, RCEM now recommends referring to national standards organizations such as NICE, SIGN, BTS, or others relevant to the area. The Sepsis Trust, in collaboration with RCEM and NICE, has published a toolkit that serves as a definitive reference point for sepsis management based on the sepsis 3 update.

      There is a consensus internationally that the terms SIRS and severe sepsis are outdated and should be abandoned. Instead, the terms sepsis and septic shock should be used. NICE defines septic shock as a life-threatening condition characterized by low blood pressure despite adequate fluid replacement and organ dysfunction or failure. Sepsis 3 defines septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, along with a serum lactate level greater than 2 mmol/l despite adequate volume resuscitation.

      NICE encourages clinicians to adopt an approach of considering sepsis in all patients, rather than relying solely on strict definitions. Early warning or flag systems can help identify patients with possible sepsis.

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  • Question 20 - You are evaluating a 68-year-old patient with a known history of COPD who...

    Incorrect

    • You are evaluating a 68-year-old patient with a known history of COPD who has come to the emergency department due to worsening shortness of breath and a cough producing green sputum. An arterial blood gas is obtained and the results are as follows:

      Parameter Result
      pH 7.31
      pO2 9.1 kPa
      pCO2 6.5 kPa
      Bicarbonate 32 mmol/l
      Base Excess +4

      The patient is given immediate doses of prednisone and amoxicillin, and nebulized salbutamol is administered. After one hour of treatment, a repeat blood gas is obtained with the patient receiving 40% inspired oxygen via venturi. The results are as follows:

      Parameter Result
      pH 7.27
      pO2 9.0 kPa
      pCO2 7.2 kPa
      Bicarbonate 33 mmol/l
      Base Excess +5

      Which of the following interventions would be the most appropriate to implement next?

      Your Answer:

      Correct Answer: Non-invasive ventilation

      Explanation:

      According to the brit-thoracic guidelines, if a patient with COPD continues to experience respiratory acidosis even after receiving standard medical therapy for one hour, it is recommended to consider using non-invasive ventilation (NIV). This is especially important if the patient’s hypoxia and hypercapnia are worsening despite the initial treatment.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 21 - A 57-year-old man comes in with a fever, difficulty breathing, and a cough...

    Incorrect

    • A 57-year-old man comes in with a fever, difficulty breathing, and a cough with phlegm. During the examination, you notice crackling sounds in his lower left lung. You diagnose him with community-acquired pneumonia.
      Which of the following statements is accurate about the CURB-65 scoring system?

      Your Answer:

      Correct Answer: A serum urea of 7.5 mmol/l scores 1 point

      Explanation:

      The CURB criteria, also referred to as the CURB-65 criteria, is a clinical prediction rule that has been scientifically proven to predict mortality in cases of community-acquired pneumonia. These criteria consist of five factors: confusion of new onset (AMTS <8), urea level greater than 7 mmol/l, respiratory rate exceeding 30 per minute, blood pressure below 90 mmHg systolic or 60 mmHg diastolic, and age over 65 years. Based on the score obtained from these criteria, the risk level can be determined. A score of 0-1 indicates a low-risk situation, where outpatient treatment is recommended. A score of 2-3 suggests a moderate risk, and either inpatient treatment or an ambulatory care pathway is recommended. A score of 4-5 indicates a high risk, requiring hospitalization and potentially critical care involvement.

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  • Question 22 - A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct...

    Incorrect

    • A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct an arterial blood gas test, and their PaCO2 level is 6.3 kPa.
      How would you categorize this asthma exacerbation?

      Your Answer:

      Correct Answer: Near-fatal asthma

      Explanation:

      This individual has presented with an episode of acute asthma. Their PaCO2 levels are elevated at 6.3 kPa, indicating a near-fatal exacerbation. According to the BTS guidelines, acute asthma can be classified as moderate, acute severe, life-threatening, or near-fatal.

      Moderate asthma is characterized by increasing symptoms and a PEFR (peak expiratory flow rate) of 50-75% of the best or predicted value. There are no features of acute severe asthma present in this classification.

      Acute severe asthma can be identified by any one of the following criteria: a PEFR of 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate surpassing 110 beats per minute, or the inability to complete sentences in one breath.

      Life-threatening asthma is determined by any one of the following indicators: a PEFR below 33% of the best or predicted value, an SpO2 (oxygen saturation) level below 92%, a PaO2 (partial pressure of oxygen) below 8 kPa, normal PaCO2 levels (ranging from 4.6-6.0 kPa), a silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension.

      Near-fatal asthma is characterized by a raised PaCO2 level and/or the need for mechanical ventilation with elevated inflation pressures.

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  • Question 23 - A 32-year-old patient with asthma is transferred to the resuscitation area of your...

    Incorrect

    • A 32-year-old patient with asthma is transferred to the resuscitation area of your Emergency Department due to a worsening of their symptoms. Your consultant administers an initial dose of intravenous aminophylline, and the patient's symptoms start to improve. The consultant requests that you obtain a blood sample to measure the patient's theophylline levels after an appropriate duration of treatment.
      How much time should elapse before obtaining the blood sample following the initiation of this treatment?

      Your Answer:

      Correct Answer: 4-6 hours

      Explanation:

      In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.

      To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.

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  • Question 24 - A child presents with a severe acute asthma attack. After a poor response...

    Incorrect

    • A child presents with a severe acute asthma attack. After a poor response to their initial salbutamol nebulizer, you administer a second nebulizer that also contains ipratropium bromide.
      What is the estimated duration of action for ipratropium bromide?

      Your Answer:

      Correct Answer: 3-6 hours

      Explanation:

      Ipratropium bromide is a medication that falls under the category of antimuscarinic drugs. It is commonly used to manage acute asthma and chronic obstructive pulmonary disease (COPD). While it can provide short-term relief for chronic asthma, it is generally recommended to use short-acting β2 agonists as they act more quickly and are preferred.

      According to the guidelines set by the British Thoracic Society (BTS), nebulized ipratropium bromide (0.5 mg every 4-6 hours) can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      For mild cases of chronic obstructive pulmonary disease, aerosol inhalation of ipratropium can be used for short-term relief, as long as the patient is not already using a long-acting antimuscarinic drug like tiotropium. The maximum effect of ipratropium occurs within 30-60 minutes after use, and its bronchodilating effects can last for 3-6 hours. Typically, treatment with ipratropium is recommended three times a day to maintain bronchodilation.

      The most common side effect of ipratropium bromide is dry mouth. Other potential side effects include constipation, cough, paroxysmal bronchospasm, headache, nausea, and palpitations. It is important to note that ipratropium can cause urinary retention in patients with prostatic hyperplasia and bladder outflow obstruction. Additionally, it can trigger acute closed-angle glaucoma in susceptible patients.

      For more information on the management of asthma, it is recommended to refer to the BTS/SIGN Guideline on the Management of Asthma.

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  • Question 25 - A 35-year-old man who resides in a Traveller community comes in with a...

    Incorrect

    • A 35-year-old man who resides in a Traveller community comes in with a severe paroxysmal cough and a fever that has persisted for the last 10 days. He reports not having received any vaccinations. A nasopharyngeal swab for pertussis comes back positive. He is currently 18 weeks into his wife's pregnancy.
      What is the most suitable initial antibiotic to prescribe?

      Your Answer:

      Correct Answer: Erythromycin

      Explanation:

      Pertussis, also known as whooping cough, is a respiratory infection caused by the bacteria Bordetella pertussis. Despite being a bacterial disease, antibiotics do not change the course of the illness once it has taken hold. However, macrolide antibiotics have been proven to shorten the period of contagiousness. Therefore, it is important to administer antibiotics as soon as possible after the onset of symptoms to eliminate the bacteria and reduce further transmission. It is crucial to start antibiotics within three weeks of symptom onset, as they do not affect the progression of the illness or the contagious period.

      First-line treatment for pertussis includes macrolide antibiotics. For babies under one month old, clarithromycin is recommended. For children one month and older, as well as non-pregnant adults, azithromycin or clarithromycin are the preferred options. Pregnant women should be treated with erythromycin. In cases where macrolides are not suitable or well-tolerated, co-trimoxazole can be used off-label.

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  • Question 26 - A 12-month-old child is brought in to the Emergency Department with a high...

    Incorrect

    • A 12-month-old child is brought in to the Emergency Department with a high temperature and difficulty breathing. You measure their respiratory rate and note that it is elevated.
      According to the NICE guidelines, what is considered to be the threshold for tachypnoea in an infant of this age?

      Your Answer:

      Correct Answer: RR >40 breaths/minute

      Explanation:

      According to the current NICE guidelines on febrile illness in children under the age of 5, there are certain symptoms and signs that may indicate the presence of pneumonia. These include tachypnoea, which is a rapid breathing rate. For infants aged 0-5 months, a respiratory rate (RR) of over 60 breaths per minute is considered suggestive of pneumonia. For infants aged 6-12 months, an RR of over 50 breaths per minute is indicative, and for children older than 12 months, an RR of over 40 breaths per minute may suggest pneumonia.

      Other signs that may point towards pneumonia include crackles in the chest, nasal flaring, chest indrawing, and cyanosis. Crackles are abnormal sounds heard during breathing, while nasal flaring refers to the widening of the nostrils during breathing. Chest indrawing is the inward movement of the chest wall during inhalation, and cyanosis is the bluish discoloration of the skin or mucous membranes due to inadequate oxygen supply.

      Additionally, a low oxygen saturation level of less than 95% while breathing air is also considered suggestive of pneumonia. These guidelines can be found in more detail in the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

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  • Question 27 - A 6-week-old baby girl presents with a low-grade fever, feeding difficulties, and a...

    Incorrect

    • A 6-week-old baby girl presents with a low-grade fever, feeding difficulties, and a persistent cough that have been present for the past three days. You suspect bronchiolitis as the diagnosis.
      What is the MOST likely causative organism in this case?

      Your Answer:

      Correct Answer: Respiratory syncytial virus

      Explanation:

      Bronchiolitis is a common respiratory infection that primarily affects infants. It typically occurs between the ages of 3-6 months and is most prevalent during the winter months from November to March. The main culprit behind bronchiolitis is the respiratory syncytial virus, accounting for about 70% of cases. However, other viruses like parainfluenza, influenza, adenovirus, coronavirus, and rhinovirus can also cause this infection.

      The clinical presentation of bronchiolitis usually starts with symptoms resembling a common cold, which last for the first 2-3 days. Infants may experience poor feeding, rapid breathing (tachypnoea), nasal flaring, and grunting. Chest wall recessions, bilateral fine crepitations, and wheezing may also be observed. In severe cases, apnoea, a temporary cessation of breathing, can occur.

      Bronchiolitis is a self-limiting illness, meaning it resolves on its own over time. Therefore, treatment mainly focuses on supportive care. However, infants with oxygen saturations below 92% may require oxygen administration. If an infant is unable to maintain oral intake or hydration, nasogastric feeding should be considered. Nasal suction is recommended to clear secretions in infants experiencing respiratory distress due to nasal blockage.

      It is important to note that there is no evidence supporting the use of antivirals (such as ribavirin), antibiotics, beta 2 agonists, anticholinergics, or corticosteroids in the management of bronchiolitis. These interventions are not recommended for this condition.

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  • Question 28 - A 60-year-old woman presents with a persistent cough and increasing difficulty breathing. She...

    Incorrect

    • A 60-year-old woman presents with a persistent cough and increasing difficulty breathing. She also complains of muscle aches and occasional joint pain, particularly in her knees and hips. She has a 40-pack-year smoking history. During the examination, you observe fine crackling sounds in the lower parts of her lungs when she exhales. Lung function testing reveals a decrease in the forced vital capacity (FVC) and the forced expiratory volume in one second (FEV1), but a preserved FEV1/FVC ratio. A photo of her hands is provided below:
      What is the SINGLE most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      This patient’s clinical presentation is consistent with a diagnosis of idiopathic pulmonary fibrosis. The typical symptoms of idiopathic pulmonary fibrosis include a dry cough, progressive breathlessness, arthralgia and muscle pain, finger clubbing (seen in 50% of cases), cyanosis, fine end-expiratory bibasal crepitations, and right heart failure and cor pulmonale in later stages.

      Finger clubbing, which is prominent in this patient, can also be caused by bronchiectasis and tuberculosis. However, these conditions would not result in a raised FEV1/FVC ratio, which is a characteristic feature of a restrictive lung disorder.

      In restrictive lung disease, the FEV1/FVC ratio is typically normal, around 70% predicted, while the FVC is reduced to less than 80% predicted. Both the FVC and FEV1 are generally reduced in this condition. The ratio can also be elevated if the FVC is reduced to a greater extent.

      It is important to note that smoking is a risk factor for developing idiopathic pulmonary fibrosis, particularly in individuals with a history of smoking greater than 20 pack-years.

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  • Question 29 - A 72-year-old man presents with a severe exacerbation of his COPD. You have...

