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Question 1
Correct
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An older woman presents to the Emergency Department with probable community acquired pneumonia (CAP). The consultant asks you to refer to the CURB-65 score to determine the next management plan.
Which of the following statements is part of the CURB-65 score?Your Answer: Urea > 7 mmol/l
Explanation:Understanding the CURB-65 Score for Assessing Severity of CAP
The CURB-65 score is a clinical prediction tool recommended by the British Thoracic Society for assessing the severity of community-acquired pneumonia (CAP). It is a 6-point score based on five criteria: confusion, urea level, respiratory rate, blood pressure, and age. Patients with a score of 0 are at low risk and may not require hospitalization, while those with a score of 3 or more are at higher risk of death and may require urgent admission. It is important to use the correct criteria for each parameter, such as an Abbreviated Mental Test Score of 8 or less for confusion and a respiratory rate of 30 or more for tachypnea. Understanding and documenting the CURB-65 score can aid in clinical decision-making for patients with CAP.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 28-year-old female patient presents to your clinic seeking help to quit smoking. Despite several attempts in the past, she has been unsuccessful. She has a medical history of bipolar disorder and well-managed epilepsy, for which she takes lamotrigine. She currently smokes 15 cigarettes per day and is especially interested in the health benefits of quitting smoking since she has recently found out that she is pregnant. As her physician, you decide to prescribe a suitable medication to assist her in her efforts. What would be the most appropriate treatment option?
Your Answer: Nicotine gum
Explanation:Standard treatments for nicotine dependence do not include amitriptyline, fluoxetine, or gabapentin. Nicotine replacement therapy (NRT) can be helpful for motivated patients, but it is not a cure for addiction and may require multiple attempts. Bupropion and varenicline are other smoking cessation aids, but they have multiple side effects and may not be suitable for all patients. NICE guidelines recommend discussing the best method of smoking cessation with the patient, but NRT is considered safer in pregnancy.
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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 35-year-old male presents with recurrent dyspnoea and cough. He has a medical history of asthma and has been hospitalized in the past due to asthma and two recent cases of pneumonia. On examination, he has bilateral wheeze and a mild fever. His sputum is thick and sticky. Blood tests reveal an ESR of 72 mm/hr (1-10) and elevated IgE levels. What is the most probable diagnosis?
Your Answer: Pulmonary fibrosis
Correct Answer: Allergic bronchopulmonary aspergillosis
Explanation:Allergic Bronchopulmonary Aspergillosis: Symptoms and Treatment
Allergic bronchopulmonary aspergillosis is a condition that occurs when the body has an allergic reaction to Aspergillus fumigatus. This can result in symptoms such as wheezing, coughing, difficulty breathing, and recurrent pneumonia. Blood tests may show an increase in IgE levels and eosinophil count. Unfortunately, it is difficult to completely eliminate the fungus, so treatment typically involves high doses of prednisolone to reduce inflammation while waiting for clinical and radiographic improvement.
Allergic bronchopulmonary aspergillosis is a condition that occurs when the body has an allergic reaction to Aspergillus fumigatus. This can result in symptoms such as wheezing, coughing, difficulty breathing, and recurrent pneumonia. Blood tests may show an increase in IgE levels and eosinophil count.
Unfortunately, it is difficult to completely eliminate the fungus, so treatment typically involves high doses of prednisolone to reduce inflammation while waiting for clinical and radiographic improvement.
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This question is part of the following fields:
- Respiratory
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Question 4
Correct
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You have a telephone consultation with a 28-year-old male who wants to start trying to conceive. He has a history of asthma and takes salbutamol 100mcg as needed.
Which of the following would be most important to advise?Your Answer: Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy
Explanation:Women who are taking antiepileptic medication and are planning to conceive should be prescribed a daily dose of 5mg folic acid instead of the standard 400mcg. This high-dose folic acid should be taken from before conception until the 12th week of pregnancy to reduce the risk of neural tube defects. It is important to refer these women to specialist care, but they should continue to use effective contraception until they have had a full assessment. Despite the medication, it is still likely that they will have a normal pregnancy and healthy baby. If trying to conceive, women should start taking folic acid as soon as possible, rather than waiting for a positive pregnancy test.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Respiratory
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Question 5
Incorrect
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A 50-year-old man in the United Kingdom presents with fever and cough. He smells strongly of alcohol and has no fixed abode. His heart rate was 123 bpm, blood pressure 93/75 mmHg, oxygen saturations 92% and respiratory rate 45 breaths per minute. Further history from him reveals no recent travel history and no contact with anyone with a history of foreign travel.
Chest X-ray revealed consolidation of the right upper zone.
Which of the following drugs is the most prudent choice in his treatment?Your Answer: Co-trimoxazole
Correct Answer: Meropenem
Explanation:Understanding Klebsiella Pneumoniae Infection and Treatment Options
Klebsiella pneumoniae (KP) is a common organism implicated in various infections such as pneumonia, urinary tract infection, intra-abdominal abscesses, or bacteraemia. Patients with underlying conditions like alcoholism, diabetes, or chronic lung disease are at higher risk of contracting KP. The new hypervirulent strains with capsular serotypes K1 or K2 are increasingly being seen. In suspected cases of Klebsiella infection, treatment is best started with carbapenems. However, strains possessing carbapenemases are also being discovered, and Polymyxin B or E or tigecycline are now used as the last line of treatment. This article provides an overview of KP infection, radiological findings, and treatment options.
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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 29-year-old electrician was referred to the hospital by his doctor. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. At the time of referral, he was experiencing mild dyspnea, a global headache, myalgia, and arthralgia. On examination, he appeared unwell, had a fever of 39°C, and had a maculopapular rash on his upper body. Fine crackles were audible in the left mid-zone of his chest, and mild neck stiffness was noted.
