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  • Question 1 - A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25...

    Incorrect

    • A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25 lb weight loss over the last 4 months. He reports a medical history significant for mild asthma controlled with an albuterol inhaler as needed. He takes no other medications and has no allergies. He has a 55 pack-year smoking history and has worked as a naval shipyard worker for 40 years. Examination reveals diffuse crackles in the posterior lung fields bilaterally and there is dullness to percussion one-third of the way up the right lung field. Ultrasound reveals free fluid in the pleural space.
      Which one of the following set of test values is most consistent with this patient’s presentation?
      (LDH: lactate dehydrogenase)
      Option LDH plasma LDH pleural Protein plasma Protein pleural
      A 180 100 7 3
      B 270 150 8 3
      C 180 150 7 4
      D 270 110 8 3
      E 180 100 7 2

      Your Answer: Option A

      Correct Answer: Option C

      Explanation:

      Interpreting Light’s Criteria for Pleural Effusions

      When evaluating a patient with a history of occupational exposure and respiratory symptoms, it is important to consider the possibility of pneumoconiosis, specifically asbestosis. Chronic exposure to asbestos can lead to primary bronchogenic carcinoma and mesothelioma. Chest radiography may reveal radio-opaque pleural and diaphragmatic plaques. In this case, the patient’s dyspnea, hemoptysis, and weight loss suggest primary lung cancer, with a likely malignant pleural effusion observed under ultrasound.

      To confirm the exudative nature of the pleural effusion, Light’s criteria can be used. These criteria include a pleural:serum protein ratio >0.5, a pleural:serum LDH ratio >0.6, and pleural LDH more than two-thirds the upper limit of normal serum LDH. Meeting any one of these criteria indicates an exudative effusion.

      Option C is the correct answer as it satisfies Light’s criteria for an exudative pleural effusion. Options A, B, D, and E do not meet the criteria. Understanding Light’s criteria can aid in the diagnosis and management of pleural effusions, particularly in cases where malignancy is suspected.

    • This question is part of the following fields:

      • Respiratory
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  • Question 2 - A 27-year-old man comes to the doctor complaining of anorexia, decreased appetite, night...

    Incorrect

    • 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: Computed tomography (CT) scanning of the chest

      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.

    • This question is part of the following fields:

      • Respiratory
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  • Question 3 - A 30-year-old woman with asthma presented with rapidly developing asthma and wheezing. She...

    Incorrect

    • A 30-year-old woman with asthma presented with rapidly developing asthma and wheezing. She was admitted, and during her treatment, she coughed out tubular gelatinous materials. A chest X-ray showed collapse of the lingular lobe.
      What is this clinical spectrum better known as?

      Your Answer: Cardiac asthma

      Correct Answer: Plastic bronchitis

      Explanation:

      Respiratory Conditions: Plastic Bronchitis, Loeffler Syndrome, Lofgren Syndrome, Cardiac Asthma, and Croup

      Plastic Bronchitis: Gelatinous or rigid casts form in the airways, leading to coughing. It is associated with asthma, bronchiectasis, cystic fibrosis, and respiratory infections. Treatment involves bronchial washing, sputum induction, and preventing infections. Bronchoscopy may be necessary for therapeutic removal of the casts.

      Loeffler Syndrome: Accumulation of eosinophils in the lungs due to parasitic larvae passage. Charcot-Leyden crystals may be present in the sputum.

      Lofgren Syndrome: Acute presentation of sarcoidosis with hilar lymphadenopathy and erythema nodosum. Usually self-resolving.

      Cardiac Asthma: Old term for acute pulmonary edema, causing peribronchial fluid collection and wheezing. Pink frothy sputum is produced.

      Croup: Acute pharyngeal infection in children aged 6 months to 3 years, presenting with stridor.

    • This question is part of the following fields:

      • Respiratory
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  • Question 4 - A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing,...

    Incorrect

    • A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing, with an AMTS score of 9. During the examination, his respiratory rate is 32 breaths/minute, and his blood pressure is 100/70 mmHg. His blood test shows a urea level of 6 mmol/l. What is a predictive factor for increased mortality in this pneumonia patient?

      Your Answer:

      Correct Answer: Respiratory rate >30 breaths/minute

      Explanation:

      Prognostic Indicators in Pneumonia: Understanding the CURB 65 Score

      The CURB 65 score is a widely used prognostic tool for patients with pneumonia. It consists of five indicators, including confusion, urea levels, respiratory rate, blood pressure, and age. A respiratory rate of >30 breaths/minute and new-onset confusion with an AMTS score of <8 are two of the indicators that make up the CURB 65 score. However, in the case of a patient with a respiratory rate of 32 breaths/minute and an AMTS score of 9, these indicators still suggest a poor prognosis. A urea level of >7 mmol/l and a blood pressure of <90 mmHg systolic and/or 60 mmHg diastolic are also indicators of a poor prognosis. Finally, age >65 is another indicator that contributes to the CURB 65 score. Understanding these indicators can help healthcare professionals assess the severity of pneumonia and determine appropriate treatment plans.

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      • Respiratory
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  • Question 5 - A 63-year-old man who used to work as a stonemason presents to the...