    Incorrect

    • A 72-year-old man presents with a severe exacerbation of his COPD. You have been asked to administer a loading dose of aminophylline. He weighs 70 kg.
      What is the appropriate loading dose for him?

      Your Answer:

      Correct Answer: 300 mg over 15 minutes

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a patient weighing 60 kg, the appropriate loading dose would be 300 mg. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

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  • Question 30 - You assess a 65-year-old woman with a history of progressively increasing shortness of...

    Incorrect

    • You assess a 65-year-old woman with a history of progressively increasing shortness of breath. As part of the patient's treatment plan, your supervisor requests that you carry out a pleural aspiration.
      Based on the BTS guidelines, what is one of the indications for performing a pleural aspiration?

      Your Answer:

      Correct Answer: Unilateral exudative pleural effusion

      Explanation:

      A pleural effusion refers to an excess accumulation of fluid in the pleural cavity, which is the space between the parietal and visceral pleura. Normally, this cavity contains a small amount of lubricating fluid, around 5-10 ml, that allows the pleurae to slide smoothly over each other. This fluid also creates surface tension, bringing the two membranes together and ensuring that as the thorax expands, the lungs expand and fill with air. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons. Firstly, it is used to investigate pleural effusion, particularly when it is unilateral and exudative in nature. Secondly, it provides symptomatic relief for breathlessness caused by pleural effusion. However, the British Thoracic Society (BTS) guidelines recommend that pleural aspiration should not be carried out if there is suspicion of unilateral or bilateral transudative effusion, unless there are atypical features or failure of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

      During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line, about 10 cm lateral to the spine, and one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.

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  • Question 31 - A 4-year-old girl presents with stridor and a barking cough. Her mother reports...

    Incorrect

    • A 4-year-old girl presents with stridor and a barking cough. Her mother reports that she has had a slight cold for a few days and her voice had been hoarse. Her vital signs are as follows: temperature 38.1°C, heart rate 135, respiratory rate 30, oxygen saturation 97% on room air. Her chest examination is unremarkable, but you observe the presence of stridor at rest.

      What is the SINGLE most probable causative organism?

      Your Answer:

      Correct Answer: Parainfluenza virus

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

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  • Question 32 - A 45 year old with asthma is brought into the ER due to...

    Incorrect

    • A 45 year old with asthma is brought into the ER due to worsening shortness of breath. You collect an arterial blood gas sample for analysis. What is the typical pH range for arterial blood?

      Your Answer:

      Correct Answer: 7.35-7.45

      Explanation:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 33 - You evaluate a 9-year-old boy with a high temperature and a persistent, forceful...

    Incorrect

    • You evaluate a 9-year-old boy with a high temperature and a persistent, forceful cough for the past two weeks. A nasopharyngeal swab has been collected and has tested positive for Bordetella pertussis. You initiate a course of antibiotics. The parents of the child would like to know the duration for which he should stay home from school after starting antibiotic treatment for this infection.

      Your Answer:

      Correct Answer: 48 hours

      Explanation:

      Whooping cough, also known as pertussis, is a respiratory infection caused by the bacteria Bordetella pertussis. It is transmitted through respiratory droplets and has an incubation period of about 7-21 days. This highly contagious disease can be passed on to around 90% of close household contacts.

      To prevent the spread of whooping cough, Public Health England advises that children with the illness should stay away from school, nursery, or childminders for 48 hours after starting antibiotic treatment. If no antibiotic treatment is given, they should be kept away for 21 days from the onset of the illness. It’s important to note that even after treatment, non-infectious coughing may persist for several weeks.

      For more information on how to control infections in schools and other childcare settings, you can refer to the guidance provided by Public Health England.

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  • Question 34 - A 32-year-old patient with asthma is transferred to the resuscitation area of your...

    Incorrect

    • A 32-year-old patient with asthma is transferred to the resuscitation area of your Emergency Department due to a worsening of their symptoms. Your consultant administers an initial dose of IV aminophylline, and the patient's symptoms start to improve. Your consultant requests that you monitor the patient's theophylline levels after a suitable period of time.
      What is the recommended therapeutic range for theophylline in plasma?

      Your Answer:

      Correct Answer: 10-20 mg/litre

      Explanation:

      In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.

      To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.

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  • Question 35 - You are overseeing the care of a 68-year-old individual with COPD. The patient...

    Incorrect

    • You are overseeing the care of a 68-year-old individual with COPD. The patient has recently started using BiPAP. What is the desired range for oxygen saturation in a patient with COPD and type 2 respiratory failure who is receiving BiPAP?

      Your Answer:

      Correct Answer: 88-92%

      Explanation:

      In patients with COPD and type 2 respiratory failure, the desired range for oxygen saturation while receiving BiPAP is typically 88-92%.

      Maintaining oxygen saturation within this range is crucial for individuals with COPD as it helps strike a balance between providing enough oxygen to meet the body’s needs and avoiding the risk of oxygen toxicity. Oxygen saturation levels below 88% may indicate inadequate oxygenation, while levels above 92% may lead to oxygen toxicity and other complications.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

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  • Question 36 - A 32-year-old woman presents with a history of increased wheezing over the past...

    Incorrect

    • A 32-year-old woman presents with a history of increased wheezing over the past two days. She suffers from seasonal allergies in the spring months, which has been worse than usual over recent weeks. When auscultating her chest, you can hear scattered polyphonic wheezes. Her peak flow at presentation was 275 L/min, and her best ever peak flow is 500 L/min. After a single salbutamol nebulizer, her peak flow improves to 455 L/min, and she feels much better.
      Which of the following drug treatments should be administered next?

      Your Answer:

      Correct Answer: Oral prednisolone

      Explanation:

      This individual has presented with an episode of acute asthma. Upon assessment, his initial peak flow is measured at 55% of his personal best, indicating a moderate exacerbation. In such cases, it is recommended to administer steroids, with a suggested dose of prednisolone 40-50 mg taken orally as the initial management step.

      Currently, the use of nebulized magnesium sulfate is not recommended for the treatment of acute asthma in adults. However, according to the current ALS guidelines, in severe or life-threatening asthma cases, IV aminophylline can be considered after seeking senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

      In situations where inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation, IV salbutamol can be considered at a slow dose of 250 mcg. However, it should be noted that there is currently no evidence supporting the use of leukotriene receptor antagonists, like montelukast, in the management of acute asthma.

      The BTS guidelines classify acute asthma into four categories: moderate, acute severe, life-threatening, and near-fatal. Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the individual’s best or predicted value, with no features of acute severe asthma. Acute severe asthma is identified by a PEFR of 33-50% of the best or predicted value, along with respiratory rate >25/min, heart rate >110/min, or the inability to complete sentences in one breath.

      Life-threatening asthma is indicated by a PEFR <33% of the best or predicted value, SpO2 <92%, PaO2 <8 kPa, normal PaCO2 (4.6-6.0 kPa), and additional symptoms such as silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension. Near-fatal asthma is characterized by raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures.

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  • Question 37 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Incorrect

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After evaluating him, you determine that he has community-acquired pneumonia. He has no significant medical history but has a known allergy to penicillin.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer:

      Correct Answer: Clarithromycin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

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  • Question 38 - You are managing a 68-year-old male patient who has been intubated due to...

    Incorrect

    • You are managing a 68-year-old male patient who has been intubated due to the development of acute severe respiratory distress syndrome (ARDS). While adjusting the ventilator settings, your consultant emphasizes the significance of employing lung protective ventilation to prevent ventilator-induced lung injury (VILI). What is a crucial element of lung protective ventilation?

      Your Answer:

      Correct Answer: Use low tidal volumes

      Explanation:

      Lung protective ventilation involves several important elements, with low tidal volumes being a crucial component. Specifically, using tidal volumes of 5-8 ml/kg is recommended to minimize the risk of lung injury. Additionally, it is important to maintain inspiratory pressures, also known as plateau pressure, below 30 cm of water to further protect the lungs. Lastly, permissible hypercapnia, or allowing for higher levels of carbon dioxide in the blood, is another key aspect of lung protective ventilation.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

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  • Question 39 - You are working in the pediatric emergency department and are asked to review...

    Incorrect

    • You are working in the pediatric emergency department and are asked to review a child's blood gas results by the resident. What is the typical range for partial pressure of carbon dioxide (pCO2)?

      Your Answer:

      Correct Answer: 4.4-6.4 kPa

      Explanation:

      The typical range for the partial pressure of carbon dioxide (pCO2) is 4.4-6.4 kilopascals (kPa). In terms of arterial blood gas (ABG) results, the normal range for pO2 (partial pressure of oxygen) is 10-14.4 kPa or 70-100 millimeters of mercury (mmHg). The normal range for pCO2 is 4.4-6.4 kPa or 35-45 mmHg. Additionally, the normal range for bicarbonate levels is 23-28 millimoles per liter (mmol/L).

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 40 - A 35-year-old dairy farmer presents with a flu-like illness that has been worsening...

    Incorrect

    • A 35-year-old dairy farmer presents with a flu-like illness that has been worsening for the past two weeks. He has high fevers, a pounding headache, and muscle aches. He has now also developed a dry cough, stomach pain, and diarrhea. During the examination, there are no notable chest signs, but a liver edge can be felt 4 cm below the costal margin.

      Today, his blood tests show the following results:
      - Hemoglobin (Hb): 13.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 21.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 17.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Platelets: 567 x 109/l (normal range: 150-400 x 109/l)
      - C-reactive protein (CRP): 187 mg/l (normal range: < 5 mg/l)
      - Sodium (Na): 127 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 122 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 7.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      - Aspartate aminotransferase (AST): 121 IU/l (normal range: 8-40 IU/l)
      - Alkaline phosphatase (ALP): 296 IU/l (normal range: 30-200 IU/l)
      - Bilirubin: 14 micromol/l (normal range: 3-17 micromol/l)

      What is the SINGLE most likely causative organism?

      Your Answer:

      Correct Answer: Coxiella burnetii

      Explanation:

      Q fever is a highly contagious infection caused by Coxiella burnetii, which can be transmitted from animals to humans. It is commonly observed as an occupational disease among individuals working in farming, slaughterhouses, and animal research. Approximately 50% of cases do not show any symptoms, while those who are affected often experience flu-like symptoms such as headache, fever, muscle pain, diarrhea, nausea, and vomiting.

      In some cases, patients may develop an atypical pneumonia characterized by a dry cough and minimal chest signs. Q fever can also lead to hepatitis and enlargement of the liver (hepatomegaly), although jaundice is not commonly observed. Typical blood test results for Q fever include an elevated white cell count (30-40%), ALT/AST levels that are usually 2-3 times higher than normal, increased ALP levels (70%), reduced sodium levels (30%), and reactive thrombocytosis.

      It is important to check patients for heart murmurs and signs of valve disease, as these conditions increase the risk of developing infective endocarditis. Treatment for Q fever typically involves a two-week course of doxycycline.

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  • Question 41 - A 35-year-old woman presents with difficulty breathing and coughing up blood after a...

    Incorrect

    • A 35-year-old woman presents with difficulty breathing and coughing up blood after a recent trip from Australia. You suspect she may have a pulmonary embolism (PE).
      Which of the following statements is true about the two-level PE Wells score?

      Your Answer:

      Correct Answer: Clinical symptoms and signs of a DVT scores 3 points

      Explanation:

      The two-level PE Wells score has been simplified to determine the likelihood of a pulmonary embolism (PE) into two outcomes: likely or unlikely. A score of over 4 indicates that a PE is likely, while a score of 4 points or less indicates that a PE is unlikely.

      The allocation of points is as follows:

      – Clinical symptoms and signs of deep vein thrombosis (DVT) = 3 points
      – An alternative diagnosis that is less likely than a PE = 3 points
      – Heart rate greater than 100 = 1.5 points
      – Immobilization for more than 3 days or recent surgery within 4 weeks = 1.5 points
      – Previous history of DVT or PE = 1.5 points
      – Presence of haemoptysis = 1 point
      – Malignancy (currently on treatment, treated in the last 6 months, or palliative care) = 1 point.

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  • Question 42 - A 42-year-old woman presents with a history of multiple recent episodes of significant...

    Incorrect

    • A 42-year-old woman presents with a history of multiple recent episodes of significant haemoptysis. She reports experiencing haemoptysis and has noticed that her urine appears very dark. During examination, bibasal crepitations are detected. A urine dipstick test reveals positive results for blood and protein.
      Her current blood test results are as follows:
      Hemoglobin (Hb): 7.9 g/dl (normal range: 13-17 g/dl)
      Mean Corpuscular Volume (MCV): 68 fl (normal range: 76-96 fl)
      White Cell Count (WCC): 19.5 x 109/l (normal range: 4-11 x 109/l)
      Neutrophils: 15.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      Lymphocytes: 2.1 x 109/l (normal range: 1.3-3.5 x 109/l)
      Eosinophils: 0.21 x 109/l (normal range: 0.04-0.44 x 109/l)
      Sodium (Na): 134 mmol/l (normal range: 133-147 mmol/l)
      Potassium (K): 4.2 mmol/l (normal range: 3.5-5.0 mmol/l)
      Creatinine (Creat): 212 micromol/l (normal range: 60-120 micromol/l)
      Urea: 11.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      Positive AntiGBM antibodies
      Positive c-ANCA
      What is the MOST LIKELY diagnosis in this case?