The following investigations were conducted: Hb 84 g/L (130-180), WBC 8 ×109/L (4-11), Platelets 210 ×109/L (150-400), Reticulocytes 8% (0.5-2.4), Na 129 mmol/L (137-144), K 4.2 mmol/L (3.5-4.9), Urea 5.0 mmol/L (2.5-7.5), Creatinine 110 µmol/L (60-110), Bilirubin 89 µmol/L (1-22), Alk phos 130 U/L (45-105), AST 54 U/L (1-31), and GGT 48 U/L (<50). A chest x-ray revealed patchy consolidation in both mid-zones.
What is the most likely cause of his abnormal blood count?Your Answer: Sepsis syndrome
Correct Answer: IgM anti-i antibodies
Explanation:The patient has pneumonia, hepatitis, and haemolytic anaemia, which can be caused by Mycoplasma pneumonia. This condition can also cause extrapulmonary manifestations such as renal failure, myocarditis, and meningitis. Haemolysis is associated with the presence of IgM antibodies, and sepsis may cause microangiopathic haemolytic anaemia. Clavulanic acid can cause hepatitis, and some drugs can induce haemolysis in patients with G6PD deficiency.
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This question is part of the following fields:
- Respiratory
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Question 7
Correct
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A 10-year-old boy visits his General Practitioner complaining of feeling unwell for the past two days. He reports having a sore throat, general malaise, and nasal congestion, but no cough or fever. During the examination, his pulse rate is 70 bpm, respiratory rate 18 breaths per minute, and temperature 37.3 °C. The doctor notes tender, swollen anterior cervical lymph nodes. What investigation should the doctor consider requesting?
Your Answer: Throat swab
Explanation:Investigations for Upper Respiratory Tract Infections: A Case Study
When a patient presents with symptoms of an upper respiratory tract infection, it is important to consider appropriate investigations to differentiate between viral and bacterial causes. In this case study, a young boy presents with a sore throat, tender/swollen lymph nodes, and absence of a cough. A McIsaac score of 3 suggests a potential for streptococcal pharyngitis.
Throat swab is a useful investigation to differentiate between symptoms of the common cold and streptococcal pharyngitis. Sputum culture may be indicated if there is spread of the infection to the lower respiratory tract. A chest X-ray is not indicated as a first-line investigation, but may be later indicated if there is a spread to the lower respiratory tract. Full blood count is not routinely indicated, as it is only likely to show lymphocytosis for viral infections. Viral testing is not conducted routinely, unless required for public health research or data in the event of a disease outbreak.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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A 54-year-old man who is a long-term cigarette smoker presents with nocturnal dry cough of 4 weeks’ duration. He has recently gone through a stressful life situation due to divorce and bankruptcy. He mentions a history of atopic diseases in his family. His symptom improves with omeprazole, one tablet daily taken in the morning.
What is the most likely diagnosis?Your Answer: Gastro-oesophageal reflux disease
Explanation:Differential Diagnosis of Nocturnal Cough: Gastro-oesophageal Reflux Disease as the Likely Cause
Nocturnal cough can have various causes, including asthma, sinusitis with post-nasal drip, congestive heart failure, and gastro-oesophageal reflux disease (GERD). In this case, the patient’s cough improved after taking omeprazole, a proton pump inhibitor, which suggests GERD as the likely cause of his symptoms. The mechanism of cough in GERD is related to a vagal reflex triggered by oesophageal irritation, which is exacerbated by stress and lying flat. Peptic ulcer disease, asthma, psychogenic cough, and chronic bronchitis are less likely causes based on the absence of relevant symptoms or response to treatment. Therefore, GERD should be considered in the differential diagnosis of nocturnal cough, especially in patients with risk factors such as smoking and obesity.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 68-year-old man with lung cancer presents to the Emergency Department complaining of chest pain and shortness of breath. He reports no cough or sputum production. Upon auscultation, his chest is clear. His pulse is irregularly irregular and measures 110 bpm, while his oxygen saturation is 86% on room air. He is breathing at a rate of 26 breaths per minute. What diagnostic investigation is most likely to be effective in this scenario?
Your Answer: Electrocardiogram (ECG)
Correct Answer: Computerised tomography pulmonary angiogram (CTPA)
Explanation:Diagnostic Tests for Pulmonary Embolism in Cancer Patients
Pulmonary embolism (PE) and deep vein thrombosis (DVT) are common in cancer patients due to their hypercoagulable state. When a cancer patient presents with dyspnea, tachycardia, chest pain, and desaturation, PE should be suspected. The gold standard investigation for PE is a computerised tomography pulmonary angiogram (CTPA), which has a high diagnostic yield.
An electrocardiogram (ECG) can also be helpful in diagnosing PE, as sinus tachycardia is the most common finding. However, in this case, the patient’s irregularly irregular pulse is likely due to atrial fibrillation with a rapid ventricular rate, which should be treated alongside investigation of the suspected PE.
A D-dimer test may not be helpful in diagnosing PE in cancer patients, as it has low specificity and may be raised due to the underlying cancer. An arterial blood gas (ABG) should be carried out to help treat the patient, but the cause of hypoxia will still need to be determined.
Bronchoscopy would not be useful in diagnosing PE and should not be performed in this case.
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This question is part of the following fields:
- Respiratory
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Question 10
Correct
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A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath, unable to speak in complete sentences, tachypnoeic and with a tachycardia of 122 bpm. Severe inspiratory wheeze is noted on examination. The patient is given nebulised salbutamol and ipratropium bromide, and IV hydrocortisone is administered. After 45 minutes of IV salbutamol infusion, there is no improvement in tachypnea and oxygen saturation has dropped to 80% at high flow oxygen. An ABG is taken, showing a pH of 7.50, pO2 of 10.3 kPa, pCO2 of 5.6 kPa, and HCO3− of 28.4 mmol/l. What is the next most appropriate course of action?