    Incorrect

    • A 63-year-old man who used to work as a stonemason presents to the clinic with complaints of shortness of breath on minimal exercise and a dry cough. He has been experiencing progressive shortness of breath over the past year. He is a smoker, consuming 20-30 cigarettes per day, and has occasional wheezing. On examination, he is clubbed and bilateral late-inspiratory crackles can be heard at both lung bases. A chest X-ray shows upper lobe nodular opacities. His test results show a haemoglobin level of 125 g/l (normal range: 135-175 g/l), a WCC of 4.6 × 109/l (normal range: 4-11 × 109/l), platelets of 189 × 109/l (normal range: 150-410 × 109/l), a sodium level of 139 mmol/l (normal range: 135-145 mmol/l), a potassium level of 4.9 mmol/l (normal range: 3.5-5.0 mmol/l), a creatinine level of 135 μmol/l (normal range: 50-120 μmol/l), an FVC of 2.1 litres (normal range: >4.05 litres), and an FEV1 of 1.82 litres (normal range: >3.15 litres). Based on these findings, what is the most likely diagnosis?

      Your Answer:

      Correct Answer: Occupational interstitial lung disease

      Explanation:

      Possible Occupational Lung Diseases and Differential Diagnosis

      This patient’s history of working as a stonemason suggests a potential occupational exposure to silica dust, which can lead to silicosis. The restrictive lung defect seen in pulmonary function tests supports this diagnosis, which can be confirmed by high-resolution computerised tomography. Smoking cessation is crucial in slowing the progression of lung function decline.

      Idiopathic pulmonary fibrosis is another possible diagnosis, but the occupational exposure makes silicosis more likely. Occupational asthma, caused by specific workplace stimuli, is also a consideration, especially for those in certain occupations such as paint sprayers, food processors, welders, and animal handlers.

      Chronic obstructive pulmonary disease (COPD) is unlikely due to the restrictive spirometry results, as it is characterised by an obstructive pattern. Non-occupational asthma is also less likely given the patient’s age, chest X-ray findings, and restrictive lung defect.

      In summary, the patient’s occupational history and pulmonary function tests suggest a potential diagnosis of silicosis, with other possible occupational lung diseases and differential diagnoses to consider.

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      • Respiratory
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  • Question 6 - A 46-year-old man, who had been working abroad in the hard metal industry,...

    Incorrect

    • A 46-year-old man, who had been working abroad in the hard metal industry, presented with progressive dyspnoea. A chest X-ray showed diffuse interstitial fibrosis bilaterally. What is the typical cellular component found in a bronchoalveolar lavage (BAL) of this patient?

      Your Answer:

      Correct Answer: Giant cells

      Explanation:

      Understanding Giant Cell Interstitial Pneumonia in Hard Metal Lung Disease

      Hard metal lung disease is a condition that affects individuals working in the hard metal industry, particularly those exposed to cobalt dust. Prolonged exposure can lead to fibrosis and the development of giant cell interstitial pneumonia (GIP), characterized by bizarre multinucleated giant cells in the alveoli. These cannibalistic cells are formed by alveolar macrophages and type II pneumocytes and can contain ingested macrophages. While cobalt exposure can also cause other respiratory conditions, GIP is a rare but serious complication that may require lung transplantation in severe cases. Understanding the significance of different cell types found in bronchoalveolar lavage can aid in the diagnosis and management of this disease.

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      • Respiratory
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  • Question 7 - A 5-year-old girl comes to her general practice clinic with her mother. She...

    Incorrect

    • A 5-year-old girl comes to her general practice clinic with her mother. She has been experiencing nasal congestion, sneezing, and a sore throat for the past few days. During the examination, her pulse rate is 80 bpm, respiratory rate is 20 breaths per minute, and temperature is 36.9 °C. She has no significant medical history. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Common cold

      Explanation:

      Possible Diagnosis for a Young Girl with Respiratory Symptoms

      A young girl is experiencing respiratory symptoms, including sore throat, sneezing, and nasal congestion. Here are some possible diagnoses to consider:

      1. Common cold: This is a common viral infection that can cause mild fever, especially in children.

      2. Hay fever: This is an allergic reaction to specific allergens, such as pollen, that can cause similar symptoms to the common cold, but with a chronic and fluctuating course.

      3. Infectious mononucleosis: This is a viral infection that can cause fatigue, fever, laryngitis, and a rash, but is less likely in this case.

      4. influenzae: This is a seasonal viral infection that can cause more severe symptoms, such as high fever, headache, and muscle aches.

      5. Meningitis: This is a serious bacterial infection that can cause non-specific respiratory symptoms, but also tachycardia, hypotension, high fever, photophobia, neck stiffness, and petechial rash, which are not mentioned here.

      Possible Diagnoses for a Young Girl with Respiratory Symptoms

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      • Respiratory
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  • Question 8 - A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough,...

    Incorrect

    • A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough, and low-grade fever. He has a medical history of hypertension and was hospitalized six months ago for an acute inferior myocardial infarction complicated by left ventricular failure and arrhythmia. His chest x-ray reveals diffuse interstitial pneumonia, and further investigations show an ESR of 110 mm/h, FEV1 of 90%, FVC of 70%, and KCO of 60%. What is the most likely cause of these findings?