      Your Answer:

      Correct Answer: Goodpasture’s syndrome

      Explanation:

      The most likely diagnosis in this case is Goodpasture’s syndrome, which is a rare autoimmune vasculitic disorder. It is characterized by a triad of symptoms including pulmonary hemorrhage, glomerulonephritis, and the presence of anti-glomerular basement membrane (Anti-GBM) antibodies. Goodpasture’s syndrome is more commonly seen in men, particularly in smokers. There is also an association with certain HLA types, specifically HLA-B7 and HLA-DRw2.

      The clinical features of Goodpasture’s syndrome include constitutional symptoms such as fever, fatigue, nausea, and weight loss. Patients may also experience haemoptysis or pulmonary hemorrhage, chest pain, breathlessness, and inspiratory crackles at the lung bases. Anemia due to intrapulmonary bleeding, arthralgia, rapidly progressive glomerulonephritis, haematuria, hypertension, and hepatosplenomegaly (rarely) may also be present.

      Blood tests will reveal an iron deficiency anemia, elevated white cell count, and renal impairment. Elisa for Anti-GBM antibodies is highly sensitive and specific, but it is not widely available. Approximately 30% of patients may also have circulating antineutrophilic cytoplasmic antibodies (ANCAs), although these are not specific for Goodpasture’s syndrome and can be found in other conditions such as Wegener’s granulomatosis.

      Diagnosis is typically confirmed through renal biopsy, which can detect the presence of anti-GBM antibodies. The management of Goodpasture’s syndrome involves a combination of plasmapheresis to remove circulating antibodies and the use of corticosteroids or cyclophosphamide.

      It is important to note that this patient’s history is inconsistent with a diagnosis of pulmonary embolism, as renal impairment, haematuria, and the presence of ANCAs and anti-GBM antibodies would not be expected. While pulmonary hemorrhage and renal impairment can occur in systemic lupus erythematosus, these are uncommon presentations, and the presence of ANCAs and anti-GBM antibodies would also be inconsistent with this diagnosis.

      Churg-Strauss syndrome can present with pulmonary hemorrhage, and c-ANCA may be present, but patients typically have a history of asthma, sinusitis, and eosinophilia. Wegener’s granulomatosis can present similarly to Goodpasture’s syndrome,

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  • Question 43 - You are caring for a hypoxic patient in the resuscitation bay. One of...

    Incorrect

    • You are caring for a hypoxic patient in the resuscitation bay. One of the potential diagnoses is methemoglobinemia. What test would you employ to confirm this diagnosis?

      Your Answer:

      Correct Answer: MetHb

      Explanation:

      COHb is a measure used to evaluate the presence of carbon monoxide poisoning in individuals who are in good health. hHb refers to deoxygenated haemoglobin.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

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  • Question 44 - A 32-year-old woman presents with a history of increased cough and wheeze over...

    Incorrect

    • A 32-year-old woman presents with a history of increased cough and wheeze over the past two days. She suffers from seasonal allergies in the spring months, which has been worse than usual over recent weeks. When auscultating her chest, you can hear scattered polyphonic wheezes. Her peak flow at presentation was 275 L/min, and her best ever peak flow is 500 L/min. After a single salbutamol nebuliser, her peak flow improves to 455 L/min, and she feels much better.
      What is the SINGLE most appropriate next step in her management?

      Your Answer:

      Correct Answer: Give oral prednisolone 40 mg

      Explanation:

      This man is experiencing an acute asthma episode. His initial peak flow is 55% of his best, indicating a moderate exacerbation. In such cases, it is recommended to administer steroids, specifically a dose of prednisolone 40-50 mg orally.

      Chest X-rays are not routinely performed to investigate acute asthma. However, they should be considered in certain situations, including suspected pneumomediastinum, consolidation, life-threatening asthma, inadequate response to treatment, and the need for ventilation.

      Nebulised ipratropium bromide is only added to treatment with nebulised salbutamol in patients with acute severe or life-threatening asthma, or those who do not respond well to salbutamol therapy. Therefore, it is not necessary in this particular case.

      While it may be reasonable to prescribe an antihistamine for a patient with a history of worsening hay fever, it should not be prioritized over treatment with steroids.

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  • Question 45 - A 40-year-old man presents very sick with an acute worsening of his asthma.
    Which...

    Incorrect

    • A 40-year-old man presents very sick with an acute worsening of his asthma.
      Which of the following is not advised in the management of acute asthma in adults?

      Your Answer:

      Correct Answer: Nebulised magnesium

      Explanation:

      Currently, there is no evidence to support the use of nebulised magnesium sulphate in the treatment of adults with asthma. For adults experiencing acute asthma, the recommended drug doses are as follows:

      – Salbutamol: 5 mg administered through an oxygen-driven nebuliser.
      – Ipratropium bromide: 500 mcg delivered via an oxygen-driven nebuliser.
      – Prednisolone: 40-50 mg taken orally.
      – Hydrocortisone: 100 mg administered intravenously.
      – Magnesium sulphate: 1.2-2 g given intravenously over a period of 20 minutes.

      Intravenous salbutamol may be considered (250 mcg administered slowly) only when inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation.

      According to the current ALS guidelines, IV aminophylline can be considered in cases of severe or life-threatening asthma, following senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

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  • Question 46 - A 45-year-old woman returns from a recent vacation on a cruise ship with...

    Incorrect

    • A 45-year-old woman returns from a recent vacation on a cruise ship with a persistent cough and a high temperature. Today she has also experienced frequent episodes of diarrhea and has developed sharp chest pain on both sides. She reports feeling short of breath, especially when she exerts herself. The cruise ship doctor had prescribed her amoxicillin a few days ago, but she has not seen any improvement.
      Her blood test results today are as follows:
      Hemoglobin (Hb): 14.4 g/dl (normal range: 13-17 g/dl)
      White blood cell count (WCC): 13.5 x 109/l (normal range: 4-11 x 109/l)
      Neutrophils: 10.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      Lymphocytes: 0.6 x 109/l (normal range: 1.3-3.5 x 109/l)
      Eosinophils: 0.35 x 109/l (normal range: 0.04-0.44 x 109/l)
      C-reactive protein (CRP): 87 mg/l (normal range: <5 mg/l)
      Sodium (Na): 122 mmol/l (normal range: 133-147 mmol/l)
      Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      Creatinine (Creat): 112 micromol/l (normal range: 60-120 micromol/l)
      Urea: 6.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      What is the SINGLE most likely causative organism?

      Your Answer:

      Correct Answer: Legionella pneumophila

      Explanation:

      Legionella pneumophila is a type of Gram-negative bacterium that can be found in natural water supplies and soil. It is responsible for causing Legionnaires’ disease, a serious illness. Outbreaks of this disease have been associated with poorly maintained air conditioning systems, whirlpool spas, and hot tubs. In the past, there have been instances of Legionnaires’ disease outbreaks on cruise ships due to inadequate maintenance of air conditioning and shower units.

      The pneumonic form of Legionnaires’ disease presents with certain clinical features. Initially, there may be a mild flu-like prodrome lasting for 1-3 days. A persistent cough, which is usually non-productive and occurs in approximately 90% of cases, is also common. Other symptoms include pleuritic chest pain, haemoptysis, headache, nausea, vomiting, diarrhoea, and anorexia. Additionally, some individuals may experience a condition called syndrome of inappropriate antidiuretic hormone secretion (SIADH), which can lead to hyponatraemia.

      It is important to note that infections caused by Legionella pneumophila are resistant to amoxicillin. However, they can be effectively treated with macrolide antibiotics like erythromycin or quinolones such as ciprofloxacin. Tetracyclines, including doxycycline, can also be used for treatment.

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  • Question 47 - A 3-year-old boy is brought in by his parents with a history of...

    Incorrect

    • A 3-year-old boy is brought in by his parents with a history of breathing difficulties, fever, and a cough. He is irritable and having difficulty eating. On examination, his temperature is 38.6°C, and you hear fine inspiratory crackles throughout his chest.

      What is the SINGLE most appropriate investigation?

      Your Answer:

      Correct Answer: Nasopharyngeal aspirate

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.

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  • Question 48 - A 30 year old patient is brought to the emergency department by bystanders...

    Incorrect

    • A 30 year old patient is brought to the emergency department by bystanders after a hit and run incident. Upon examination, you observe that the patient is experiencing difficulty breathing and has tracheal deviation towards the left side. Based on these findings, you suspect the presence of a tension pneumothorax. What signs would you anticipate observing in this patient?

      Your Answer:

      Correct Answer: Elevated jugular venous pressure

      Explanation:

      Tension pneumothorax is a condition characterized by certain clinical signs. These signs include pulsus paradoxus, which is an abnormal decrease in blood pressure during inspiration; elevated JVP or distended neck veins; diaphoresis or excessive sweating; and cyanosis, which is a bluish discoloration of the skin. Tracheal deviation to the left is often observed in patients with a right-sided pneumothorax. On the affected side, hyper-resonance and absent breath sounds can be expected. Patients with tension pneumothorax typically appear agitated and distressed, and they experience noticeable difficulty in breathing. Hypotension, a pulse rate exceeding 135 bpm, pulsus paradoxus, and elevated JVP are additional signs associated with tension pneumothorax. These signs occur because the expanding pneumothorax compresses the mediastinum, leading to impaired venous return and cardiac output.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

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  • Question 49 - A 40 year old is brought to the emergency department by his hiking...

    Incorrect

    • A 40 year old is brought to the emergency department by his hiking guide after complaining of right sided chest pain and difficulty breathing whilst on the hike back to the trailhead following a strenuous climb. On examination you note reduced breath sounds and hyper-resonant percussion to the right base and right apex. Observations are shown below:

      Pulse 98 bpm
      Blood pressure 130/82 mmHg
      Respiratory rate 22 bpm
      Oxygen saturations 96% on air
      Temperature 37.2°C

      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Pneumothorax

      Explanation:

      SCUBA divers face the potential danger of developing pulmonary barotrauma, which can lead to conditions like arterial gas embolism (AGE) or pneumothorax. Based on the patient’s diving history and clinical symptoms, it is highly likely that they are experiencing a left-sided pneumothorax caused by barotrauma. To confirm the presence of pneumothorax, a chest X-ray is usually performed, unless the patient shows signs of tension pneumothorax. In such cases, immediate decompression is necessary, which can be achieved by inserting a chest tube.

      Further Reading:

      Decompression illness (DCI) is a term that encompasses both decompression sickness (DCS) and arterial gas embolism (AGE). When diving underwater, the increasing pressure causes gases to become more soluble and reduces the size of gas bubbles. As a diver ascends, nitrogen can come out of solution and form gas bubbles, leading to decompression sickness or the bends. Boyle’s and Henry’s gas laws help explain the changes in gases during changing pressure.

      Henry’s law states that the amount of gas that dissolves in a liquid is proportional to the partial pressure of the gas. Divers often use atmospheres (ATM) as a measure of pressure, with 1 ATM being the pressure at sea level. Boyle’s law states that the volume of gas is inversely proportional to the pressure. As pressure increases, volume decreases.

      Decompression sickness occurs when nitrogen comes out of solution as a diver ascends. The evolved gas can physically damage tissue by stretching or tearing it as bubbles expand, or by provoking an inflammatory response. Joints and spinal nervous tissue are commonly affected. Symptoms of primary damage usually appear immediately or soon after a dive, while secondary damage may present hours or days later.

      Arterial gas embolism occurs when nitrogen bubbles escape into the arterial circulation and cause distal ischemia. The consequences depend on where the embolism lodges, ranging from tissue ischemia to stroke if it lodges in the cerebral arterial circulation. Mechanisms for distal embolism include pulmonary barotrauma, right to left shunt, and pulmonary filter overload.

      Clinical features of decompression illness vary, but symptoms often appear within six hours of a dive. These can include joint pain, neurological symptoms, chest pain or breathing difficulties, rash, vestibular problems, and constitutional symptoms. Factors that increase the risk of DCI include diving at greater depth, longer duration, multiple dives close together, problems with ascent, closed rebreather circuits, flying shortly after diving, exercise shortly after diving, dehydration, and alcohol use.

      Diagnosis of DCI is clinical, and investigations depend on the presentation. All patients should receive high flow oxygen, and a low threshold for ordering a chest X-ray should be maintained. Hydration is important, and IV fluids may be necessary. Definitive treatment is recompression therapy in a hyperbaric oxygen chamber, which should be arranged as soon as possible. Entonox should not be given, as it will increase the pressure effect in air spaces.

