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Question 1
Incorrect
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Which one of the following paraneoplastic features is less likely to be seen in patients with squamous cell lung cancer?
Your Answer: Hyperthyroidism
Correct Answer: Lambert-Eaton syndrome
Explanation:Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission in which release of acetylcholine (ACh) is impaired, causing a unique set of clinical characteristics, which include proximal muscle weakness, depressed tendon reflexes, post-tetanic potentiation, and autonomic changes.
In 40% of patients with LEMS, cancer is present when the weakness begins or is found later. This is usually a small cell lung cancer (SCLC). However, LEMS has also been associated with non-SCLC, lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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Briefly state the mechanism of action of salbutamol.
Your Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation
Explanation:Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).
Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.
Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath. On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%. CXR reveals a left pneumothorax with a 4 cm rim of air visible. Which management strategy is appropriate in this patient?
Your Answer: Insertion of intercostal chest drain
Correct Answer: Needle aspiration
Explanation:Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.
Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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Which of the following is not a known cause of occupational asthma?
Your Answer: Soldering flux resin
Correct Answer: Cadmium
Explanation:Occupational asthma (OA) could be divided into a nonimmunological, irritant-induced asthma and an immunological, allergy-induced asthma. In addition, allergy-induced asthma can be caused by two different groups of agents: high molecular weight proteins (>5,000 Da) or low molecular weight agents (<5,000 Da), generally chemicals like the isocyanates.
Isocyanates are very reactive chemicals characterized by one or more isocyanate groups (–N=C=O). The main reactions of this chemical group are addition reactions with ethanol, resulting in urethanes, with amines (resulting in urea derivates) and with water. Here, the product is carbamic acid which is not stable and reacts further to amines, releasing free carbon dioxide.Diisocyanates and polyisocyanates are, together with the largely nontoxic polyol group, the basic building blocks of the polyurethane (PU) chemical industry, where they are used solely or in combination with solvents or additives in the production of adhesives, foams, elastomers, paintings, coatings and other materials.
The complex salts of platinum are one of the most potent respiratory sensitising agents having caused occupational asthma in more than 50% of exposed workers. Substitution of ammonium hexachlor platinate with platinum tetra amine dichloride in the manufacture of catalyst has controlled the problem in the catalyst industry. Ammonium hexachlorplatinate exposure still occurs in the refining process.
Rosin based solder flux fume is produced when soldering. This fume is a top cause of occupational asthma.
Bakeries, flour mills and kitchens where flour dust and additives in the flour are a common cause of occupational asthma.
Cadmium was not found to cause occupational asthma.
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This question is part of the following fields:
- Respiratory
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Question 5
Incorrect
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A 51 year old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread. What is the stage of this cancer?
Your Answer:
Correct Answer: T2 N1 M0
Explanation:The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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A number of tests have been ordered for a 49 year old male who has systemic lupus erythematosus (SLE). He was referred to the clinic because he has increased shortness of breath. One test in particular is transfer factor of the lung for carbon monoxide (TLCO), which is elevated. Which respiratory complication of SLE is associated with this finding?
Your Answer:
Correct Answer: Alveolar haemorrhage
Explanation:Alveolar haemorrhage (AH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution. Extrapulmonary disease may be minimal and may be masked in patients who are already receiving immunosuppressants for other symptoms of SLE.
DLCO or TLCO (diffusing capacity or transfer factor of the lung for carbon monoxide (CO)) is the extent to which oxygen passes from the air sacs of the lungs into the blood.