      Your Answer:

      Correct Answer: Amiodarone

      Explanation:

      Side Effects of Amiodarone

      Amiodarone is a medication that is known to cause several side effects. Among these, pneumonitis and pulmonary fibrosis are the most common. These conditions are characterized by a progressively-worsening dry cough, pleuritic chest pain, dyspnoea, and malaise. Other side effects of amiodarone include neutropenia, hepatitis, phototoxicity, slate-grey skin discolouration, hypothyroidism, hyperthyroidism, arrhythmias, corneal deposits, peripheral neuropathy, and myopathy. It is important to be aware of these potential side effects when taking amiodarone, and to seek medical attention if any of these symptoms occur. Proper monitoring and management can help to minimize the risk of serious complications.

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      • Respiratory
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  • Question 9 - What condition is typically linked to obstructive sleep apnea? ...

    Incorrect

    • What condition is typically linked to obstructive sleep apnea?

      Your Answer:

      Correct Answer: Hypersomnolence

      Explanation:

      Symptoms and Associations of Obstructive Sleep Apnoea

      Obstructive sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Other common symptoms include personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less frequent symptom. The condition may be associated with acromegaly, myxoedema, obesity, and micrognathia/retrognathia. Sleep apnoea is a serious condition that can lead to complications such as hypertension, cardiovascular disease, and stroke.

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  • Question 10 - A 38-year-old man from Somalia presents at your general practice surgery as a...

    Incorrect

    • 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:

      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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      • Respiratory
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  • Question 11 - A 50-year-old patient came in with worsening shortness of breath. A CT scan...

    Incorrect

    • A 50-year-old patient came in with worsening shortness of breath. A CT scan of the chest revealed a lesion in the right middle lobe of the lung. The radiologist described the findings as an area of ground-glass opacity surrounded by denser lung tissue.

      What is the more common name for this sign?

      Your Answer:

      Correct Answer: Atoll sign

      Explanation:

      Radiological Signs in Lung Imaging: Atoll, Halo, Kerley B, Signet Ring, and Tree-in-Bud

      When examining CT scans of the lungs, radiologists look for specific patterns that can indicate various pathologies. One such pattern is the atoll sign, also known as the reversed halo sign. This sign is characterized by a region of ground-glass opacity surrounded by denser tissue, forming a crescent or annular shape that is at least 2 mm thick. It is often seen in cases of cryptogenic organizing pneumonia (COP), but can also be caused by tuberculosis or other infections.

      Another important sign is the halo sign, which is seen in angioinvasive aspergillosis. This sign appears as a ground-glass opacity surrounding a pulmonary nodule or mass, indicating alveolar hemorrhage.

      Kerley B lines are another pattern that can be seen on lung imaging, indicating pulmonary edema. These lines are caused by fluid accumulation in the interlobular septae at the periphery of the lung.

      The signet ring sign is a pattern seen in bronchiectasis, where a dilated bronchus and accompanying pulmonary artery branch are visible in cross-section. This sign is characterized by a marked dilation of the bronchus, which is not seen in the normal population.

      Finally, the tree-in-bud sign is a pattern seen in endobronchial tuberculosis or other endobronchial pathologies. This sign appears as multiple centrilobular nodules with a linear branching pattern, and can also be seen in cases of cystic fibrosis or viral pneumonia.

      Overall, understanding these radiological signs can help clinicians diagnose and treat various lung pathologies.

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      • Respiratory
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  • Question 12 - A 67-year-old woman has had bowel surgery two days ago. She is currently...

    Incorrect

    • A 67-year-old woman has had bowel surgery two days ago. She is currently on postoperative day one, and you are called to see her as she has developed sudden-onset shortness of breath. She denies any coughing but complains of chest discomfort. The surgical scar appears clean. Upon examination, the patient is afebrile; vital signs are stable other than rapid and irregular heartbeat and upon auscultation, the chest sounds are clear. The patient does not have any other significant past medical history, aside from her breast cancer for which she had a mastectomy five years ago. She has no family history of any heart disease.
      What is the patient’s most likely diagnosis?

      Your Answer:

      Correct Answer: Pulmonary embolism

      Explanation:

      Differential Diagnosis for Sudden Onset Shortness of Breath postoperatively

      When a patient experiences sudden onset shortness of breath postoperatively, it is important to consider various differential diagnoses. One possible diagnosis is pulmonary embolism, which is supported by the patient’s chest discomfort. Anaphylaxis is another potential diagnosis, but there is no mention of an allergen exposure or other signs of a severe allergic reaction. Pneumonia is unlikely given the absence of fever and clear chest sounds. Lung fibrosis is also an unlikely diagnosis as it typically presents gradually and is associated with restrictive respiratory diseases. Finally, cellulitis is not a probable diagnosis as there are no signs of infection and the surgical wound is clean. Overall, a thorough evaluation is necessary to determine the underlying cause of the patient’s sudden onset shortness of breath.

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      • Respiratory
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  • Question 13 - A 65 year-old man, who had recently undergone a full bone marrow transplantation...