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  • Question 50 - A 6-month-old infant is brought to the Emergency Department with a high fever...

    Incorrect

    • A 6-month-old infant is brought to the Emergency Department with a high fever and difficulty breathing. You assess the infant's respiratory rate and observe that it is increased.
      As per the NICE guidelines, what is considered the cutoff for tachypnea in an infant of this age?

      Your Answer:

      Correct Answer: RR >60 breaths/minute

      Explanation:

      According to the current NICE guidelines on febrile illness in children under the age of 5, there are certain symptoms and signs that may indicate the presence of pneumonia. These include tachypnoea, which is a rapid breathing rate. For infants aged 0-5 months, a respiratory rate (RR) of over 60 breaths per minute is considered suggestive of pneumonia. For infants aged 6-12 months, an RR of over 50 breaths per minute is indicative, and for children older than 12 months, an RR of over 40 breaths per minute may suggest pneumonia.

      Other signs that may point towards pneumonia include crackles in the chest, nasal flaring, chest indrawing, and cyanosis. Crackles are abnormal sounds heard during breathing, while nasal flaring refers to the widening of the nostrils during breathing. Chest indrawing is the inward movement of the chest wall during inhalation, and cyanosis is the bluish discoloration of the skin or mucous membranes due to inadequate oxygen supply.

      Additionally, a low oxygen saturation level of less than 95% while breathing air is also considered suggestive of pneumonia. These guidelines can be found in more detail in the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

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  • Question 51 - A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Incorrect

    • A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Australia. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
      What is the PRIMARY diagnosis in this case?

      Your Answer:

      Correct Answer: Pulmonary embolism

      Explanation:

      Based on the clinical history and examination, it strongly indicates that the patient has developed a pulmonary embolism due to a deep vein thrombosis in his right leg.

      The symptoms commonly associated with a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. These symptoms may also suggest the presence of a deep vein thrombosis. Other clinical features that may be observed are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.

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  • Question 52 - A 3-year-old girl presents with stridor and a barking cough. Her mother reports...

    Incorrect

    • A 3-year-old girl presents with stridor and a barking cough. Her mother reports that she has had a slight cold for a few days and her voice had been hoarse. Her vital signs are as follows: temperature 38.1°C, heart rate 135, respiratory rate 30, oxygen saturation 97% on room air. Her chest examination is unremarkable, but you observe the presence of stridor at rest.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Croup

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

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  • Question 53 - A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing,...

    Incorrect

    • A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing, and wheezing. Blood tests reveal an elevated packed cell volume (PCV). A chest X-ray shows more than 6 ribs visible above the diaphragm in the midclavicular line. An arterial blood gas indicates slightly low pO2 levels.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: COPD

      Explanation:

      Based on the provided information, it is highly probable that this patient is suffering from chronic obstructive pulmonary disease (COPD). This conclusion is supported by several factors. Firstly, the patient has a history of chronic productive cough and wheezing, which are common symptoms of COPD. Additionally, the patient has a long-term smoking history, which is a major risk factor for developing this condition.

      Furthermore, the patient’s raised packed cell volume (PCV) is likely a result of chronic hypoxemia, a common complication of COPD. This indicates that the patient’s body is trying to compensate for the low oxygen levels in their blood.

      Moreover, the chest X-ray reveals evidence of hyperinflation, which is a characteristic finding in patients with COPD. This suggests that the patient’s lungs are overinflated and not functioning optimally.

      Lastly, the arterial blood gas analysis shows hypoxemia, indicating that the patient has low levels of oxygen in their blood. This is another significant finding that aligns with a diagnosis of COPD.

      In summary, based on the patient’s history, smoking habits, raised PCV, chest X-ray findings, and arterial blood gas results, it is highly likely that they have COPD.

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  • Question 54 - A toddler is brought to the hospital with bronchiolitis because of low oxygen...

    Incorrect

    • A toddler is brought to the hospital with bronchiolitis because of low oxygen levels and difficulty with eating.
      What is the MOST suitable treatment option?

      Your Answer:

      Correct Answer: Nasogastric feeding

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.

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  • Question 55 - You are treating a 45-year-old patient with known COPD who has been brought...

    Incorrect

    • You are treating a 45-year-old patient with known COPD who has been brought to the ED due to worsening shortness of breath and suspected sepsis. You plan to obtain an arterial blood gas from the radial artery to assess for acidosis and evaluate lactate and base excess levels. What is the typical range for lactate?

      Your Answer:

      Correct Answer: 0.5-2.2 mmol/L

      Explanation:

      The typical range for lactate levels in the body is 0.5-2.2 mmol/L, according to most UK trusts. However, it is important to mention that the RCEM sepsis guides consider a lactate level above 2 mmol/L to be abnormal.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 56 - You evaluate a 32-year-old woman who has been diagnosed with Mycoplasma pneumoniae pneumonia.
    Which...

    Incorrect

    • You evaluate a 32-year-old woman who has been diagnosed with Mycoplasma pneumoniae pneumonia.
      Which of the following is NOT a recognized complication of Mycoplasma pneumoniae infection?

      Your Answer:

      Correct Answer: Infective endocarditis

      Explanation:

      Mycoplasma pneumoniae infection does not have a connection with infective endocarditis. However, it is associated with various extra-pulmonary complications. These include skin conditions such as erythema multiforme and Stevens-Johnson syndrome. In the central nervous system, it can lead to Guillain-Barre syndrome, meningitis, encephalitis, optic neuritis, cerebellar ataxia, and cranial nerve palsies. Gastrointestinal symptoms may include anorexia, nausea, diarrhea, hepatitis, and pancreatitis. Hematological complications can manifest as cold agglutinins, hemolytic anemia, thrombocytopenia, and disseminated intravascular coagulation. Mycoplasma pneumoniae infection can also cause pericarditis and myocarditis. Rheumatic symptoms such as arthralgia and arthritides may occur, and acute glomerulonephritis can affect the kidneys.

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  • Question 57 - A 62-year-old woman presents with a persistent cough that has been ongoing for...

    Incorrect

    • A 62-year-old woman presents with a persistent cough that has been ongoing for several months. She reports that the cough occasionally produces a small amount of phlegm, especially in the morning. She has experienced a significant weight loss of 28 pounds over the past six months and constantly feels fatigued. Even with minimal physical activity, she becomes short of breath. She has no significant medical history and is a non-smoker. She enjoys keeping and racing pigeons as a hobby. Upon examination, bilateral fine end-inspiratory crackles are heard.

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

      This patient is likely to have pigeon fancier’s lung, which is a type of extrinsic allergic alveolitis (EAA) caused by chronic exposure to avian antigens found in bird droppings. This condition leads to hypersensitivity pneumonitis and the formation of granulomas in the lungs.

      While his presentation could also be consistent with idiopathic pulmonary fibrosis, the fact that he keeps and races pigeons makes EAA more likely in this case.

      EAA can manifest as either an acute or chronic condition. The acute form typically presents with flu-like symptoms such as fever, cough, chest tightness, and breathlessness occurring 4 to 6 hours after exposure.

      The clinical features of chronic pigeon fancier’s lung include a productive cough, progressive breathlessness, weight loss, anorexia, fatigue, and malaise.

      Other forms of EAA include farmer’s lung (caused by exposure to Saccharopolyspora rectivirgula from wet hay), malt-worker’s lung (caused by exposure to Aspergillus clavatus from moldy malt), cheese-worker’s lung (caused by exposure to Penicillium casei from moldy cheese), chemical worker’s lung (caused by exposure to trimetallic anhydride, diisocyanate, and methylene diisocyanate), mushroom worker’s lung (caused by exposure to thermophilic actinomycetes in mushroom compost), and hot tub lung (caused by exposure to Mycobacterium avium from poorly maintained hot tubs).

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  • Question 58 - A 6 month old girl is brought into the emergency department with a...

    Incorrect

    • A 6 month old girl is brought into the emergency department with a history of being submerged in the pool while swimming with her parents. One of the parents explains that the child was floating on a pool noodle when a wave hit, causing the child to fall off the noodle. The child was not wearing any flotation devices and it took approximately 1 minute to find and rescue her from the water. Your consultant mentions that the child's diving reflex would have been activated. Which of the following statements accurately describes the diving reflex?

      Your Answer:

      Correct Answer: Results in peripheral vasoconstriction

      Explanation:

      The diving reflex occurs when the face comes into contact with cold water, leading to apnoea, bradycardia, and peripheral vasoconstriction. This response helps decrease the workload on the heart, lower oxygen demand in the heart muscle, and ensure adequate blood flow to the brain and vital organs. The trigeminal nerve (CN V) is responsible for transmitting sensory information, while the vagus nerve (CN X) primarily controls the motor response. This reflex is more prominent in young children and is believed to contribute to their improved survival rates in prolonged submersion in cold water.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

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  • Question 59 - A 14 year old patient is brought into the emergency department struggling to...

    Incorrect

    • A 14 year old patient is brought into the emergency department struggling to breathe. Upon initial assessment, you observe tracheal deviation to the right, absence of breath sounds in the left hemithorax, and hyper-resonant percussion in the left hemithorax.

      What is the most crucial immediate intervention for this patient?

      Your Answer:

      Correct Answer: Needle thoracocentesis

      Explanation:

      The key initial management for tension pneumothorax is needle thoracocentesis. This procedure is crucial as it rapidly decompresses the tension and allows for more definitive management to be implemented. It is important to note that according to ATLS guidelines, needle thoracocentesis should no longer be performed at the second intercostal space midclavicular line. Studies have shown that the fourth or fifth intercostal space midaxillary line is more successful in reaching the thoracic cavity in adult patients. Therefore, ATLS now recommends this location for needle decompression in adult patients.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

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  • Question 60 - You are managing a 72-year-old patient with type 2 respiratory failure. It has...

    Incorrect

    • You are managing a 72-year-old patient with type 2 respiratory failure. It has been decided to initiate BiPAP therapy. What initial EPAP and IPAP pressure settings would you recommend?

      Your Answer:

      Correct Answer:

      Explanation:

      When determining the initial EPAP and IPAP pressure settings for this patient, it is important to consider their specific needs and condition. In general, the EPAP pressure should be set between 3-5 cmH2O, which helps to maintain positive pressure in the airways during exhalation, preventing them from collapsing. This can improve oxygenation and reduce the work of breathing.

      The IPAP pressure, on the other hand, should be set between 10-15 cmH2O. This higher pressure during inhalation helps to overcome any resistance in the airways and ensures adequate ventilation. It also assists in improving the patient’s tidal volume and reducing carbon dioxide levels.

      Therefore, the recommended initial EPAP and IPAP pressure settings for this patient would be EPAP 3-5 cmH2O / IPAP 10-15 cmH2O. These settings provide a balance between maintaining airway patency during exhalation and ensuring sufficient ventilation during inhalation. However, it is important to regularly assess the patient’s response to therapy and adjust the settings as needed to optimize their respiratory function.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

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  • Question 61 - A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting,...

    Incorrect

    • A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting, fatigue, and fainting. He has recently returned from a wellness retreat in France. The patient is referred to the medical team on duty and admitted to the hospital. They suspect a potential diagnosis of Legionnaires' disease.
      What is the definitive test used to confirm a case of Legionnaires' disease?

      Your Answer:

      Correct Answer: Isolation and culture from a sputum sample

      Explanation:

      The guidelines from the British Thoracic Society (BTS) recommend conducting investigations for Legionella infection in the following cases: severe community-acquired pneumonia, patients with specific risk factors, and during outbreaks of community-acquired pneumonia. To confirm a case, the Public Health England (PHE) requires one of the following: isolation and culture of Legionella species from clinical specimens (typically sputum), seroconversion with a four-fold increase in titre of indirect immunofluorescent antibody test (IFAT) using a validated technique, or confirmation of Legionella pneumophila urinary antigen using validated reagents or kits. The gold standard for confirmation is the isolation and culture of Legionella species, while cases of Pontiac fever are usually culture-negative. The HPA considers a case presumptive if there is a clinical diagnosis of pneumonia with a single high titre of 128 using IFAT, or a single titre of 64 in an outbreak. A positive result by direct immunofluorescence on a clinical specimen using validated monoclonal antibodies is also considered a presumptive case.

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      • Respiratory
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  • Question 62 - A 35 year old female is brought into the emergency department (ED) due...

    Incorrect

    • A 35 year old female is brought into the emergency department (ED) due to an altered level of consciousness. An arterial blood gas sample is collected. The results are as follows:

      pH: 7.25
      pO2: 12.8 kPa
      pCO2: 5.9 kPa
      Bicarbonate: 14 mmol/L
      Chloride: 98 mmol/L
      Potassium: 6.0 mmol/L
      Sodium: 137 mmol/L

      Which of the following options best describes the anion gap?