Your Answer: Request an anaesthetic assessment for the Intensive Care Unit (ICU)
Explanation:Why an Anaesthetic Assessment is Needed for a Severe Asthma Attack in ICU
When a patient is experiencing a severe asthma attack, it is important to take the appropriate steps to provide the best care possible. In this scenario, the patient has already received nebulisers, an iv salbutamol infusion, and hydrocortisone, but their condition has not improved. The next best step is to request an anaesthetic assessment for ICU, as rapid intubation may be required and the patient may need ventilation support.
While there are other options such as CPAP and NIPPV, these should only be used in a controlled environment with anaesthetic backup. Administering oral magnesium is also not recommended, and iv aminophylline should only be considered after an anaesthetic review. By requesting an anaesthetic assessment for ICU, the patient can receive the best possible care for their severe asthma attack.
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This question is part of the following fields:
- Respiratory
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Question 11
Incorrect
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A 38-year-old man from Somalia presents at your general practice surgery as a temporary resident. He has noticed some lumps on the back of his neck recently. He reports having a productive cough for the last 3 months, but no haemoptysis. He has lost 3 kg in weight in the last month. He is a non-smoker and lives with six others in a flat. His chest X-ray shows several large calcified, cavitating lesions bilaterally.
What is the GOLD standard investigation for active disease, given the likely diagnosis?Your Answer: Tuberculin skin test
Correct Answer: Sputum culture
Explanation:The patient in question has several risk factors for tuberculosis (TB), including being from an ethnic minority and living in overcrowded accommodation. The presence of symptoms and chest X-ray findings of bilateral large calcified, cavitating lesions strongly suggest a diagnosis of TB. The gold standard investigation for TB is to send at least three spontaneous sputum samples for culture and microscopy, including one early morning sample. Treatment should be initiated without waiting for culture results if clinical symptoms and signs of TB are present. Treatment involves a 6-month course of antibiotics, with the first 2 months consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampicin. Even if culture results are negative, the full course of antibiotics should be completed. Public health must be notified of the diagnosis for contact tracing and surveillance. Pulmonary function testing is useful for assessing the severity of lung disease but is not used in the diagnosis of TB. Tissue biopsy is not recommended as the gold standard investigation for TB, but may be useful in some cases of extrapulmonary TB. The tuberculin skin test is used to determine if a patient has ever been exposed to TB, but is not the gold standard investigation for active TB. Interferon-γ release assays measure a person’s immune reactivity to TB and can suggest the likelihood of M tuberculosis infection.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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A 45-year-old woman with known asthma presents to the Emergency Department with severe breathlessness and wheeze.
Which of the following is the most concerning finding on examination and initial investigations?Your Answer: Peak expiratory flow rate (PEFR) 35% predicted
Correct Answer: PaCO2 5.5 kPa
Explanation:Assessing the Severity of an Acute Asthma Exacerbation
When assessing the severity of an acute asthma exacerbation, several factors must be considered. A PaCO2 level of 5.5 kPa in an acutely exacerbating asthmatic is a worrying sign and is a marker of a life-threatening exacerbation. A respiratory rate of 30 breaths per minute or higher is a sign of acute severe asthma, while poor respiratory effort is a sign of life-threatening asthma. Peak expiratory flow rate (PEFR) can also be used to help assess the severity of an acute exacerbation of asthma. A PEFR of 33-35% best or predicted is a sign of acute severe asthma, while a PEFR < 33% best or predicted is a sign of life-threatening asthma. A heart rate of 140 bpm or higher is a feature of acute severe asthma, while arrhythmia and/or hypotension are signs of life-threatening asthma. Inability to complete sentences in one breath is a sign of acute severe asthma, while an altered conscious level is a sign of life-threatening asthma. By considering these factors, healthcare professionals can accurately assess the severity of an acute asthma exacerbation and provide appropriate treatment.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 75-year-old man with chronic obstructive pulmonary disease (COPD) comes in for a review of his home oxygen therapy. The results of his arterial blood gas (ABG) are as follows:
Investigation Result Normal range
pH 7.34 7.35–7.45
pa(O2) 8.0 kPa 10.5–13.5 kPa
pa(CO2) 7.6 kPa 4.6–6.0 kPa
HCO3- 36 mmol 24–30 mmol/l
Base excess +4 mmol −2 to +2 mmol
What is the best interpretation of this man's ABG results?Your Answer: Metabolic alkalosis with partial respiratory compensation
Correct Answer: Respiratory acidosis with partial metabolic compensation
Explanation:Understanding Arterial Blood Gas (ABG) Results: A Five-Step Approach
Arterial Blood Gas (ABG) results provide valuable information about a patient’s acid-base balance and oxygenation status. Understanding ABG results requires a systematic approach. The Resuscitation Council (UK) recommends a five-step approach to assessing ABGs.
Step 1: Assess the patient and their oxygenation status. A pa(O2) level of >10 kPa is considered normal.
Step 2: Determine if the patient is acidotic (pH <7.35) or alkalotic (pH >7.45).
Step 3: Evaluate the respiratory component of the acid-base balance. A high pa(CO2) level (>6.0) suggests respiratory acidosis or compensation for metabolic alkalosis, while a low pa(CO2) level (<4.5) suggests respiratory alkalosis or compensation for metabolic acidosis. Step 4: Evaluate the metabolic component of the acid-base balance. A high bicarbonate (HCO3) level (>26 mmol) suggests metabolic alkalosis or renal compensation for respiratory acidosis, while a low bicarbonate level (<22 mmol) suggests metabolic acidosis or renal compensation for respiratory alkalosis. Step 5: Interpret the results in the context of the patient’s clinical history and presentation. It is important to note that ABG results should not be interpreted in isolation. A thorough clinical assessment is necessary to fully understand a patient’s acid-base balance and oxygenation status.