    Incorrect

    • A 65 year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. There was an associated dry cough, but no fever. Examination revealed scattered wheezes and some expiratory high-pitched sounds. C-reactive protein (CRP) level was normal. Mantoux test was negative. Spirometry revealed the following report:
      FEV1 51%
      FVC 88%
      FEV1/FVC 58%
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Bronchiolitis obliterans (BO)

      Explanation:

      Respiratory Disorders: Bronchiolitis Obliterans, ARDS, Pneumocystis Pneumonia, COPD Exacerbation, and Idiopathic Pulmonary Hypertension

      Bronchiolitis obliterans (BO) is a respiratory disorder that may occur after bone marrow, heart, or lung transplant. It presents with an obstructive pattern on spirometry, low DLCO, and hypoxia. CT scan shows air trapping, and chest X-ray may show interstitial infiltrates with hyperinflation. BO may also occur in connective tissue diseases, such as rheumatoid arthritis, and idiopathic variety called cryptogenic organising pneumonia (COP). In contrast, acute respiratory distress syndrome (ARDS) patients deteriorate quickly, and pneumocystis pneumonia usually presents with normal clinical findings. Infective exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a productive cough and raised CRP, while idiopathic pulmonary hypertension has a restrictive pattern and inspiratory fine crepitations.

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      • Respiratory
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  • Question 14 - A 14-year-old boy comes to your clinic complaining of wheezing for the past...

    Incorrect

    • A 14-year-old boy comes to your clinic complaining of wheezing for the past week. His mother mentions that he had a similar issue a couple of years ago but hasn't had any problems since. He was treated with inhalers and recovered quickly at that time. The boy is an animal lover and has always had multiple pets, including dogs, cats, birds, and reptiles. He hasn't acquired any new pets in the last two months. Upon examination, there are no clinical findings. What would be the best next step to take?

      Your Answer:

      Correct Answer: Peak flow self-monitoring

      Explanation:

      Diagnosis of Wheezing in Children

      Wheezing is a common symptom in children, but it can have many causes. While asthma is a common cause of wheezing, it is important not to jump to conclusions and make a diagnosis based on conjecture alone. Instead, the next best course of action is to use a peak flow meter at home and follow up with lung function tests if necessary. It is also important to note that wheezing can sometimes be a symptom of cardiac failure, but this is not the case in the scenario presented.

      Removing pets from the home is not a necessary step at this point, as it may cause unnecessary stress for the child. Instead, if a particular pet is identified as the cause of the allergy, it can be removed at a later time. Skin patch tests for allergens are also not useful in this scenario, as they are only done in cases with high suspicion or when desensitization therapy is planned.

      In summary, a diagnosis of wheezing in children should not be made based on conjecture alone. Instead, it is important to use objective measures such as peak flow meters and lung function tests to determine the cause of the wheezing. Removing pets or conducting skin patch tests may not be necessary or useful at this point.

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      • Respiratory
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  • Question 15 - A 50-year-old man visits the Respiratory Outpatients Department complaining of a dry cough...

    Incorrect

    • A 50-year-old man visits the Respiratory Outpatients Department complaining of a dry cough and increasing breathlessness. During the examination, the doctor observes finger clubbing, central cyanosis, and fine end-inspiratory crackles upon auscultation. The chest X-ray shows reticular shadows and peripheral honeycombing, while respiratory function tests indicate a restrictive pattern with reduced lung volumes but a normal forced expiratory volume in 1 second (FEV1): forced vital capacity (FVC) ratio. The patient's pulmonary fibrosis is attributed to which of the following medications?

      Your Answer:

      Correct Answer: Bleomycin

      Explanation:

      Drug-Induced Pulmonary Fibrosis: Causes and Investigations

      Pulmonary fibrosis is a condition characterized by scarring of the lungs, which can be caused by various diseases and drugs. One drug that has been linked to pulmonary fibrosis is bleomycin, while other causes include pneumoconiosis, occupational lung diseases, and certain medications. To aid in diagnosis, chest X-rays, high-resolution computed tomography (CT), and lung function tests may be performed. Treatment involves addressing the underlying cause. However, drugs such as aspirin, ramipril, spironolactone, and simvastatin have not been associated with pulmonary fibrosis. It is important to be aware of the potential risks of certain medications and to monitor for any adverse effects.

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      • Respiratory
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  • Question 16 - A trauma call is initiated in the Emergency Department after a young cyclist...

    Incorrect

    • A trauma call is initiated in the Emergency Department after a young cyclist is brought in following a road traffic collision. The cyclist was riding on a dual carriageway when a car collided with them side-on, causing them to land in the middle of the road with severe injuries, shortness of breath, and chest pain. A bystander called an ambulance which transported the young patient to the Emergency Department. The anaesthetist on the trauma team assesses the patient and diagnoses them with a tension pneumothorax. The anaesthetist then inserts a grey cannula into the patient's second intercostal space in the mid-clavicular line. Within a few minutes, the patient expresses relief at being able to breathe more easily.

      What signs would the anaesthetist have observed during the examination?