      Your Answer:

      Correct Answer: High anion gap acidosis

      Explanation:

      An anion gap greater than 11 is considered high when using modern ion-selective electrode analyzers. This indicates a condition known as high anion gap acidosis. The anion gap can be calculated using the equation: ([Na+] + [K+]) – ([Cl-] + [HCO3-]). In this particular case, the calculation results in a value of 30.4 mmol/l. Anion gaps greater than 11 are considered high.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 63 - A 35-year-old dairy farmer presents with a flu-like illness that has been worsening...

    Incorrect

    • A 35-year-old dairy farmer presents with a flu-like illness that has been worsening for the past two weeks. He has high fevers, a pounding headache, and muscle aches. He has now also developed a dry cough, stomach pain, and diarrhea. During the examination, there are no notable chest signs, but a liver edge can be felt 4 cm below the costal margin.

      Today, his blood tests show the following results:
      - Hemoglobin (Hb): 13.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 21.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 17.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Platelets: 567 x 109/l (normal range: 150-400 x 109/l)
      - C-reactive protein (CRP): 187 mg/l (normal range: < 5 mg/l)
      - Sodium (Na): 127 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 122 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 7.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      - Aspartate aminotransferase (AST): 121 IU/l (normal range: 8-40 IU/l)
      - Alkaline phosphatase (ALP): 296 IU/l (normal range: 30-200 IU/l)
      - Bilirubin: 14 micromol/l (normal range: 3-17 micromol/l)

      What is the SINGLE most appropriate antibiotic choice for this patient?

      Your Answer:

      Correct Answer: Doxycycline

      Explanation:

      Q fever is a highly contagious infection caused by Coxiella burnetii, which can be transmitted from animals to humans. It is commonly observed as an occupational disease among individuals working in farming, slaughterhouses, and animal research. Approximately 50% of cases do not show any symptoms, while those who are affected often experience flu-like symptoms such as headache, fever, muscle pain, diarrhea, nausea, and vomiting.

      In some cases, patients may develop an atypical pneumonia characterized by a dry cough and minimal chest signs. Q fever can also lead to hepatitis and enlargement of the liver (hepatomegaly), although jaundice is not commonly observed. Typical blood test results for Q fever include an elevated white cell count (30-40%), ALT/AST levels that are usually 2-3 times higher than normal, increased ALP levels (70%), reduced sodium levels (30%), and reactive thrombocytosis.

      It is important to check patients for heart murmurs and signs of valve disease, as these conditions increase the risk of developing infective endocarditis. Treatment for Q fever typically involves a two-week course of doxycycline.

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      • Respiratory
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  • Question 64 - A 45-year-old man comes in with a dry cough that has been going...

    Incorrect

    • A 45-year-old man comes in with a dry cough that has been going on for a week. He also complains of muscle aches, fatigue, and a sore throat. In the past day, he has developed diarrhea and a mild throbbing headache. During the examination, his temperature is measured at 37.8°C, and faint crackles are heard at the base of his lungs.

      What is the SINGLE most probable organism responsible for these symptoms?

      Your Answer:

      Correct Answer: Mycoplasma pneumoniae

      Explanation:

      This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features commonly associated with Mycoplasma pneumoniae infection include a flu-like illness that occurs before respiratory symptoms, fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness. It is worth noting that Mycoplasma pneumoniae is frequently linked to the development of erythema multiforme and can also be a cause of Steven-Johnson syndrome. The rash associated with erythema multiforme is characterized by multiple red lesions on the limbs that develop into target lesions a few days after the rash first appears.

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      • Respiratory
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  • Question 65 - A 10-year-old girl presents with a history of a persistent cough that has...

    Incorrect

    • A 10-year-old girl presents with a history of a persistent cough that has been present for the past three weeks. The cough occurs in short bursts with an inspiration followed by a series of hacking coughs. She occasionally vomits after coughing. She mentions that the cough is worse at night and that she has fainted once during a coughing fit. She is otherwise healthy, and her vaccinations are up-to-date.

      Upon examination, her chest is clear, but there are three small subconjunctival hemorrhages and some petechiae on her face. A complete blood count reveals a lymphocyte count of 22 x 109/l (1.3-3.5 x 109/l).

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Pertussis

      Explanation:

      This presentation strongly indicates a diagnosis of whooping cough, also known as pertussis. Whooping cough is a respiratory infection caused by the bacteria Bordetella pertussis. It is transmitted through respiratory droplets and has an incubation period of about 7-21 days. The disease is highly contagious and can be transmitted to around 90% of close household contacts.

      The clinical course of whooping cough can be divided into two stages. The first stage is called the catarrhal stage, which resembles a mild respiratory infection with low-grade fever and symptoms similar to a cold. A cough may be present, but it is usually mild and not as severe as in the second stage. The catarrhal stage typically lasts for about a week.

      The second stage is known as the paroxysmal stage. During this stage, the characteristic paroxysmal cough develops as the symptoms from the catarrhal stage start to improve. The coughing occurs in spasms, often preceded by an inspiratory whoop sound, followed by a series of rapid coughs. Vomiting may occur, and patients may develop subconjunctival hemorrhages and petechiae. Patients generally feel well between coughing spasms, and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this stage are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures. It is important to note that a history of vaccination does not guarantee immunity, as it only provides about 95% protection.

      The presence of marked lymphocytosis in this case also supports a diagnosis of pertussis, as it is a common finding. A lymphocyte count greater than 20 x 109/l is highly suggestive of the disease.

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  • Question 66 - A 45-year-old man comes in with a high temperature, shivering, aching head, cough,...

    Incorrect

    • A 45-year-old man comes in with a high temperature, shivering, aching head, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the birdhouse. During the examination, a red rash is noticed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.
      What is the BEST antibiotic to prescribe for this patient?

      Your Answer:

      Correct Answer: Doxycycline

      Explanation:

      Psittacosis is a type of infection that can be transmitted from animals to humans, known as a zoonotic infection. It is caused by a bacterium called Chlamydia psittaci. This infection is most commonly seen in people who own domestic birds, but it can also affect those who work in pet shops or zoos.

      The typical presentation of psittacosis includes symptoms similar to those of pneumonia that is acquired within the community. People may experience flu-like symptoms along with severe headaches and sensitivity to light. In about two-thirds of patients, an enlargement of the spleen, known as splenomegaly, can be observed.

      Infected individuals often develop a reddish rash with flat spots on their face, known as Horder’s spots. Additionally, they may experience skin conditions such as erythema nodosum or erythema multiforme.

      The recommended treatment for psittacosis is a course of tetracycline or doxycycline, which should be taken for a period of 2-3 weeks.

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  • Question 67 - A 45-year-old man presents with a severe exacerbation of his asthma. You have...

    Incorrect

    • A 45-year-old man presents with a severe exacerbation of his asthma. You have been asked to administer a loading dose of albuterol. He weighs 70 kg.
      What is the appropriate loading dose for him?

      Your Answer:

      Correct Answer: 250 mg over 15 minutes

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a patient weighing 50 kg, the appropriate loading dose would be 250 mg. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

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  • Question 68 - A 6-year-old girl presents very sick with severe acute asthma. She has received...

    Incorrect

    • A 6-year-old girl presents very sick with severe acute asthma. She has received one dose of salbutamol through a spacer device, 20 mg of oral prednisolone, and a single dose of nebulized salbutamol and ipratropium bromide combined. She remains sick and has oxygen saturations on air of 90%. Her heart rate is 142 bpm, and her respiratory rate is 40/minute. Examination of her chest reveals widespread wheezing but good air entry.

      What is the most appropriate next step in her management?

      Your Answer:

      Correct Answer: Further salbutamol nebuliser with 150 mg magnesium sulphate added

      Explanation:

      The BTS guidelines for managing acute asthma in children over the age of 2 recommend the following approaches:

      Bronchodilator therapy is the first-line treatment for acute asthma. Inhaled β agonists are preferred, and a pmDI + spacer is the recommended option for children with mild to moderate asthma. It is important to individualize drug dosing based on the severity of the condition and adjust it according to the patient’s response. If initial β agonist treatment does not alleviate symptoms, ipratropium bromide can be added to the nebulized β2 agonist solution. In cases where children with a short duration of acute severe asthma symptoms have an oxygen saturation level below 92%, it is advisable to consider adding 150 mg of magnesium sulfate to each nebulized salbutamol and ipratropium within the first hour.

      Long-acting β2 agonists should be discontinued if short-acting β2 agonists are required more frequently than every four hours.

      Steroid therapy should be initiated early in the treatment of acute asthma attacks. For children aged 2-5 years, a dose of 20 mg prednisolone is recommended, while children over the age of 5 should receive a dose of 30-40 mg. Children already on maintenance steroid tablets should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the initial dose of prednisolone, the dose should be repeated. In cases where a child is unable to retain orally ingested medication, intravenous steroids should be considered. Typically, treatment with oral steroids for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering is not necessary unless the course of steroids exceeds 14 days.

      In cases where initial inhaled therapy does not yield a response in severe asthma attacks, the early addition of a single bolus dose of intravenous salbutamol (15 micrograms/kg over 10 minutes) should be considered. Aminophylline is not recommended for children with mild to moderate acute asthma, but it may be considered for those with severe or life-threatening asthma that is unresponsive to maximum doses of bronchodilators and steroids. The use of IV magnesium sulfate as a treatment for acute asthma in children is considered safe, although its role in management is not yet fully established.

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  • Question 69 - A 35-year-old woman presents with a two-week history of a persistent cough that...

    Incorrect

    • A 35-year-old woman presents with a two-week history of a persistent cough that has now started to produce a small amount of sputum. She is also experiencing muscle aches, fatigue, headaches, and has had diarrhea for the past three days. Her vital signs are as follows: temperature 37.8°C, heart rate 88, blood pressure 120/80, respiratory rate 20, oxygen saturation 99% on room air. Upon examination, she has crackling sounds heard on the left side of her chest. A chest X-ray reveals consolidation in the left lower lobe.

      What is the MOST appropriate course of action for management?

      Your Answer:

      Correct Answer: Clarithromycin 500 mg PO BD for 14 days

      Explanation:

      This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features of Mycoplasma pneumoniae infection typically include a flu-like illness that precedes respiratory symptoms, along with fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs may develop later in the illness. Interestingly, the X-ray features of the pneumonia are often more noticeable than the severity of the chest symptoms.

      Treatment for Mycoplasma pneumoniae infection can involve the use of macrolides, such as clarithromycin, or tetracyclines, such as doxycycline. The recommended minimum treatment period is 10-14 days, making clarithromycin a preferable option over doxycycline in this particular case.

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      • Respiratory
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  • Question 70 - A 72 year old male with a history of COPD is brought into...

    Incorrect

    • A 72 year old male with a history of COPD is brought into the emergency department due to worsening shortness of breath. You observe that the patient has been utilizing home oxygen, home salbutamol and ipratropium nebulizers, and began taking a rescue pack of antibiotics and steroids yesterday.

      Which of the following factors would indicate the initiation of BiPAP ventilation?

      Your Answer:

      Correct Answer: pH less than 7.35 on arterial blood gas

      Explanation:

      Non-invasive ventilation is recommended for patients with hypercapnia and acidosis. Respiratory acidosis, indicated by a pH level below 7.35, is a strong indication for the use of BiPAP. However, patients with a pH level of 7.25 or lower may not respond well to non-invasive ventilation and should be considered for intensive care unit (ITU) treatment. Another criterion for the use of BiPAP is hypercapnia, which is characterized by an arterial pCO2 level greater than 6.0 KPa.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

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  • Question 71 - A 45-year-old woman presents with increasing shortness of breath at rest and severe...

    Incorrect

    • A 45-year-old woman presents with increasing shortness of breath at rest and severe left shoulder pain. The pain travels down the inner side of her left arm and into her ring and little finger. She has a long history of smoking, having smoked 30 packs of cigarettes per year. During the examination, her voice sounds hoarse and there is muscle wasting in her left hand and forearm. Additionally, she has a left-sided ptosis and miosis.

      What is the MOST suitable initial test to perform?

      Your Answer:

      Correct Answer: Chest X-ray

      Explanation:

      This individual, who has been smoking for a long time, is likely to have squamous cell carcinoma of the lung located at the right apex. This particular type of cancer is causing Pancoast’s syndrome. Pancoast’s syndrome typically presents with rib erosion, leading to severe shoulder pain, as well as Horner’s syndrome due to the infiltration of the lower part of the brachial plexus. Additionally, there may be hoarseness of the voice and a ‘bovine cough’ due to a concurrent recurrent laryngeal nerve palsy.

      The classic description of Horner’s syndrome includes the following clinical features on the same side as the tumor: miosis (constricted pupil), ptosis (drooping eyelid), anhidrosis (lack of sweating), and enophthalmos (sunken appearance of the eye). A chest X-ray would be able to detect the presence of the apical tumor and confirm the diagnosis.