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This question is part of the following fields:
- Respiratory
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Question 14
Correct
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After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the respiratory consultant discusses the anatomy of the lungs with a group of undergraduate students.
With regard to the lungs, which one of the following statements is accurate?Your Answer: The lungs receive a dual blood supply
Explanation:Facts about the Anatomy of the Lungs
The lungs are a vital organ responsible for respiration. Here are some important facts about their anatomy:
– The lungs receive a dual blood supply from the pulmonary artery and the bronchial arteries. A pulmonary embolus may only result in infarction when the circulation is already inadequate.
– The left lung has two lobes, while the right lung has three. The horizontal fissure is present only in the right lung.
– Each lung has ten bronchopulmonary segments, which can be selectively removed surgically if diseased.
– The right bronchus is shorter, wider, and more vertical than the left bronchus, making it more likely for foreign bodies to enter it. Aspiration pneumonia and abscess formation are common in the apical segment of the right lower lobe.Important Facts about the Anatomy of the Lungs
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 60-year-old man comes to you with complaints of increasing shortness of breath on exertion over the past year. During the examination, you observe early finger clubbing and bibasal fine crackles on auscultation. You suspect that he may have pulmonary fibrosis.
What is the imaging modality considered the gold standard for diagnosing pulmonary fibrosis?Your Answer: Ventilation–perfusion (V/Q) chest scan
Correct Answer: High-resolution computed tomography (HRCT) chest
Explanation:Imaging Modalities for Pulmonary Fibrosis and Pulmonary Embolus
When it comes to diagnosing pulmonary fibrosis and pulmonary embolus, there are several imaging modalities available. High-resolution computed tomography (HRCT) chest is considered the gold standard for suspected pulmonary fibrosis as it provides detailed images of the lung parenchyma. On the other hand, computed tomography pulmonary angiogram (CTPA) is the gold standard for suspected pulmonary embolus. A chest X-ray may be useful initially for investigating patients with suspected pulmonary fibrosis, but HRCT provides more detail. Ventilation-perfusion (V/Q) chest scan is used for certain patients with suspected pulmonary embolus, but not for pulmonary fibrosis. Magnetic resonance imaging (MRI) chest is not commonly used for either condition, as HRCT remains the preferred imaging modality for pulmonary fibrosis.
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This question is part of the following fields:
- Respiratory
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Question 16
Correct
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A 28-year-old man with cystic fibrosis (CF) arrives at the Emergency Department (ED) with haemoptysis. During his stay in the ED, he experiences another episode of frank haemoptysis, which measures 180 ml.
A prompt computed tomography (CT) aortogram is conducted, revealing dilated and tortuous bronchial arteries.
What action could potentially harm the management of this patient?Your Answer: Non-invasive ventilation
Explanation:Treatment options for massive haemoptysis in cystic fibrosis patients
Massive haemoptysis in cystic fibrosis (CF) patients can be a life-threatening complication. Non-invasive ventilation is not recommended as it may increase the risk of aspiration of blood and disturb clot formation. IV antibiotics should be given to treat acute inflammation related to pulmonary infection. Tranexamic acid, an anti-fibrinolytic drug, can be given orally or intravenously up to four times per day until bleeding is controlled. CF patients have impaired absorption of fat-soluble vitamins, including vitamin K, which may lead to prolonged prothrombin time. In such cases, IV vitamin K should be given. Bronchial artery embolisation is often required to treat massive haemoptysis, particularly when larger hypertrophied bronchial arteries are seen on CT. This procedure is performed by an interventional vascular radiologist and may be done under sedation or general anaesthetic if the patient is in extremis.
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This question is part of the following fields:
- Respiratory
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Question 17
Incorrect
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A 29-year-old electrician was referred to the hospital by his general practitioner. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for the past three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. On the day of referral, he reported mild dyspnea, a global headache, myalgia, and arthralgia. During the examination, a maculopapular rash was observed on his upper body, and fine crackles were audible in the left mid-zone of his chest. Mild neck stiffness was also noted. His vital signs showed a fever of 39°C and a blood pressure of 120/70 mmHg.
The following investigations were conducted:
- Hb: 84 g/L (130-180)
- WBC: 8 ×109/L (4-11)
- Platelets: 210 ×109/L (150-400)
- Reticulocytes: 8% (0.5-2.4)
- Na: 137 mmol/L (137-144)
- K: 4.2 mmol/L (3.5-4.9)
- Urea: 5.0 mmol/L (2.5-7.5)
- Creatinine: 110 µmol/L (60-110)
- Bilirubin: 19 µmol/L (1-22)
- Alk phos: 130 U/L (45-105)
- AST: 54 U/L (1-31)
- GGT: 48 U/L (<50)
The chest x-ray revealed patchy consolidation in both mid-zones. What is the most appropriate course of treatment?Your Answer:
Correct Answer: Clarithromycin
Explanation:Mycoplasma Pneumonia: Symptoms, Complications, and Treatment
Mycoplasma pneumonia is a type of pneumonia that commonly affects individuals aged 15-30 years. It is characterized by systemic upset, dry cough, and fever, with myalgia and arthralgia being common symptoms. Unlike other types of pneumonia, the white blood cell count is often within the normal range. In some cases, Mycoplasma pneumonia can also cause extrapulmonary manifestations such as haemolytic anaemia, renal failure, hepatitis, myocarditis, meningism and meningitis, transverse myelitis, cerebellar ataxia, and erythema multiforme.