      Your Answer:

      Correct Answer: Contralateral tracheal deviation, reduced chest expansion, increased resonance on percussion, absent breath sounds

      Explanation:

      Understanding Tension Pneumothorax: Symptoms and Treatment

      Tension pneumothorax is a medical emergency that occurs when air enters the pleural space but cannot exit, causing the pressure in the pleural space to increase and the lung to collapse. This condition can be diagnosed clinically by observing contralateral tracheal deviation, reduced chest expansion, increased resonance on percussion, and absent breath sounds. Treatment involves inserting a wide-bore cannula to release the trapped air. Delay in treatment can be fatal, so diagnosis should not be delayed by investigations such as chest X-rays. Other respiratory conditions may present with different symptoms, such as normal trachea, reduced chest expansion, reduced resonance on percussion, and normal vesicular breath sounds. Tracheal tug is a sign of severe respiratory distress in paediatrics, while ipsilateral tracheal deviation is not a symptom of tension pneumothorax. Understanding the symptoms of tension pneumothorax is crucial for prompt diagnosis and treatment.

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  • Question 17 - A 56-year-old woman presents to the Emergency Department with a 2-week history of...

    Incorrect

    • A 56-year-old woman presents to the Emergency Department with a 2-week history of productive cough with green sputum and a one day history of palpitations. She also had some rigors and fever. On examination:
      Result Normal
      Respiratory rate (RR) 26 breaths/min 12–18 breaths/min
      Sats 96% on air 94–98%
      Blood pressure (BP) 92/48 mmHg <120/80 mmHg
      Heart rate (HR) 130 bpm 60–100 beats/min
      Some bronchial breathing at left lung base, heart sounds normal however with an irregularly irregular pulse. electrocardiogram (ECG) showed fast atrial fibrillation (AF). She was previously fit and well.
      Which of the following is the most appropriate initial management?

      Your Answer:

      Correct Answer: Intravenous fluids

      Explanation:

      Treatment for AF in a Patient with Sepsis

      In a patient with sepsis secondary to pneumonia, the new onset of AF is likely due to the sepsis. Therefore, the priority is to urgently treat the sepsis with intravenous fluids and broad-spectrum antibiotics. If the AF persists after the sepsis is treated, other options for AF treatment can be considered. Bisoprolol and digoxin are not the first-line treatments for AF in this case. Oral antibiotics are not recommended for septic patients. Flecainide may be considered if the AF persists after the sepsis is treated.

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  • Question 18 - A 58-year-old woman presents with a history of recurrent cough, haemoptysis, and copious...

    Incorrect

    • A 58-year-old woman presents with a history of recurrent cough, haemoptysis, and copious amounts of mucopurulent sputum for the past 10 years. Sputum analysis shows mixed flora with anaerobes present. During childhood, she experienced multiple episodes of pneumonia.

      What is the probable diagnosis for this patient?

      Your Answer:

      Correct Answer: Bronchiectasis

      Explanation:

      Recognizing Bronchiectasis: Symptoms and Indicators

      Bronchiectasis is a respiratory condition that can be identified through several symptoms and indicators. One of the most common signs is the production of large amounts of sputum, which can be thick and difficult to cough up. Additionally, crackles may be heard when listening to the chest with a stethoscope. In some cases, finger clubbing may also be present. This occurs when the fingertips become enlarged and rounded, resembling drumsticks.

      It is important to note that bronchiectasis can be caused by a variety of factors, including childhood pneumonia or previous tuberculosis. These conditions can lead to damage in the airways, which can result in bronchiectasis.

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  • Question 19 - A 65-year-old man snores at night and his wife reports it is so...

    Incorrect

    • A 65-year-old man snores at night and his wife reports it is so loud that he often wakes her up. She notes that her husband sometimes appears to not take a breath for a long time and then gasps for air before continuing to snore. He suffers from daytime headaches and sleepiness. He has a body mass index (BMI) of 40 kg/m2.
      What would the most likely arterial blood gas result be if it was measured in this patient?

      Your Answer:

      Correct Answer: Compensated respiratory acidosis

      Explanation:

      Understanding Compensated and Uncompensated Acid-Base Disorders

      Acid-base disorders are a group of conditions that affect the pH balance of the body. Compensation is the body’s natural response to maintain a normal pH level. Here are some examples of compensated and uncompensated acid-base disorders:

      Compensated respiratory acidosis occurs in patients with obstructive sleep apnea. The kidney compensates for the chronic respiratory acidosis by increasing bicarbonate production, which buffers the increase in acid caused by carbon dioxide.

      Compensated respiratory alkalosis is seen in high-altitude areas. The kidney compensates by reducing the rate of bicarbonate reabsorption and increasing reabsorption of H+.

      Compensated metabolic acidosis occurs in patients with diabetic ketoacidosis. The body compensates by hyperventilating to release carbon dioxide and reduce the acid burden. The kidney also compensates by increasing bicarbonate production and sequestering acid into proteins.

      Uncompensated respiratory acidosis occurs in patients with Guillain–Barré syndrome, an obstructed airway, or respiratory depression from opiate toxicity. There is an abrupt failure in ventilation, leading to an acute respiratory acidosis.

      Uncompensated metabolic acidosis occurs in patients with lactic acidosis or diabetic ketoacidosis. The body cannot produce enough bicarbonate to buffer the added acid, leading to an acute metabolic acidosis.

      Understanding these different types of acid-base disorders and their compensatory mechanisms is crucial in diagnosing and treating patients with these conditions.