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  • Question 72 - A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18...

    Incorrect

    • A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18 kg.
      As per the BTS guidelines, what dosage of prednisolone should be prescribed for him?

      Your Answer:

      Correct Answer: 30 mg

      Explanation:

      The BTS guidelines for acute asthma in children recommend administering oral steroids early in the treatment of asthma attacks. It is advised to give a dose of 20 mg prednisolone for children aged 2–5 years and a dose of 30–40 mg for children over 5 years old. If a child is already taking maintenance steroid tablets, they should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the medication, the dose of prednisolone should be repeated. In cases where a child is unable to keep down orally ingested medication, intravenous steroids should be considered. Typically, treatment for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering off the medication is not necessary unless the steroid course exceeds 14 days. For more information, refer to the BTS/SIGN Guideline on the Management of Asthma.

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  • Question 73 - A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct...

    Incorrect

    • A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct an arterial blood gas test and find that their PaCO2 level is 4.8 kPa.
      How would you categorize this asthma exacerbation?

      Your Answer:

      Correct Answer: Life-threatening asthma

      Explanation:

      The BTS guidelines categorize acute asthma into four classifications: moderate, acute severe, life-threatening, and near-fatal.

      Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the best or predicted value. There are no signs of acute severe asthma present in this classification.

      Acute severe asthma is identified by any one of the following criteria: a PEFR between 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, or the inability to complete sentences in one breath.

      Life-threatening asthma is determined by any one of the following indicators: a PEFR below 33% of the best or predicted value, a blood oxygen saturation level (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kilopascals (kPa), a normal partial pressure of carbon dioxide (PaCO2) between 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension.

      Near-fatal asthma is characterized by elevated PaCO2 levels and/or the need for mechanical ventilation with increased inflation pressures.

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  • Question 74 - A 30-year-old man comes in with a cough and wheezing.
    What ONE clinical...

    Incorrect

    • A 30-year-old man comes in with a cough and wheezing.
      What ONE clinical feature would indicate a potential diagnosis of severe asthma?

      Your Answer:

      Correct Answer: Normal PaCO2

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

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  • Question 75 - A 4-year-old girl is diagnosed with whooping cough. There are two individuals in...

    Incorrect

    • A 4-year-old girl is diagnosed with whooping cough. There are two individuals in the household who are considered to be in a 'priority group' for post-exposure chemoprophylaxis.
      What is the BEST antibiotic to prescribe for this purpose?

      Your Answer:

      Correct Answer: Erythromycin

      Explanation:

      Whooping cough is a respiratory infection caused by the bacteria Bordetella pertussis. It is highly contagious and can be transmitted to about 90% of close household contacts. The Health Protection Agency has identified two priority groups for public health action in managing whooping cough contacts.

      Group 1 consists of individuals who are at a higher risk of severe or complicated infection. This includes infants under one year old who have received less than three doses of the pertussis vaccine.

      Group 2 consists of individuals who are at a higher risk of transmitting the infection to those in Group 1. This includes pregnant women who are at or beyond 32 weeks of gestation, healthcare workers who work with infants and pregnant women, individuals who work with infants too young to be vaccinated (under 4 months old), and individuals who share a household with infants too young to be vaccinated.

      According to current guidance, antibiotic prophylaxis with a macrolide antibiotic, like erythromycin, should only be offered to close contacts if two criteria are met. First, the index case (the person with whooping cough) must have developed symptoms within the past 21 days. Second, there must be a close contact in one of the two priority groups.

      If both criteria are met, all contacts, regardless of their vaccination status and age, should be offered chemoprophylaxis. In this case, the mother is in Group 2, so the current recommendation is that all household contacts, including the mother, father, and brother, should receive chemoprophylaxis.

      Additionally, immunization or a booster dose should be considered for those who have been offered chemoprophylaxis, depending on their current vaccination status.

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  • Question 76 - A 40-year-old man presents with a sudden worsening of his asthma symptoms. His...

    Incorrect

    • A 40-year-old man presents with a sudden worsening of his asthma symptoms. His heart rate is 110 bpm, respiratory rate 30/min, and his oxygen levels are 88% on room air. He is feeling fatigued and his breathing is labored, with no audible sounds in his chest. He has already received consecutive salbutamol nebulizers, a single ipratropium bromide nebulizer, and 40 mg of prednisolone orally. The ICU outreach team has been notified and will arrive soon.
      Which of the following medications would be most appropriate to administer while waiting for the ICU outreach team to arrive?

      Your Answer:

      Correct Answer: IV aminophylline

      Explanation:

      This patient exhibits signs of potentially life-threatening asthma. In adults, acute severe asthma is characterized by a peak expiratory flow (PEF) of 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, and an inability to complete sentences in one breath. On the other hand, life-threatening asthma is indicated by a PEF below 33% of the best or predicted value, a blood oxygen saturation (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kPA, a normal partial pressure of carbon dioxide (PaCO2) within the range of 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, and hypotension.

      To address acute asthma in adults, the recommended drug doses include administering 5 mg of salbutamol through an oxygen-driven nebulizer, delivering 500 mcg of ipratropium bromide via an oxygen-driven nebulizer, providing 40-50 mg of prednisolone orally, administering 100 mg of hydrocortisone intravenously, and infusing 1.2-2 g of magnesium sulfate intravenously over a period of 20 minutes.

      According to the current Advanced Life Support (ALS) guidelines, it is advisable to seek senior advice before considering the use of intravenous aminophylline in cases of severe or life-threatening asthma. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by a continuous infusion of 500-700 mcg/kg/hour. To prevent toxicity, it is important to maintain serum theophylline levels below 20 mcg/ml.

      In situations where inhaled therapy is not feasible, intravenous salbutamol can be considered, with a slow administration of 250 mcg. However, it should only be used when a patient is receiving bag-mask ventilation.

      It is worth noting that there is currently no evidence supporting the use of leukotriene receptor antagonists, such as montelukast, or Heliox in the management of acute severe or life-threatening asthma.

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  • Question 77 - A 45-year-old man presents with a sudden onset of severe asthma symptoms. You...

    Incorrect

    • A 45-year-old man presents with a sudden onset of severe asthma symptoms. You begin treatment for the patient, following the most recent BTS guidelines.

      According to the BTS guidelines, what is the appropriate course of action for management?

      Your Answer:

      Correct Answer: Steroids should be given in all cases of acute asthma attack

      Explanation:

      The BTS guidelines for managing acute asthma in adults provide the following recommendations:

      Oxygen:
      – It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.

      β2 agonists therapy:
      – High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
      – Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
      – For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
      – In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.

      Ipratropium bromide:
      – Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      Steroid therapy:
      – Steroids should be given in adequate doses for all cases of acute asthma attacks.
      – Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.

      Other therapies:
      – Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
      – A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
      – Routine prescription of antibiotics is not necessary for patients with acute asthma.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

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  • Question 78 - A 6-month-old girl is brought by her parents to see her pediatrician due...

    Incorrect

    • A 6-month-old girl is brought by her parents to see her pediatrician due to a history of fever, cough, and difficulty breathing. The pediatrician diagnoses her with acute bronchiolitis and calls the Emergency Department to discuss whether the child will require admission.
      What would be a reason for referring the child to the hospital?

      Your Answer:

      Correct Answer:

      Explanation:

      Bronchiolitis is a respiratory infection that primarily affects infants aged 2 to 6 months. It is typically caused by a viral infection, with respiratory syncytial virus (RSV) being the most common culprit. RSV infections are most prevalent during the winter months, from November to March. In fact, bronchiolitis is the leading cause of hospitalization among infants in the UK.

      The symptoms of bronchiolitis include poor feeding (consuming less than 50% of their usual intake in the past 24 hours), lethargy, a history of apnea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis (bluish discoloration of the skin), and low oxygen saturation levels. For children aged 6 weeks and older, oxygen saturation levels below 90% indicate a need for medical attention. For babies under 6 weeks or those with underlying health conditions, oxygen saturation levels below 92% require medical attention.

      To confirm the diagnosis of bronchiolitis, a nasopharyngeal aspirate can be taken for rapid testing of RSV. This test is useful in preventing unnecessary further testing and allows for the isolation of the infected infant.

      Most infants with bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in cases of poor feeding, lethargy, a history of apnea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, and oxygen saturation levels below 94%. If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers for the treatment of bronchiolitis.

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  • Question 79 - You are managing a young woman in the Emergency Department who is feeling...

    Incorrect

    • You are managing a young woman in the Emergency Department who is feeling unwell. She informs you that she has a history of bronchial asthma and has suddenly developed difficulty breathing since this morning. You can hear wheezing when you listen to her chest, and her peripheral oxygen saturation remains low despite receiving nebulized salbutamol. After a few minutes, she starts to become more drowsy. You recently completed your Advanced Life Support (ALS) training and feel confident in managing acutely unwell patients.

      What is the most appropriate initial step to take in this situation?

      Your Answer:

      Correct Answer: Summon the resuscitation team

      Explanation:

      This question discusses the prioritization of patient care, specifically focusing on the initial management of acutely unwell patients. The sequence followed in such cases is known as ‘ABCDE’, which stands for airway, breathing, circulation, disability, and exposure. It is crucial to call for help as soon as possible, as the patient’s condition may deteriorate rapidly. If a patient’s consciousness level is dropping, urgent assistance is required, and it is unlikely that you will be able to handle the situation independently.

      While waiting for the resuscitation team to arrive, you will be occupied with managing the patient. Therefore, it is not appropriate to make a phone call to the Emergency Department consultant for advice. Although the Emergency Department nurses may be helpful, it is essential to call the resuscitation team first. Continuing to handle the situation alone, regardless of the patient’s clinical condition, indicates a failure to recognize the need for assistance in this scenario.

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  • Question 80 - You are managing a 72-year-old male patient who has been intubated as a...

    Incorrect

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What measure is utilized to categorize the severity of ARDS?

      Your Answer:

      Correct Answer: PaO2/FiO2 ratio

      Explanation:

      The PaO2/FiO2 ratio is a measurement used to determine the severity of Acute Respiratory Distress Syndrome (ARDS). It is calculated by dividing the arterial oxygen partial pressure (PaO2) by the fraction of inspired oxygen (FiO2). However, it is important to note that this calculation should only be done when the patient is receiving a minimum positive end-expiratory pressure (PEEP) of 5 cm water. The resulting ratio is then used to classify the severity of ARDS, with specific thresholds provided below.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

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  • Question 81 - A 72-year-old man presents with a severe exacerbation of his COPD. He has...

    Incorrect

    • A 72-year-old man presents with a severe exacerbation of his COPD. He has been given a loading dose of aminophylline and you now intend to establish a maintenance infusion. He weighs 70 kg.
      What is the appropriate maintenance infusion rate for him?

      Your Answer:

      Correct Answer: 25 mg/hour

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a 50 kg individual, the appropriate infusion rate would be 25 mg/hour. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

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  • Question 82 - A 6-year-old girl presents with a history of a persistent cough that has...

    Incorrect

    • A 6-year-old girl presents with a history of a persistent cough that has been present for the past four weeks. The cough occurs in quick bursts with a deep breath in followed by a series of forceful coughs. She occasionally vomits after coughing. Her mother reports that the cough is more severe at night.

      During the examination, her chest sounds clear, but you observe two small subconjunctival hemorrhages and some tiny red spots on her face.

      What is the MOST suitable test to perform in this case?

      Your Answer:

      Correct Answer: Serology for anti-pertussis toxin IgG antibody levels

      Explanation:

      This presentation strongly suggests a diagnosis of whooping cough, which is an infection of the upper respiratory tract caused by the bacteria Bordetella pertussis. The disease is highly contagious and is transmitted through respiratory droplets. The incubation period is typically 7-21 days, and it is estimated that about 90% of close household contacts will become infected.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, is similar to a mild respiratory infection with symptoms such as low-grade fever and a runny nose. A cough may be present, but it is usually not as severe as in the second stage. This phase typically lasts about a week.

      The second stage, called the paroxysmal stage, is characterized by the development of a distinctive cough. The coughing occurs in spasms, often preceded by an inspiratory whoop sound. These spasms are followed by a series of rapid, hacking coughs. Patients may also experience vomiting and develop subconjunctival hemorrhages and petechiae. Between spasms, patients generally feel well and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) has specific recommendations for testing for whooping cough based on the age of the patient, the time since onset of illness, and the severity of the presentation.

      For infants under 12 months of age, hospitalized patients should be tested using PCR testing. Non-hospitalized patients within two weeks of onset should be investigated with culture of a nasopharyngeal swab or aspirate. Non-hospitalized patients presenting over two weeks after onset should be tested using serology for anti-pertussis toxin IgG antibody levels.

      For children over 12 months of age and adults, patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Patients aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after onset should have oral fluid testing for anti-pertussis toxin IgG antibody levels.

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  • Question 83 - A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Incorrect

    • A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Brazil. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
      Which of the following tests should be ordered?