One of the most common complications of Mycoplasma pneumonia is haemolytic anaemia, which is associated with the presence of cold agglutinins found in up to 50% of cases. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies in paired sera. Treatment typically involves the use of macrolide antibiotics such as clarithromycin or erythromycin, with tetracycline or doxycycline being alternative options.
In summary, Mycoplasma pneumonia is a type of pneumonia that can cause a range of symptoms and complications, including haemolytic anaemia and extrapulmonary manifestations. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies, and treatment typically involves the use of macrolide antibiotics.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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A 36-year-old woman of African origin presented to the Emergency Department with sudden-onset dyspnoea. She was a known case of systemic lupus erythematosus (SLE), previously treated for nephropathy and presently on mycophenolate mofetil and hydroxychloroquine sulfate. She had no fever. On examination, her respiratory rate was 45 breaths per minute, with coarse crepitations in the right lung base. After admission, blood test results revealed:
Investigation Value Normal range
Haemoglobin 100g/l 115–155 g/l
Sodium (Na+) 136 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
PaO2on room air 85 mmHg 95–100 mmHg
C-reactive protein (CRP) 6.6mg/l 0-10 mg/l
C3 level 41 mg/dl 83–180 mg/dl
Which of the following is most likely to be found in this patient as the cause for her dyspnoea?Your Answer:
Correct Answer: High diffusing capacity of the lungs for carbon monoxide (DLCO)
Explanation:This case discusses diffuse alveolar haemorrhage (DAH), a rare but serious complication of systemic lupus erythematosus (SLE). Symptoms include sudden-onset shortness of breath, decreased haematocrit levels, and possibly coughing up blood. A chest X-ray may show diffuse infiltrates and crepitations in the lungs. It is important to rule out infections before starting treatment with methylprednisolone or cyclophosphamide. A high DLCO, indicating increased diffusion capacity across the alveoli, may be present in DAH. A pulmonary function test may not be possible due to severe dyspnoea, so diagnosis is based on clinical presentation, imaging, and bronchoscopy. Lung biopsy may show pulmonary capillaritis with neutrophilic infiltration. A high ESR is non-specific and sputum for AFB is not relevant in this acute presentation. BAL fluid in DAH is progressively haemorrhagic, and lung scan with isotopes is not typical for this condition.
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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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A 58-year-old Afro-Caribbean man presents to you with increasing difficulty in breathing and shortness of breath. A chest examination reveals decreased expansion on the right side of the chest, along with decreased breath sounds and stony dullness to percussion. A chest X-ray reveals a pleural effusion which you proceed to tap for diagnostic serum biochemistry, cytology and culture. The cytology and culture results are still awaited, although the serum biochemistry returns back showing the following:
Pleural fluid protein 55 g/dl
Pleural fluid cholesterol 4.5 g/dl
Pleural fluid lactate dehydrogenase (LDH) : serum ratio 0.7
Which of the following might be considered as a diagnosis in this patient?Your Answer:
Correct Answer: Sarcoidosis
Explanation:Differentiating Causes of Pleural Effusion: Sarcoidosis, Myxoedema, Meigs Syndrome, Cardiac Failure, and Nephrotic Syndrome
When analyzing a pleural effusion, the protein levels can help differentiate between potential causes. An exudate pleural effusion, with protein levels greater than 30 g/l, can be caused by inflammatory or malignant conditions such as sarcoidosis, tuberculosis, or carcinoma. However, if the protein level falls between 25 and 35 g/l, Light’s criteria should be applied to accurately differentiate. On the other hand, a transudate pleural effusion, with protein levels less than 30 g/l, can be caused by conditions such as myxoedema or cardiac failure. Meigs syndrome, a pleural effusion caused by a benign ovarian tumor, and nephrotic syndrome, which causes a transudate pleural effusion, can also be ruled out based on the biochemistry results. It is important to consider all potential causes and conduct further investigations to properly diagnose and manage the underlying condition.
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This question is part of the following fields:
- Respiratory
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Question 20
Incorrect
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A 65-year-old man with chronic obstructive pulmonary disease (COPD) continues to be breathless at rest despite maximal inhaler therapy, pulmonary rehabilitation and home oxygen therapy. He has been reviewed for lung volume reduction surgery but was deemed unsuitable. He is referred for consideration of lung transplantation.
His FEV1 is 30% predicted, he has not smoked for 12 years, and his past medical history includes bowel cancer, for which he underwent partial colectomy and adjunctive chemotherapy six years previously without evidence of recurrence on surveillance, and pulmonary tuberculosis age 37, which was fully sensitive and treated with six months of anti-tuberculous therapy. The patient’s body mass index (BMI) is 29 kg/m2.
What feature in this patient’s history would make him ineligible for listing for lung transplantation at this time?Your Answer:
Correct Answer: FEV1 30% predicted
Explanation:Contraindications for Lung Transplantation in a Patient with COPD
Lung transplantation is a potential treatment option for patients with end-stage chronic obstructive pulmonary disease (COPD). However, certain factors may make a patient ineligible for the procedure.