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  • Question 20 - An 80-year-old known alcoholic is brought by ambulance after being found unconscious on...

    Incorrect

    • An 80-year-old known alcoholic is brought by ambulance after being found unconscious on the road on a Sunday afternoon. He has a superficial laceration in the right frontal region. He is admitted for observation over the bank holiday weekend. Admission chest X-ray is normal. Before discharge on Tuesday morning, he is noted to be febrile and dyspnoeic. Blood tests reveal neutrophilia and elevated C-reactive protein (CRP) levels. A chest X-ray demonstrates consolidation in the right lower zone of the lung.
      What is the most likely diagnosis for this patient?

      Your Answer:

      Correct Answer: Aspiration pneumonia

      Explanation:

      Aspiration pneumonia is a type of pneumonia that typically affects the lower lobes of the lungs, particularly the right middle or lower lobes or left lower lobe. It occurs when someone inhales foreign material, such as vomit, into their lungs. If an alcoholic is found unconscious and has a consolidation in the lower zone of their lungs, it is highly likely that they have aspiration pneumonia. Antibiotics should be prescribed accordingly.

      Allergic bronchopulmonary aspergillosis is another condition that can cause breathlessness and consolidation on chest X-ray. However, it is unlikely to develop in a hospital setting and does not typically cause a fever. Treatment involves prednisolone and sometimes itraconazole.

      Tuberculosis (TB) is becoming more common in the UK and Europe, especially among immunosuppressed individuals like alcoholics. However, TB usually affects the upper lobes of the lungs, and the patient’s chest X-ray from two days prior makes it an unlikely diagnosis.

      Staphylococcal pneumonia can occur in alcoholics, but it is characterized by cavitating lesions and often accompanied by empyema.

      Pneumocystis jiroveci pneumonia is also common in immunosuppressed individuals and causes bilateral perihilar consolidations, sometimes with pneumatocele formation.

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  • Question 21 - A 65-year-old man presents to the Emergency Department with sudden breathlessness and haemoptysis....

    Incorrect

    • A 65-year-old man presents to the Emergency Department with sudden breathlessness and haemoptysis. He had just returned from a trip to Thailand and had been complaining of pain in his left leg. His oxygen saturation is 88% on room air, blood pressure is 95/70 mmHg, and heart rate is 120 bpm. He has a history of hypertension managed with lifestyle measures only and used to work as a construction worker. While receiving initial management, the patient suddenly becomes unresponsive, stops breathing, and has no pulse. Despite prolonged resuscitation efforts, the patient is declared dead after 40 minutes. Which vessel is most likely to be affected, leading to this patient's death?

      Your Answer:

      Correct Answer: Pulmonary artery

      Explanation:

      Differentiating Thrombosis in Varicose Veins: Symptoms and Diagnosis

      Pulmonary artery thrombosis is a serious condition that can cause sudden-onset breathlessness, haemoptysis, pleuritic chest pain, and cough. It is usually caused by a deep vein thrombosis that travels to the pulmonary artery. Computed tomography pulmonary angiogram (CTPA) is the preferred imaging modality for diagnosis.

      Pulmonary vein thrombosis is a rare condition that is typically associated with lobectomy, metastatic carcinoma, coagulopathies, and lung transplantation. Patients usually present with gradual onset dyspnoea, lethargy, and peripheral oedema.

      Azygos vein thrombosis is a rare occurrence that is usually associated with azygos vein aneurysms and hepatobiliary pathologies. It is rarely fatal.

      Brachiocephalic vein thrombosis is usually accompanied by arm swelling, pain, and limitation of movement. It is less likely to progress to a pulmonary embolus than lower limb deep vein thrombosis.

      Coronary artery thrombus resulting in myocardial infarction (MI) is characterised by cardiac chest pain, hypotension, and sweating. Haemoptysis is not a feature of MI. Electrocardiographic changes and serum troponin and cardiac enzyme levels are typically seen in MI, but not in pulmonary embolism.

      In summary, the symptoms and diagnosis of thrombosis vary depending on the affected vein. It is important to consider the patient’s medical history and perform appropriate imaging and laboratory tests for accurate diagnosis and treatment.

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  • Question 22 - A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath,...

    Incorrect

    • 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:

      Correct 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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  • Question 23 - A 55-year-old female presents with worsening dyspnoea and the need to sit down...

    Incorrect

    • A 55-year-old female presents with worsening dyspnoea and the need to sit down frequently. She has had no other health issues. The patient works in an office.
      During the physical examination, the patient is found to have clubbing and fine end-inspiratory crackles upon auscultation. A chest X-ray reveals diffuse reticulonodular shadows, particularly in the lower lobes.
      What is the most suitable next step in managing this patient?

      Your Answer:

      Correct Answer: Oxygen therapy

      Explanation:

      Treatment Options for Pulmonary Fibrosis

      Pulmonary fibrosis is a condition that can be diagnosed through a patient’s medical history. When it comes to treatment options, oxygen therapy is the most appropriate as it can prevent the development of pulmonary hypertension. However, there are other treatments available such as steroids and immune modulators like azathioprine, cyclophosphamide methotrexate, and cyclosporin. In some cases, anticoagulation may also be used to reduce the risk of pulmonary embolism. It is important to consult with a healthcare professional to determine the best course of treatment for each individual case.