      Your Answer:

      Correct Answer: Doppler ultrasound scan of leg

      Explanation:

      Based on the clinical history and examination, it strongly indicates that the patient may have a pulmonary embolism caused by a deep vein thrombosis in his right leg. To confirm this, it is recommended that he undergoes a CT pulmonary angiogram and doppler ultrasound scan of his right leg.

      The typical symptoms of a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. Additionally, there may be symptoms suggesting the presence of a deep vein thrombosis. Other signs to look out for are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.

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  • Question 84 - A 45-year-old Irish woman comes to you with a complaint of increasing shortness...

    Incorrect

    • A 45-year-old Irish woman comes to you with a complaint of increasing shortness of breath. During the interview, she mentions that she has been experiencing joint pain and painful skin lesions on her shins for the past few months. A chest X-ray is performed and shows bilateral hilar lymphadenopathy.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Sarcoidosis

      Explanation:

      The patient presents with a medical history and physical examination findings that are consistent with a diagnosis of Löfgren’s syndrome, which is a specific subtype of sarcoidosis. This syndrome is most commonly observed in women in their 30s and 40s, and it is more prevalent among individuals of Nordic and Irish descent.

      Löfgren’s syndrome is typically characterized by a triad of clinical features, including bilateral hilar lymphadenopathy seen on chest X-ray, erythema nodosum, and arthralgia, with a particular emphasis on ankle involvement. Additionally, other symptoms commonly associated with sarcoidosis may also be present, such as a dry cough, breathlessness, fever, night sweats, malaise, weight loss, Achilles tendonitis, and uveitis.

      In order to further evaluate this patient’s condition, it is recommended to refer them to a respiratory specialist for additional investigations. These investigations may include measuring the serum calcium level, as it may be elevated, and assessing the serum angiotensin-converting enzyme (ACE) level, which may also be elevated. A high-resolution CT scan can be performed to assess the extent of involvement and identify specific lymph nodes for potential biopsy. If there are any atypical features, a lymph node biopsy may be necessary. Lung function tests can be conducted to evaluate the patient’s vital capacity, and an MRI scan of the ankles may also be considered.

      Fortunately, the prognosis for Löfgren’s syndrome is generally very good, and it is considered a self-limiting and benign condition. The patient can expect to recover within a timeframe of six months to two years.

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  • Question 85 - A 45-year-old man comes in with a history of a high temperature, loss...

    Incorrect

    • A 45-year-old man comes in with a history of a high temperature, loss of smell, a persistent cough, and increasing difficulty breathing. He underwent a COVID-19 test two days ago, which has returned positive.
      Which established scoring system can be utilized to forecast the risk of severe respiratory illness within 24 hours for patients admitted from the emergency department with COVID-19?

      Your Answer:

      Correct Answer: qCSI Score

      Explanation:

      The qCSI Score, also known as the Quick COVID-19 Severity Index, is a tool that can predict the risk of critical respiratory illness in patients who are admitted from the emergency department with COVID-19. This score takes into consideration three criteria: respiratory rate, pulse oximetry, and oxygen flow rate. By assessing these factors, the qCSI Score can provide an estimation of the 24-hour risk of severe respiratory complications in these patients.

      On the other hand, the qSOFA Score is a different tool that is used to identify high-risk patients for in-hospital mortality when there is a suspicion of infection, particularly in cases of sepsis. However, it is important to note that the qSOFA Score is not specifically designed for use in the setting of febrile neutropenia.

      Another scoring system, known as the CURB-65 Score, is utilized to estimate the mortality risk associated with community-acquired pneumonia. This score helps healthcare professionals determine whether a patient should receive inpatient or outpatient treatment based on their likelihood of experiencing adverse outcomes.

      Lastly, the SCAP Score is a scoring system that predicts the risk of adverse outcomes in patients with community-acquired pneumonia who present to the emergency department. By assessing various clinical factors, this score can provide valuable information to healthcare providers regarding the potential severity of the illness and the need for further intervention.

      In addition to these scores, there is also the MASCC Risk Index Score, which is specifically used in the context of cancer patients receiving supportive care. This score helps assess the risk of complications in this vulnerable population and aids in making informed decisions regarding their treatment and management.

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  • Question 86 - A 3-year-old girl comes in with stridor and a barking cough. Her mother...

    Incorrect

    • A 3-year-old girl comes in with stridor and a barking cough. Her mother mentions that she has had a slight cold for a few days and her voice has been hoarse. Here are her observations: temperature 38.1°C, HR 135, RR 30, SaO2 97% on air. Her chest examination appears normal, but you notice the presence of stridor at rest.

      Which of the following medications is most likely to alleviate her symptoms?

      Your Answer:

      Correct Answer: Nebulised budesonide

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

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  • Question 87 - You are managing a 72-year-old male patient who has been intubated as a...

    Incorrect

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What is one of the four diagnostic criteria for ARDS?

      Your Answer:

      Correct Answer: Presence of hypoxaemia

      Explanation:

      One of the diagnostic criteria for ARDS is the presence of hypoxemia. Other criteria include the onset of symptoms within 7 days of a clinical insult or new/worsening respiratory symptoms, bilateral opacities on chest X-ray that cannot be fully explained by other conditions, and respiratory failure that cannot be fully attributed to cardiac failure or fluid overload.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

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  • Question 88 - A 60-year-old woman comes to the clinic with a fever, chest pain that...

    Incorrect

    • A 60-year-old woman comes to the clinic with a fever, chest pain that worsens with breathing, and coughing up thick, yellowish sputum. A chest X-ray is done and shows signs of cavitating pneumonia in the upper lobe.

      Which of the following bacteria is most frequently linked to cavitating pneumonia in the upper lobe?

      Your Answer:

      Correct Answer: Klebsiella pneumoniae

      Explanation:

      Klebsiella pneumoniae is commonly observed in individuals who are dependent on alcohol. It is more prevalent in men compared to women and typically manifests after the age of 40.

      The clinical manifestations of this condition include fevers and rigors, pleuritic chest pain, purulent sputum, and haemoptysis, which occurs more frequently than with other bacterial pneumonias. Klebsiella pneumoniae tends to affect the upper lobes of the lungs and often leads to the formation of cavitating lesions.

      While Staphylococcus aureus can also cause cavitation, it usually affects multiple lobes and is not limited to the upper lobes. Other potential causes of cavitating pneumonia include Pseudomonas aeruginosa, Mycobacterium tuberculosis, and, although rare, Legionella pneumophila.

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  • Question 89 - A 40-year-old businessman presents with sudden onset breathlessness and right-sided pleuritic chest pain....

    Incorrect

    • A 40-year-old businessman presents with sudden onset breathlessness and right-sided pleuritic chest pain. He has recently returned from a trip to Australia. He has no past medical history of note and suffers no known allergies. His observations are as follows: temperature 38.2°C, oxygen saturations 93% on air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, he has a tender, swollen left calf, and his chest is clear.

      What is the SINGLE investigation most likely to confirm the diagnosis?

      Your Answer:

      Correct Answer: CT pulmonary angiogram

      Explanation:

      The clinical history and examination strongly suggest that the patient has a pulmonary embolism caused by a deep vein thrombosis in his right leg.

      The typical symptoms of a pulmonary embolism include shortness of breath, chest pain that worsens with breathing, coughing, and/or coughing up blood. There may also be symptoms indicating the presence of a deep vein thrombosis. Other signs include rapid breathing and heart rate, fever, and in severe cases, signs of shock, an abnormal heart rhythm, and increased pressure in the jugular veins.

      Given the patient’s high probability Wells score, it is recommended that an immediate CT pulmonary angiogram (CPTA) be performed. This test is considered the most reliable method for diagnosing a pulmonary embolism. A d-dimer test would not provide any additional benefit in this case. While a chest X-ray and ECG may provide useful information, they alone cannot confirm the diagnosis.

      For patients who have an allergy to contrast media, renal impairment, or are at high risk from radiation exposure, a ventilation/perfusion single-photon emission computed tomography (V/Q SPECT) scan or a V/Q planar scan can be offered as an alternative to CTPA.

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  • Question 90 - A 28 year old male is brought into the ED after being discovered...

    Incorrect

    • A 28 year old male is brought into the ED after being discovered in a collapsed state. The patient is making minimal effort to breathe. The patient is a known IV drug user. The attending physician requests that you obtain an arterial blood gas sample from the radial artery. The blood gas is collected and the results are as follows:

      pH 7.30
      pO2 8.8 kPa
      pCO2 7.4 kPa
      Bicarbonate 26 mmol/L
      Chloride 98 mmol/L
      Potassium 5.6 mmol/L
      Sodium 135 mmol/L

      What type of acid-base abnormality is indicated?

      Your Answer:

      Correct Answer: Respiratory acidosis

      Explanation:

      Respiratory acidosis occurs when the respiratory system is unable to effectively remove carbon dioxide from the body, leading to an increase in acidity. This is often seen in cases of opioid overdose, where respiratory depression can occur. In respiratory acidosis, the bicarbonate levels may rise as the body’s metabolic system tries to compensate for the increased acidity.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 91 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Incorrect

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After conducting a clinical evaluation, you determine that he has community-acquired pneumonia. He has no significant medical history and no reported drug allergies.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer:

      Correct Answer: Amoxicillin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

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  • Question 92 - A 35-year-old woman comes to the clinic complaining of a persistent dry cough...

    Incorrect

    • A 35-year-old woman comes to the clinic complaining of a persistent dry cough and fever for the past few days. She has noticed that her cough does not produce any phlegm. Today, she has also experienced multiple episodes of diarrhea and has developed sharp chest pain on both sides. She mentions feeling short of breath, especially when she exerts herself. She works as a Jacuzzi and whirlpool installer and smokes 10 cigarettes per day.

      What is the SINGLE most probable causative organism in this scenario?

      Your Answer:

      Correct Answer: Legionella pneumophila

      Explanation:

      Legionella pneumophila, a Gram-negative bacterium, can be found in natural water supplies and soil. It is responsible for causing Legionnaires’ disease, a serious illness. Outbreaks of this disease have been associated with poorly maintained air conditioning systems, whirlpool spas, and hot tubs.

      The pneumonic form of Legionnaires’ disease presents with specific clinical features. Initially, there may be a mild flu-like prodrome lasting for 1-3 days. A non-productive cough, occurring in approximately 90% of cases, is also common. Pleuritic chest pain, haemoptysis, headache, nausea, vomiting, diarrhoea, and anorexia are other symptoms that may be experienced.

      Fortunately, Legionella pneumophila infections can be effectively treated with macrolide antibiotics like erythromycin, or quinolones such as ciprofloxacin. Tetracyclines, including doxycycline, can also be used as a treatment option.

      While the majority of Legionnaires’ disease cases are caused by Legionella pneumophila, there are several other species of Legionella that have been identified. One such species is Legionella longbeachae, which is less commonly encountered. It is primarily found in soil and potting compost and has been associated with outbreaks of Pontiac fever, a milder variant of Legionnaires’ disease that does not primarily affect the respiratory system.

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  • Question 93 - A 35 year old female is brought into the emergency department (ED) with...

    Incorrect

    • A 35 year old female is brought into the emergency department (ED) with a decreased level of consciousness. An arterial blood gas sample is collected. The results are as follows:

      pH 7.21
      pO2 12.6 kPa
      pCO2 6.9 kPa
      Bicarbonate 16 mmol/L
      Chloride 96 mmol/L
      Potassium 5.4 mmol/L
      Sodium 135 mmol/L

      Which of the following options best describes the acid-base disturbance?

      Your Answer:

      Correct Answer: Mixed acidosis

      Explanation:

      In cases of mixed acidosis, both the respiratory and metabolic systems play a role in causing the low pH levels. This means that the patient’s acidotic state is a result of both low bicarbonate levels in the metabolic system and high levels of CO2 in the respiratory system.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

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  • Question 94 - A 32-year-old woman with a documented history of asthma arrives with severe difficulty...

    Incorrect

    • A 32-year-old woman with a documented history of asthma arrives with severe difficulty breathing and wheezing. After initial assessment, it is determined that she is experiencing a life-threatening asthma attack, and she is immediately transferred to the resuscitation area. An arterial blood gas is obtained to aid in her treatment.
      What type of acid-base imbalance would you anticipate as a result of this life-threatening asthma episode?

      Your Answer:

      Correct Answer: Respiratory acidosis

      Explanation:

      The following list provides a summary of common causes for different acid-base disorders.

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. It can also occur due to pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

      Metabolic alkalosis can be caused by vomiting, potassium depletion (often due to diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can occur due to lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction) or ketoacidosis (such as in diabetes, starvation, or alcohol excess). It can also be a result of renal failure or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).

      Metabolic acidosis with a normal anion gap can be caused by conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

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  • Question 95 - A 45-year-old Irish woman comes in with a complaint of increasingly severe shortness...