One important factor is the patient’s forced expiratory volume in one second (FEV1) percentage predicted. The International Society for Heart and Lung Transplantation recommends a minimum FEV1 of less than 25% predicted for lung transplantation. In addition, patients must have a Body mass index, airflow Obstruction, Dyspnea and Exercise capacity (BODE) index of 5 to 6, a PaCO2 > 6.6 kPa and/or a PaO2 < 8 kPa. A previous history of pulmonary tuberculosis is also a contraindication to lung transplantation, as active infection with Mycobacterium tuberculosis can complicate the procedure. The patient’s body mass index (BMI) is another important consideration. A BMI greater than 35 kg/m2 is an absolute contraindication to transplant, while a BMI between 30 and 35 kg/m2 is a relative contraindication. Age is also a factor, with patients over 65 years old being considered a relative contraindication to lung transplantation. However, there is no absolute age limit for the procedure. Finally, a previous history of malignancy may also impact a patient’s eligibility for lung transplantation. If the malignancy has a low risk of recurrence, such as basal cell carcinoma, patients may be considered for transplant after two years. For most other cancers, a five-year period without recurrence is required. In this case, the patient’s previous malignancy occurred six years ago and would not be an absolute contraindication to transplantation.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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What is the most effective tool for assessing a patient who is suspected of having occupational asthma?
Your Answer:
Correct Answer: Serial measurements of ventilatory function performed before, during, and after work
Explanation:Occupational Asthma
Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable airflow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases. To diagnose occupational asthma, several investigations are conducted, including serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. A consistent fall in peak flow values and increased intraday variability on working days, along with improvement on days away from work, confirms the diagnosis of occupational asthma. It is important to understand the causes and symptoms of occupational asthma to prevent and manage this condition effectively.
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This question is part of the following fields:
- Respiratory
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Question 22
Incorrect
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A 30-year-old man is brought to the Emergency Department after he suddenly collapsed while playing soccer, complaining of pleuritic chest pain and difficulty in breathing. Upon examination, the patient appears pale and short of breath. His pulse rate is 120 bpm and blood pressure is 105/60 mmHg. Palpation reveals a deviated trachea to the right, without breath sounds over the left lower zone on auscultation. Percussion of the left lung field is hyper-resonant.
What would be the most appropriate immediate management for this patient?Your Answer:
Correct Answer: Oxygen and aspirate using a 16G cannula inserted into the second anterior intercostal space mid-clavicular line
Explanation:A pneumothorax is a condition where air accumulates in the pleural space between the parietal and visceral pleura. It can be primary or secondary, with the latter being more common in patients over 50 years old, smokers, or those with underlying lung disease. Symptoms include sudden chest pain, breathlessness, and, in severe cases, pallor, tachycardia, and hypotension. Primary spontaneous pneumothorax is more common in young adult smokers and often recurs. Secondary pneumothorax is associated with various lung diseases, including COPD and α-1-antitrypsin deficiency. A tension pneumothorax is a medical emergency that can lead to respiratory or cardiovascular compromise. Diagnosis is usually made through chest X-ray, but if a tension pneumothorax is suspected, treatment should be initiated immediately. Management varies depending on the size and type of pneumothorax, with larger pneumothoraces requiring aspiration or chest drain insertion. The safest location for chest drain insertion is the fifth intercostal space mid-axillary line within the safe triangle.
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This question is part of the following fields:
- Respiratory
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Question 23
Incorrect
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A 14-year-old male is brought in with acute severe asthma. During examination, it is noted that his peripheral pulse volume decreases during inspiration. What is the most probable reason for this clinical finding?
Your Answer:
Correct Answer: Reduced left atrial filling pressure on inspiration
Explanation:Pulsus Paradoxus
Pulsus paradoxus is a medical condition where there is an abnormal drop in blood pressure during inhalation. This occurs when the right heart responds directly to changes in intrathoracic pressure, while the filling of the left heart depends on the pulmonary vascular volume. In cases of severe airflow limitation, such as acute asthma, high respiratory rates can cause sudden negative intrathoracic pressure during inhalation. This enhances the normal fall in blood pressure, leading to pulsus paradoxus.
It is important to understand the underlying mechanisms of pulsus paradoxus to properly diagnose and treat the condition. By recognizing the relationship between intrathoracic pressure and blood pressure, healthcare professionals can provide appropriate interventions to manage the symptoms and prevent complications. With proper management, patients with pulsus paradoxus can lead healthy and fulfilling lives.
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This question is part of the following fields:
- Respiratory
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Question 24
Incorrect
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An 80-year-old man comes to the clinic complaining of increasing shortness of breath and dry cough over the past three months. He gets breathless after walking a few hundred metres. He is a non-smoker and takes medication for type II diabetes mellitus. During examination, his pulse is 80/minute and regular, blood pressure (BP) 130/70 mmHg, bilateral clubbing of digits, oxygen saturation (SpO2) in room air is 90%. Auscultation reveals bilateral, fine, late inspiratory crackles, more marked in the mid-zones and at the lung bases. Chest X-ray reveals patchy shadowing at the lung bases. What is the definitive investigation to guide his management?
Your Answer:
Correct Answer: High-resolution computed tomography (HRCT) chest
Explanation:High-resolution computed tomography (HRCT) chest is the most reliable test for diagnosing idiopathic pulmonary fibrosis (IPF). The radiological pattern seen in IPF is called usual interstitial pneumonia (UIP), which is characterized by honeycombing, reticular opacities, and lung architectural distortion. In advanced cases, there may be lobar volume loss, particularly in the lower lobes.
Antinuclear antibody (ANA) and anti-cyclic citrullinated peptide (anti-CCP) tests are not useful for diagnosing IPF, as they are typically normal or only mildly elevated in this condition. These tests may be helpful in diagnosing interstitial lung disease associated with rheumatologic conditions, such as systemic lupus erythematosus or rheumatoid arthritis.
Arterial blood gas (ABG) analysis can be performed in patients with IPF who are experiencing respiratory distress. This test typically shows type I respiratory failure with low oxygen levels and normal or decreased carbon dioxide levels. However, ABG analysis is not the definitive test for diagnosing IPF.
Bronchoalveolar lavage may be considered if HRCT chest cannot detect the UIP pattern, but it is not typically necessary for diagnosing IPF.