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  • Question 24 - A 32-year-old postal worker with asthma visits his GP for his annual asthma...

    Incorrect

    • A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?

      Your Answer:

      Correct Answer: Suboptimal therapy

      Explanation:

      Differentiating Between Respiratory Conditions: A Guide

      When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.

      Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.

      Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.

      Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.

      Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.

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  • Question 25 - A 68-year-old woman with a long history of rheumatoid arthritis presents to her...

    Incorrect

    • A 68-year-old woman with a long history of rheumatoid arthritis presents to her general practitioner complaining of a chronic cough, weight loss and haemoptysis. She smokes ten cigarettes a day. You understand that she has begun anti-tumour necrosis factor (TNF) antibody treatment around 9 months earlier. On examination, her rheumatoid appears quiescent at present.
      Investigations:
      Investigation Result Normal value
      Chest X-ray Calcified hilar lymph nodes,
      possible left upper lobe fibrosis
      Haemoglobin 109 g/l 115–155 g/l
      White cell count (WCC) 11.1 × 109/l 4–11 × 109/l
      Platelets 295 × 109/l 150–400 × 109/l
      Erythrocyte sedimentation rate (ESR) 61 mm/h 0–10mm in the 1st hour
      C-reactive protein (CRP) 55 mg/l 0–10 mg/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer:

      Correct Answer: Active pulmonary tuberculosis

      Explanation:

      Differential diagnosis of calcified lymph nodes and upper lobe fibrosis in a patient with rheumatoid arthritis

      A patient with rheumatoid arthritis presents with calcified lymph nodes and upper lobe fibrosis on a chest X-ray. Several possible causes need to be considered, including active pulmonary tuberculosis, lymphoma, rheumatoid lung disease, bronchial carcinoma, and invasive aspergillosis. While anti-TNF antibody medication for rheumatoid arthritis may increase the risk of tuberculosis and aspergillosis, it is important to rule out other potential etiologies based on clinical examination, imaging studies, and laboratory tests. The presence of soft, fluffy, and ill-defined lesions on chest X-ray may suggest active tuberculosis, while the absence of upper lobe fibrosis may argue against lymphoma or radiotherapy-induced fibrosis. Pulmonary nodules and lung fibrosis at the lung bases are more typical of rheumatoid lung disease, but calcified nodes with upper lobe fibrosis are unusual. Bronchial carcinoma may be a concern given the patient’s age and smoking history, but typically lymph nodes are not calcified. Invasive aspergillosis is more likely in immunosuppressed patients and can be detected by a CT scan and a serum galactomannan test. A comprehensive differential diagnosis can guide further evaluation and management of this complex case.

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  • Question 26 - A 72-year-old woman is discovered outside in the early hours of the morning...

    Incorrect

    • A 72-year-old woman is discovered outside in the early hours of the morning after falling to the ground. She is confused and uncertain of what happened and is admitted to the hospital. An abbreviated mental test (AMT) is conducted, and she scores 4/10. During the examination, crackles are heard at the base of her left lung.

      Blood tests reveal:

      Investigation Result Normal value
      C-reactive protein (CRP) 89 mg/l < 10 mg/l
      White cell count (WCC) 15 × 109/l 4–11 × 109/l
      Neutrophils 11.4 × 109/l 5–7.58 × 109/l

      The remainder of her blood tests, including full blood count (FBC), urea and electrolytes (U&Es), and liver function test (LFT), were normal.

      Observations:

      Investigation Result Normal value
      Respiratory rate 32 breaths/min 12–18 breaths/min
      Oxygen saturation 90% on air
      Heart rate (HR) 88 beats/min 60–100 beats/min
      Blood pressure (BP) 105/68 mmHg Hypertension: >120/80 mmHg*
      Hypotension: <90/60 mmHg*
      Temperature 39.1°C 1–37.2°C

      *Normal ranges should be based on the individual's clinical picture. The values are provided as estimates.

      Based on her CURB 65 score, what is the most appropriate management for this patient?

      Your Answer:

      Correct Answer: Admit the patient and consider ITU

      Explanation:

      Understanding the CURB Score and Appropriate Patient Management

      The CURB score is a tool used to assess the severity of community-acquired pneumonia and determine the appropriate level of care for the patient. A score of 0-1 indicates that the patient can be discharged home, a score of 2 suggests hospital treatment, and a score of 3 or more warrants consideration for intensive care unit (ITU) admission.

      In the case of a patient with a CURB score of 3, such as a 68-year-old with a respiratory rate of >30 breaths/min and confusion (AMT score of 4), ITU admission should be considered. Admitting the patient to a general ward or discharging them home with advice to see their GP the following day would not be appropriate.

      It is important for healthcare professionals to understand and utilize the CURB score to ensure appropriate management of patients with community-acquired pneumonia.

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  • Question 27 - A 67-year-old man, who had recently undergone a full bone marrow transplantation for...