    Incorrect

    • A 45-year-old Irish woman comes in with a complaint of increasingly severe shortness of breath. During the interview, she mentions experiencing joint pain for several months and having painful skin lesions on both shins. A chest X-ray is performed, which shows bilateral hilar lymphadenopathy.
      What is the specific syndrome she is experiencing?

      Your Answer:

      Correct Answer: Löfgren’s syndrome

      Explanation:

      The patient presents with a medical history and physical examination findings that are consistent with a diagnosis of Löfgren’s syndrome, which is a specific subtype of sarcoidosis. This syndrome is most commonly observed in women in their 30s and 40s, and it is more prevalent among individuals of Nordic and Irish descent.

      Löfgren’s syndrome is typically characterized by a triad of clinical features, including bilateral hilar lymphadenopathy seen on chest X-ray, erythema nodosum, and arthralgia, with a particular emphasis on ankle involvement. Additionally, other symptoms commonly associated with sarcoidosis may also be present, such as a dry cough, breathlessness, fever, night sweats, malaise, weight loss, Achilles tendonitis, and uveitis.

      In order to further evaluate this patient’s condition, it is recommended to refer them to a respiratory specialist for additional investigations. These investigations may include measuring the serum calcium level, as it may be elevated, and assessing the serum angiotensin-converting enzyme (ACE) level, which may also be elevated. A high-resolution CT scan can be performed to assess the extent of involvement and identify specific lymph nodes for potential biopsy. If there are any atypical features, a lymph node biopsy may be necessary. Lung function tests can be conducted to evaluate the patient’s vital capacity, and an MRI scan of the ankles may also be considered.

      Fortunately, the prognosis for Löfgren’s syndrome is generally very good, and it is considered a self-limiting and benign condition. The patient can expect to recover within a timeframe of six months to two years.

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  • Question 96 - A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has...

    Incorrect

    • A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has been feeling extremely tired and has been experiencing worsening nausea over the past few days. She also complains of intermittent chest pain. The patient mentions that her urine has been dark in color. She has no significant medical history and smokes 10 cigarettes per day. On examination, she appears pale and has inspiratory crackles at both bases. Her blood pressure is elevated at 175/94 mmHg. Urinalysis reveals proteinuria and microscopic haematuria.

      Her blood results today are as follows:
      Hb 8.4 g/dl (13-17 g/dl)
      MCV 69 fl (76-96 fl)
      WCC 21.5 x 109/l (4-11 x 109/l)
      Neutrophils 17.2 x 109/l (2.5-7.5 x 109/l)
      Na 134 mmol/l (133-147 mmol/l)
      K 4.2 mmol/l (3.5-5.0 mmol/l)
      Creat 232 micromol/l (60-120 micromol/l)
      Urea 12.8 mmol/l (2.5-7.5 mmol/l)

      Which SINGLE investigation will confirm the diagnosis in this case?

      Your Answer:

      Correct Answer: Renal biopsy

      Explanation:

      The most probable diagnosis in this situation is Goodpasture’s syndrome, a rare autoimmune vasculitic disorder characterized by three main symptoms: pulmonary hemorrhage, glomerulonephritis, and the presence of anti-glomerular basement membrane (Anti-GBM) antibodies. Goodpasture’s syndrome is more prevalent in men, particularly in smokers. It is also associated with HLA-B7 and HLA-DRw2.

      The clinical manifestations of Goodpasture’s syndrome include constitutional symptoms like fever, fatigue, nausea, and weight loss. Patients may also experience hemoptysis or pulmonary hemorrhage, chest pain, breathlessness, and inspiratory crackles at the lung bases. Anemia due to bleeding within the lungs, arthralgia, rapidly progressive glomerulonephritis, hematuria, hypertension, and rarely hepatosplenomegaly may also be present.

      Blood tests will reveal iron deficiency anemia, an elevated white cell count, and renal impairment. Elisa for Anti-GBM antibodies is highly sensitive and specific, but it is not widely available. Approximately 30% of patients may also have circulating antineutrophilic cytoplasmic antibodies (ANCAs), although these are not specific for Goodpasture’s syndrome and can be found in other conditions such as Wegener’s granulomatosis, which also cause renal impairment and pulmonary hemorrhage.

      Diagnosis is typically confirmed through a renal biopsy, which can detect the presence of anti-GBM antibodies. This would be the most appropriate investigation to confirm the diagnosis in this case.

      The management of Goodpasture’s syndrome involves a combination of plasmapheresis to remove circulating antibodies and the use of corticosteroids or cyclophosphamide.

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  • Question 97 - A 10-month-old child is brought in to the Emergency Department with a high...

    Incorrect

    • A 10-month-old child is brought in to the Emergency Department with a high temperature and difficulty breathing. You measure his respiratory rate and note that it is elevated.
      According to the NICE guidelines, what is considered to be the threshold for tachypnoea in an infant of this age?

      Your Answer:

      Correct Answer: RR >50 breaths/minute

      Explanation:

      According to the current NICE guidelines on febrile illness in children under the age of 5, there are certain symptoms and signs that may indicate the presence of pneumonia. These include tachypnoea, which is a rapid breathing rate. For infants aged 0-5 months, a respiratory rate (RR) of over 60 breaths per minute is considered suggestive of pneumonia. For infants aged 6-12 months, an RR of over 50 breaths per minute is indicative, and for children older than 12 months, an RR of over 40 breaths per minute may suggest pneumonia.

      Other signs that may point towards pneumonia include crackles in the chest, nasal flaring, chest indrawing, and cyanosis. Crackles are abnormal sounds heard during breathing, while nasal flaring refers to the widening of the nostrils during breathing. Chest indrawing is the inward movement of the chest wall during inhalation, and cyanosis is the bluish discoloration of the skin or mucous membranes due to inadequate oxygen supply.

      Additionally, a low oxygen saturation level of less than 95% while breathing air is also considered suggestive of pneumonia. These guidelines can be found in more detail in the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

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  • Question 98 - A 12-year-old girl from an Irish Traveller community presents with a history of...

    Incorrect

    • A 12-year-old girl from an Irish Traveller community presents with a history of a persistent cough that has been present for the past two weeks. The cough occurs in short bursts with an inhalation followed by a series of hacking coughs. She has never received any immunizations.

      What is the MOST suitable test to perform?

      Your Answer:

      Correct Answer: Culture of nasopharyngeal aspirate

      Explanation:

      This presentation strongly suggests a diagnosis of whooping cough, which is an infection of the upper respiratory tract caused by the bacteria Bordetella pertussis. The disease is highly contagious and is transmitted through respiratory droplets. The incubation period is typically 7-21 days, and it is estimated that about 90% of close household contacts will become infected.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, is similar to a mild respiratory infection with symptoms such as low-grade fever and a runny nose. A cough may be present, but it is usually mild compared to the second stage. This phase typically lasts about a week.

      The second stage, called the paroxysmal stage, is characterized by the development of a distinctive cough. The coughing occurs in spasms, often preceded by an inspiratory whoop sound. These spasms are followed by a series of rapid, hacking coughs. Patients may experience vomiting and may develop subconjunctival hemorrhages and petechiae. Between spasms, patients generally feel well and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) provides recommendations for testing for whooping cough based on the age of the patient, time since onset of illness, and severity of presentation. For infants under 12 months of age, hospitalised patients should undergo PCR testing, while non-hospitalised patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Non-hospitalised patients presenting over two weeks after onset should be investigated with serology for anti-pertussis toxin IgG antibody levels.

      For children over 12 months of age and adults, patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Patients aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after onset should have oral fluid testing for anti-pertussis toxin IgG antibody levels.

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  • Question 99 - A 3-month-old boy is brought in by his parents with a history of...

    Incorrect

    • A 3-month-old boy is brought in by his parents with a history of breathing difficulties, fever, and a cough. He is irritable and having trouble with feeding. On examination, his temperature is 38.6°C, and you hear fine inspiratory crackles across his chest.

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Bronchiolitis

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.

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  • Question 100 - A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain...

    Incorrect

    • A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain radiating down the inner side of his left upper arm into his forearm and hand. He has a history of heavy smoking and has been diagnosed with COPD. Upon examination, he exhibits weakness and noticeable muscle wasting in his forearm and hand on the same side. Additionally, he has a Horner's syndrome on the affected side. The Chest X-ray image is provided below:

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer:

      Correct Answer: Pancoast tumour

      Explanation:

      This patient presents with a noticeable mass at the top of the right lung, which is clearly visible on the chest X-ray. Based on the symptoms and clinical presentation, it is highly likely that this is a Pancoast tumor, and the overall diagnosis is Pancoast syndrome.

      A Pancoast tumor is a type of tumor that develops at the apex of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. The majority of Pancoast tumors are classified as non-small cell cancers.

      Pancoast syndrome occurs when the tumor invades various structures and tissues around the thoracic inlet. This includes the invasion of the cervical sympathetic plexus on the same side as the tumor, leading to the development of Horner’s syndrome. Additionally, there may be reflex sympathetic dystrophy in the arm on the affected side, resulting in increased sensitivity to touch and changes in the skin.

      Patients with Pancoast syndrome may also experience shoulder and arm pain due to the tumor invading the brachial plexus roots C8-T1. This can lead to muscle wasting in the hand and tingling sensations in the inner side of the arm. In some cases, there may be involvement of the unilateral recurrent laryngeal nerve, causing unilateral vocal cord paralysis and resulting in a hoarse voice and/or a bovine cough. Phrenic nerve involvement is less common but can also occur.

      Horner’s syndrome, which is a key feature of Pancoast syndrome, is caused by compression of the sympathetic chain from the hypothalamus to the orbit. The three main symptoms of Horner’s syndrome are drooping of the eyelid (ptosis), constriction of the pupil (pupillary miosis), and lack of sweating on the forehead (anhydrosis).

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  • Question 101 - A 32 year old is brought into the emergency department after being rescued...

    Incorrect

    • A 32 year old is brought into the emergency department after being rescued from the water by a lifeguard at a nearby beach following signs of distress and submersion. In terms of drowning, what is the primary determinant of prognosis?

      Your Answer:

      Correct Answer: Submersion time

      Explanation:

      The duration of submersion is the most crucial factor in predicting the outcome of drowning incidents. If the submersion time is less than 10 minutes, it is considered a positive indicator for prognosis, while if it exceeds 25 minutes, it is considered a negative indicator. There are other factors that are associated with higher rates of illness and death, such as a low Glasgow Coma Score, absence of pupillary response, pH imbalance (acidosis), and low blood pressure (hypotension). However, it is important to note that these prognostic factors have not been consistently validated in studies and cannot reliably predict the outcome of drowning incidents.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

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  • Question 102 - A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty...

    Incorrect

    • A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the bird exhibit. During the examination, a reddish macular rash is observed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.

      What is the specific name of the rash on his face that is associated with this condition?

      Your Answer:

      Correct Answer: Horder’s spots

      Explanation:

      Psittacosis is a type of infection that can be transmitted from animals to humans, caused by a bacterium called Chlamydia psittaci. It is most commonly seen in people who own domestic birds, as well as those who work in pet shops or zoos. The typical symptoms of psittacosis include pneumonia that is acquired within the community, along with flu-like symptoms. Many patients also experience severe headaches and sensitivity to light. Enlargement of the spleen is a common finding in about two-thirds of individuals with this infection.

      Infected individuals often develop a rash on their face, known as Horder’s spots, which appear as reddish macules. In some cases, erythema nodosum and erythema multiforme may also occur. The recommended treatment for psittacosis is a course of tetracycline or doxycycline for a period of 2-3 weeks.

      On the other hand, rose spots are typically observed in cases of typhoid fever. These spots have a similar appearance to Horder’s spots but are usually found on the trunk rather than the face. Erythema marginatum is a pale red rash seen in rheumatic fever, while malar flush, also known as ‘mitral facies’, refers to the reddish discoloration of the cheeks commonly seen in individuals with mitral stenosis. Lastly, erythema chronicum migrans is the distinctive rash seen in Lyme disease, characterized by a circular rash with a central ‘bulls-eye’ appearance that spreads outward from the site of a tick bite.

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  • Question 103 - You review a 30-year-old man who presents with an acute exacerbation of asthma...

    Incorrect

    • You review a 30-year-old man who presents with an acute exacerbation of asthma and consider ordering a chest X-ray.
      Which of the following is NOT a reason to perform a chest X-ray in the evaluation of acute asthma?

      Your Answer:

      Correct Answer: Acute severe asthma

      Explanation:

      Chest X-rays are not typically recommended as a routine investigation for acute asthma. However, they may be necessary in specific situations. These situations include suspected pneumomediastinum or consolidation, as well as cases of life-threatening asthma. Additionally, if a patient fails to respond adequately to treatment or requires ventilation, a chest X-ray may be performed. It is important to note that these circumstances warrant the use of chest X-rays, but they are not routinely indicated for the investigation of acute asthma.

    • This question is part