Pulmonary function tests (PFTs) can help differentiate between obstructive and restrictive lung diseases. In IPF, PFTs typically show a restrictive pattern, with decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), and a normal or increased FEV1/FVC ratio. While PFTs are a useful initial test for evaluating lung function in patients with suspected IPF, they are not definitive for establishing a diagnosis.
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This question is part of the following fields:
- Respiratory
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Question 25
Incorrect
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A 49-year-old farmer presented with progressive dyspnoea. He had a dry cough and exercise intolerance. On examination, few crackles were found in the upper zones of both lungs. Surgical lung biopsy was done which was reported as:
Interstitial inflammation, chronic bronchiolitis, and two foci of non-necrotizing granuloma.
What is the most likely clinical diagnosis?Your Answer:
Correct Answer: Hypersensitivity pneumonitis
Explanation:Differentiating Lung Disorders: Histological Features
Hypersensitivity Pneumonitis: This lung disorder is caused by a hypersensitivity reaction to mouldy hay or other organic materials. A farmer is likely to develop this condition due to exposure to such materials. The histological triad of hypersensitivity pneumonitis includes lymphocytic alveolitis, non-caseating granulomas, and poorly formed granulomas.
Aspergillosis: This lung disorder is rarely invasive. In cases where it is invasive, lung biopsy shows hyphae with vascular invasion and surrounding tissue necrosis.
Sarcoidosis: This lung disorder of unknown aetiology presents with non-caseating granuloma. Schumann bodies, which are calcified, rounded, laminated concretions inside the non-caseating granuloma, are found in sarcoidosis. The granulomas are formed of foreign body giant cells. Within the giant cells, there are star-shaped inclusions called asteroid bodies.
Histiocytosis X: This lung disorder presents with scattered nodules of Langerhans cells. Associated with it are eosinophils, macrophages, and giant cells. The Langerhans cells contain racket-shaped Birbeck granules.
Tuberculosis: This lung disorder typically has caseating granulomas in the lung parenchyma. There is also fibrosis in later stages. Ziehl–Neelsen staining of the smear reveals acid-fast bacilli (AFB) in many cases. Vasculitic lesions can also be found.
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This question is part of the following fields:
- Respiratory
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Question 26
Incorrect
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A 42-year-old man presents to the Emergency Department with complaints of severe breathlessness after being exposed to smoke during a house fire. He reports vomiting twice and experiencing a headache and dizziness.
Upon examination, the patient is found to be tachypnoeic with good air entry, and his oxygen saturations are at 100% on air. He appears drowsy, but his Glasgow Coma Scale (GCS) score is 15, and there are no signs of head injury on his neurological examination.
What is the initial step in managing this patient's condition?Your Answer:
Correct Answer: High-flow oxygen
Explanation:Treatment Options for Smoke Inhalation Injury
Smoke inhalation injury can lead to carbon monoxide (CO) poisoning, which is characterized by symptoms such as headache, dizziness, and vomiting. It is important to note that normal oxygen saturation may be present despite respiratory distress due to the inability of a pulse oximeter to differentiate between carboxyhaemoglobin and oxyhaemoglobin. Therefore, any conscious patient with suspected CO poisoning should be immediately treated with high-flow oxygen, which can reduce the half-life of carboxyhaemoglobin from up to four hours to 90 minutes.
Cyanide poisoning, which is comparatively rare, can also be caused by smoke inhalation. The treatment of choice for cyanide poisoning is a combination of hydroxocobalamin and sodium thiosulphate.
Hyperbaric oxygen may be beneficial for managing patients with CO poisoning, but high-flow oxygen should be provided immediately while waiting for initiation. Indications for hyperbaric oxygen include an unconscious patient, COHb > 25%, pH < 7.1, and evidence of end-organ damage due to CO poisoning. Bronchodilators such as nebulised salbutamol and ipratropium may be useful as supportive care in cases of inhalation injury where signs of bronchospasm occur. However, in this case, compatible signs such as wheeze and reduced air entry are not present. Metoclopramide may provide symptomatic relief of nausea, but it does not replace the need for immediate high-flow oxygen. Therefore, it is crucial to prioritize the administration of high-flow oxygen in patients with suspected smoke inhalation injury. Managing Smoke Inhalation Injury: Treatment Options and Priorities
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A 41-year-old man presents with wheezing and shortness of breath. He reports no history of smoking or drug use. An ultrasound reveals cirrhosis of the liver, and he is diagnosed with alpha-1-antitrypsin deficiency. He undergoes a liver transplant. What type of emphysema is he now at higher risk of developing?
Your Answer:
Correct Answer: Panacinar
Explanation:Different Types of Emphysema and Their Characteristics
Emphysema is a lung condition that has various forms, each with its own distinct characteristics. The four main types of emphysema are panacinar, compensatory, interstitial, centriacinar, and paraseptal.
Panacinar emphysema affects the entire acinus, from the respiratory bronchiole to the distal alveoli. It is often associated with α-1-antitrypsin deficiency.
Compensatory emphysema occurs when the lung parenchyma is scarred, but it is usually asymptomatic.
Interstitial emphysema is not a true form of emphysema, but rather occurs when air penetrates the pulmonary interstitium. It can be caused by chest wounds or alveolar tears resulting from coughing and airway obstruction.
Centriacinar emphysema is characterized by enlargement of the central portions of the acinus, specifically the respiratory bronchiole. It is often caused by exposure to coal dust and tobacco products.
Paraseptal emphysema is associated with scarring and can lead to spontaneous pneumothorax in young patients. It is more severe when it occurs in areas adjacent to the pleura, where it can cause the development of large, cyst-like structures that can rupture into the pleural cavity.