    Incorrect

    • A 67-year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. He also had a dry cough, but no fever. During examination, scattered wheeze and some expiratory high-pitched sounds were observed. The C-reactive protein (CRP) level was normal, and the Mantoux test was negative. Spirometry results showed a Forced expiratory volume in 1 second (FEV1) of 51%, Forced vital capacity (FVC) of 88%, and FEV1/FVC of 58%. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Bronchiolitis obliterans

      Explanation:

      Understanding Bronchiolitis Obliterans: Symptoms, Causes, and Treatment Options

      Bronchiolitis obliterans (BO) is a condition that can occur in patients who have undergone bone marrow, heart, or lung transplants. It is characterized by an obstructive picture on spirometry, which may be accompanied by cough, cold, dyspnea, tachypnea, chest wall retraction, and cyanosis. The pulmonary defect is usually irreversible, and a CT scan may show areas of air trapping. Common infections associated with bronchiolitis include influenzae, adenovirus, Mycoplasma, and Bordetella. In adults, bronchiolitis is mainly caused by Mycoplasma, while among connective tissue disorders, BO is found in rheumatoid arthritis and, rarely, in Sjögren’s syndrome or systemic lupus erythematosus. Treatment options include corticosteroids, with variable results. Lung biopsy reveals concentric inflammation and fibrosis around bronchioles. Other conditions, such as acute respiratory distress syndrome (ARDS), drug-induced lung disorder, fungal infection, and pneumocystis pneumonia, have different clinical findings and require different treatment approaches.

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  • Question 28 - A 62-year-old man presents to Accident and Emergency with complaints of chest pain...

    Incorrect

    • A 62-year-old man presents to Accident and Emergency with complaints of chest pain and shortness of breath, which is predominantly worse on the right side. He has been experiencing these symptoms for about 24 hours, but they have worsened since he woke up this morning. The patient reports that the pain is worse on inspiration and that he has never experienced chest pain before. He is mostly bedridden due to obesity but has no history of respiratory issues. The patient is currently receiving treatment for newly diagnosed prostate cancer. There is a high suspicion that he may have a pulmonary embolus (PE). His vital signs are as follows:
      Temperature 36.5 °C
      Blood pressure 136/82 mmHg
      Heart rate 124 bpm
      Saturations 94% on room air
      His 12-lead electrocardiogram (ECG) shows sinus tachycardia and nothing else.
      What would be the most appropriate initial step in managing this case?

      Your Answer:

      Correct Answer: Rivaroxaban

      Explanation:

      Treatment Options for Suspected Pulmonary Embolism

      Pulmonary embolism (PE) is a serious medical condition that requires prompt diagnosis and treatment. In cases where there is a high clinical suspicion of a PE, treatment with treatment-dose direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban or low-molecular-weight heparin (LMWH) should be administered before diagnostic confirmation of a PE on computed tomography (CT) pulmonary angiography (CTPA). Thrombolysis with alteplase may be necessary in certain cases where there is a massive PE with signs of haemodynamic instability or right heart strain on ECG. Intravenous (IV) unfractionated heparin is not beneficial in treating a PE. While a chest X-ray may be useful in the workup for pleuritic chest pain, the priority in suspected PE cases should be administering treatment-dose DOAC or LMWH.

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  • Question 29 - A 29-year-old electrician was referred to the hospital by his doctor. He had...

    Incorrect

    • 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:

      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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  • Question 30 - You are the Foundation Year 2 doctor on a general practice (GP) attachment...

    Incorrect

    • You are the Foundation Year 2 doctor on a general practice (GP) attachment when a 65-year-old man presents, complaining of malaise, cough and breathlessness. He says these symptoms have been present for 2 days, and he has brought up some yellow-coloured sputum on a few occasions. He reports no pain and no palpitations and is coping at home, although he has taken 2 days off work. He has no long-standing conditions but smokes five cigarettes a day and has done so for the last 15 years. He has no known allergies. On examination, he is alert and orientated, and has a respiratory rate of 22 breaths per minute, a blood pressure of 126/84 mmHg and a temperature of 38.1 °C. There is bronchial breathing and crepitations on auscultation, particularly on the right-hand side of the chest, and heart sounds are normal.
      What would be the most appropriate management for this patient?

      Your Answer:

      Correct Answer: 5-day course of amoxicillin

      Explanation:

      Treatment and Management of Community-Acquired Pneumonia

      Community-acquired pneumonia is a common respiratory infection that can be effectively managed in the community with appropriate treatment and management. The severity of the infection can be assessed using the CRB-65 score, which takes into account confusion, respiratory rate, blood pressure, and age. A score of zero indicates low severity and suggests that oral antibiotics and community treatment should suffice. However, admission to hospital may be necessary in certain cases.

      The first-choice antibiotic for community-acquired pneumonia is amoxicillin, although a macrolide may be considered in patients with penicillin allergy. Flucloxacillin may be added if there is suspicion of a staphylococcal infection or associated influenzae.

      It is important to provide safety-netting advice to patients, advising them to return if symptoms worsen or do not improve on antibiotics. Additionally, the absence of wheeze on auscultation and no history of respiratory disease suggests that a salbutamol inhaler is not necessary.

      While the CURB-65 score is commonly used, the CRB-65 score is more practical in community settings as it does not require laboratory analysis. Overall, prompt and appropriate treatment and management can effectively manage community-acquired pneumonia in the community.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (0/3) 0%
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