Factors that can increase the DLCO include polycythaemia, asthma (can also have normal DLCO) and increased pulmonary blood volume as occurs in exercise. Other factors are left to right intracardiac shunting, mild left heart failure (increased blood volume) and alveolar haemorrhage (increased blood available for which CO does not have to cross a barrier to enter). -
This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 47-year-old woman complains of dyspnoea, occasional fevers and mild weight loss which have all gotten worse over the past months. She does not complain of a cough but remembered that she had coughed once and produced a twig-shaped mucoid sputum mass. She has no haemoptysis. She has no past medical history and is on no medications. Her chest X-ray reveals bilateral, perihilar, dense airspace shadowing. A HRCT of her thorax showed a ‘crazy paving’ pattern of extensive, dense, white infiltrates. Her spirometry was a restrictive pattern with reduced total lung capacity. She also had a bronchoscopy and lavage, which revealed periodic acid–Schiff (PAS)-positive proteinaceous fluid and elevated levels of surfactant proteins A and D. What is the most likely diagnosis?
Your Answer:
Correct Answer: Pulmonary alveolar proteinosis
Explanation:Pulmonary alveolar proteinosis (PAP) is a lung condition that is caused by a build-up of proteins and other substances in the alveoli. The alveoli are the part of the lungs that contain air. PAP has the following symptoms:
Shortness of breath, also called dyspnoea
Chest pain or tightness
Fever
Weight loss
Cough (sometimes, but not always)
Low levels of oxygen in the blood
Nail clubbing (abnormal growth of toenails or fingernails)Serologic studies are generally not useful for PAP. Flexible bronchoscopy with bronchoalveolar lavage (BAL) remains the criterion standard. Elevated levels of the proteins SP-A and SP-D in serum and BAL fluid may be useful. Elevated titer of neutralizing autoantibody against GM-CSF (immunoglobulin G [IgG] isotype) in serum and BAL fluid may be useful. Recent studies have proposed that deficiency of GM-CSF causes pulmonary alveolar proteinosis (PAP); all patients studied had the antibody to GM-CSF. Serum lactate dehydrogenase (LDH) level is usually elevated, but this finding is nonspecific.
High-resolution computed tomography (HRCT) scan of the chest demonstrates areas of patchy ground-glass opacification with smooth interlobular septal thickening and intralobular interstitial thickening, which produces a polygonal pattern referred to as crazy paving.
Light microscopy of the lung parenchymal tissue shows alveoli filled with a granular PAS base-reactive and diastase-resistant eosinophilic material.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 26 year old male from Eastern Europe has been experiencing night sweats, fevers, and decreased weight for several months. He also has a chronic cough which at times consists of blood. He is reviewed at the clinic and a calcified lesion was detected in his right lung with enlarged calcified right hilar lymph nodes. His leukocytes are just below normal range and there is a normochromic normocytic anaemia. Acid-fast bacilli (AFB) are found in one out of five sputum samples. Sputum is sent for extended culture. Which diagnosis fits best with his signs and symptoms?
Your Answer:
Correct Answer: Active pulmonary tuberculosis
Explanation:Classic clinical features associated with active pulmonary TB are as follows (elderly individuals with TB may not display typical signs and symptoms):
– Cough
– Weight loss/anorexia
– Fever
– Night sweats
– Haemoptysis
– Chest pain (can also result from tuberculous acute pericarditis)
– FatigueTest:
Acid-fast bacilli (AFB) smear and culture – Using sputum obtained from the patient.
AFB stain is quick but requires a very high organism load for positivity, as well as the expertise to read the stained sample. This test is more useful in patients with pulmonary disease.
Obtain a chest radiograph to evaluate for possible associated pulmonary findings. If chest radiography findings suggest TB and a sputum smear is positive for AFB, initiate treatment for TB. -
This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 78 year old male presents to the emergency department with shortness of breath that has developed gradually over the last 4 days. His symptoms include fever and cough productive of greenish sputum. Past history is notable for COPD for which he was once admitted to the ICU, 2 years back. He now takes nebulizers (ipratropium bromide) at home. The patient previously suffered from myocardial infarction 7 years ago. He also has Diabetes Mellitus type II controlled by lifestyle modification. On examination, the following vitals are obtained. BP : 159/92 mmHg Pulse: 91/min (regular) Temp: Febrile On auscultation, there are scattered ronchi bilaterally and right sided basal crackles. Cardiovascular and abdominal examinations are unremarkable. Lab findings are given below: pH 7.31 pa(O2) 7.6 kPa pa(CO2) 6.3 kPa Bicarbonate 30 mmol/L, Sodium 136 mmol/L, Potassium 3.7 mmol/L, Urea 7.0 mmol/L, Creatinine 111 μmol/L, Haemoglobin 11.3 g/dL, Platelets 233 x 109 /l Mean cell volume (MCV) 83 fl White blood cells (WBC) 15.2 x 109 /l. CXR shows an opacity obscuring the right heart border. Which of the following interventions should be started immediately while managing this patient?