In summary, understanding the different types of emphysema and their characteristics is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 28
Incorrect
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A 27-year-old man comes to the doctor complaining of anorexia, decreased appetite, night sweats, and weight loss over the last six months. He has been coughing up phlegm and experiencing occasional fevers for the past month. A chest X-ray reveals a sizable (4.5 cm) cavity in the upper left lobe. What diagnostic test would provide a conclusive diagnosis?
Your Answer:
Correct Answer: Sputum sample
Explanation:Diagnostic Methods for Tuberculosis
Tuberculosis (TB) is a bacterial infection that primarily affects the lungs. The diagnosis of TB relies on various diagnostic methods. Here are some of the commonly used diagnostic methods for TB:
Sputum Sample: The examination and culture of sputum or other respiratory tract specimens can help diagnose pulmonary TB. The growth of Mycobacterium tuberculosis from respiratory secretions confirms the diagnosis.
Blood Cultures: Blood cultures are rarely positive in TB. A probable diagnosis can be based on typical clinical and chest X-ray findings, together with either sputum positive for acid-fast bacilli or typical histopathological findings on biopsy material.
Computed Tomography (CT) Scanning of the Chest: CT imaging can provide clinical information and be helpful in ascertaining the likelihood of TB, but it will not provide a definitive diagnosis.
Mantoux Test: The Mantoux test is primarily used to diagnose latent TB. It may be strongly positive in active TB, but it does not give a definitive diagnosis of active TB. False-positive tests can occur with previous Bacillus Calmette–Guérin (BCG) vaccination and infection with non-tuberculous mycobacteria. False-negative results can occur in overwhelming TB, immunocompromised, previous TB, and some viral illnesses like measles and chickenpox.
Serum Inflammatory Markers: Serum inflammatory markers are not specific enough to diagnose TB if raised.
In conclusion, a combination of diagnostic methods is often used to diagnose TB. The definitive diagnosis requires the growth of Mycobacterium tuberculosis from respiratory secretions.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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A 44-year-old woman who is undergoing treatment for breast cancer has collapsed and has been brought to the Emergency Department. Upon regaining consciousness, she reports experiencing chest pain, shortness of breath, and reduced exercise capacity for the past 3 days. During auscultation, a loud pulmonary second heart sound is detected. An electrocardiogram (ECG) reveals right axis deviation and tall R-waves with T-wave inversion in V1-V3. The chest X-ray appears normal.
What is the most probable diagnosis?Your Answer:
Correct Answer: Multiple pulmonary emboli
Explanation:Differential Diagnosis for a Patient with Collapse and Reduced Exercise Capacity
A patient presents with collapse and reduced exercise capacity. Upon examination, there is evidence of right ventricular hypertrophy and pulmonary hypertension (loud P2). The following are potential diagnoses:
1. Multiple Pulmonary Emboli: This is the most likely cause, especially given the patient’s underlying cancer that predisposes to deep vein thrombosis. A computed tomography pulmonary angiography is the investigation of choice.
2. Hypertrophic Cardiomyopathy (HCM): While HCM could present with collapse and ECG changes, it is less common and not known to cause shortness of breath. The patient’s risk factors of malignancy, symptoms of shortness of breath, and signs of a loud pulmonary second heart sound make pulmonary embolism more likely than HCM.
3. Idiopathic Pulmonary Arterial Hypertension: This condition can present with reduced exercise capacity, chest pain, and syncope, loud P2, and features of right ventricular hypertrophy. However, it is less common, and the patient has an obvious predisposing factor to thrombosis, making pulmonary emboli a more likely diagnosis.
4. Angina: Angina typically presents with exertional chest pain and breathlessness, which is not consistent with the patient’s history.
5. Ventricular Tachycardia: While ventricular tachycardia can cause collapse, it does not explain any of the other findings.
In summary, multiple pulmonary emboli are the most likely cause of the patient’s symptoms, but other potential diagnoses should also be considered.
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This question is part of the following fields:
- Respiratory
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Question 30
Incorrect
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After a tennis match, a thin 25-year-old woman complains of left-sided chest pain that radiates into her abdomen. The physical examination reveals reduced air entry at the left base of the lung with hyper-resonant percussion sounds at the left side of the chest. The abdominal examination shows generalised tenderness. A few minutes later she develops cyanosis.
What is the diagnosis?Your Answer:
Correct Answer: Tension pneumothorax
Explanation:Differentiating Tension Pneumothorax from Other Conditions: Clinical Features and Management
Tension pneumothorax is a medical emergency that occurs when the pressure in the pleural space exceeds atmospheric pressure during both inspiration and expiration. This can lead to impaired venous return, reduced cardiac output, and hypoxemia. The development of tension pneumothorax is not dependent on the size of the pneumothorax, and clinical presentation can be sudden and severe, with rapid, labored respiration, cyanosis, sweating, and tachycardia.
It is important to differentiate tension pneumothorax from other conditions that may present with similar symptoms. Acute pancreatitis, ectopic pregnancy, myocardial infarction, and pulmonary embolism can all cause abdominal pain and other non-specific symptoms, but they do not typically present with decreased air entry and hyper-resonant percussion note, which are indicative of pneumothorax.
Prompt management of tension pneumothorax is crucial and involves inserting a cannula into the pleural space to remove air until the patient is no longer compromised, followed by insertion of an intercostal tube. Advanced Trauma Life Support (ATLS) guidelines recommend using a cannula of at least 4.5 cm in length for needle thoracocentesis in patients with tension pneumothorax. The cannula should be left in place until bubbling is confirmed in the underwater-seal system to ensure proper function of the intercostal tube.
In summary, recognizing the clinical features of tension pneumothorax and differentiating it from other conditions is essential for prompt and effective management.
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This question is part of the following fields:
- Respiratory
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