Your Answer:
Correct Answer: Salbutamol and ipratropium bromide nebulisers
Explanation:Acute exacerbations of chronic obstructive pulmonary disease (COPD) are immediately treated with inhaled beta2 agonists and inhaled anticholinergics, followed by antibiotics (if indicated) and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators.
High flow oxygen would worsen his symptoms. Usually titrated oxygen (88 to 92 %) is given in such patients to avoid the risk of hyperoxic hypercarbia in which increasing oxygen saturation in a chronic carbon dioxide retainer can inadvertently lead to respiratory acidosis and death. -
This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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A 21 year old university student is taken to the A&E. She lives alone in a small apartment. She is normally fit and well but she has been complaining of difficulty with concentrating in classes. She is a one pack per day smoker and she has no significant past medical history. She is also not on any medication. She had a pulse of 123 beats per minute and her blood pressure was measured to be 182/101mmHg. She looked flushed. Chest x-ray was normal and her oxygen saturations were normal. She has typical features of carbon monoxide poisoning. Initial investigations showed:
- Haemoglobin 13.0 g/dL (11.5-16.5)
- White cell count 10.3 x109/L (4-11 x109)
- Platelets 281 x109/L (150-400 x109)
- Serum sodium 133 mmol/L (137-144)
- Serum potassium 3.7 mmol/L (3.5-4.9)
- Serum urea 7.3 mmol/L (2.5-7.5)
- Serum creatinine 83 μmol/L (60-110)
- pO2 7.9 kPa (11.3-12.6)
- pCO2 4.7 kPa (4.7-6.0)
- pH 7.43 (7.36-7.44)
Your Answer:
Correct Answer: Carboxy haemoglobin
Explanation:Carbon monoxide (CO) is a colourless, odourless gas produced by incomplete combustion of carbonaceous material. Clinical presentation in patients with CO poisoning ranges from headache and dizziness to coma and death. Hyperbaric oxygen therapy can significantly reduce the morbidity of CO poisoning, but a portion of survivors still suffer significant long-term neurologic and affective sequelae.
Complaints:
Malaise, flulike symptoms, fatigue
Dyspnoea on exertion
Chest pain, palpitations
Lethargy
Confusion
Depression
Impulsiveness
Distractibility
Hallucination, confabulation
Agitation
Nausea, vomiting, diarrhoea
Abdominal pain
Headache, drowsiness
Dizziness, weakness, confusion
Visual disturbance, syncope, seizure
Faecal and urinary incontinence
Memory and gait disturbances
Bizarre neurologic symptoms, comaVital signs may include the following:
Tachycardia
Hypertension or hypotension
Hyperthermia
Marked tachypnoea (rare; severe intoxication often associated with mild or no tachypnoea)
Although so-called cherry-red skin has traditionally been considered a sign of CO poisoning, it is in fact rare.The clinical diagnosis of acute carbon monoxide (CO) poisoning should be confirmed by demonstrating an elevated level of carboxyhaemoglobin (HbCO). Either arterial or venous blood can be used for testing. Analysis of HbCO requires direct spectrophotometric measurement in specific blood gas analysers. Elevated CO levels of at least 3–4% in non-smokers and at least 10% in smokers are significant.
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This question is part of the following fields:
- Respiratory
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