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  • Question 1 - A 32 year old is brought into the emergency department after being rescued...

    Incorrect

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

      Your Answer: Length of resuscitation

      Correct Answer: Submersion time

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      70.3
      Seconds
  • Question 2 - A 40-year-old businessman presents with sudden onset breathlessness and right-sided pleuritic chest pain....

    Incorrect

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

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

      Your Answer: D-dimer

      Correct Answer: CT pulmonary angiogram

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      31.2
      Seconds
  • Question 3 - A 6-year-old girl presents with a history of a persistent cough that has...

    Correct

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

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

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

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

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      59.2
      Seconds
  • Question 4 - A 35-year-old woman presents with a two-week history of a persistent cough that...

    Incorrect

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

      What is the MOST appropriate course of action for management?

      Your Answer: Co-amoxiclav 1.2 g IV TDS for 7 days

      Correct Answer: Clarithromycin 500 mg PO BD for 14 days

      Explanation:

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

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

    • This question is part of the following fields:

      • Respiratory
      44.4
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  • Question 5 - A 45 year old with asthma is brought into the ER due to...

    Correct

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

      Your Answer: 7.35-7.45

      Explanation:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      11.8
      Seconds
  • Question 6 - A 72 year old male presents to the emergency department complaining of shortness...

    Incorrect

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

      Your Answer: Remove outer tracheostomy tube & tracheostomy assembly

      Correct Answer: Pass suction catheter

      Explanation:

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

      Further Reading:

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

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

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

    • This question is part of the following fields:

      • Respiratory
      103.3
      Seconds
  • Question 7 - A 45-year-old Irish woman comes to you with a complaint of increasing shortness...

    Correct

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

      Your Answer: Sarcoidosis

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      25.6
      Seconds
  • Question 8 - A 3-year-old girl presents with stridor and a barking cough. Her mother reports...

    Correct

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

      What is the SINGLE most probable diagnosis?

      Your Answer: Croup

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Respiratory
      47.4
      Seconds
  • Question 9 - A 45-year-old woman presents with increasing shortness of breath at rest and severe...

    Correct

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

      What is the MOST suitable initial test to perform?

      Your Answer: Chest X-ray

      Explanation:

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

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

    • This question is part of the following fields:

      • Respiratory
      70.3
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  • Question 10 - A 72 year old female who is a known heavy smoker visits the...

    Correct

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

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

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

      Your Answer: Respiratory acidosis with metabolic compensation

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      34.6
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  • Question 11 - A 6-year-old girl presents very sick with severe acute asthma. She has received...

    Incorrect

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

      What is the most appropriate next step in her management?

      Your Answer: Set up aminophylline infusion

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

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
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  • Question 12 - You evaluate a 9-year-old boy with a high temperature and a persistent, forceful...

    Incorrect

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

      Your Answer: 7 days

      Correct Answer: 48 hours

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Respiratory
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  • Question 13 - A 6-month-old boy has been brought to the hospital for evaluation of a...

    Incorrect

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

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

      Correct Answer: PCR testing

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
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  • Question 14 - A 40-year-old man presents with a sudden worsening of his asthma symptoms. His...

    Incorrect

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

      Your Answer: IV salbutamol

      Correct Answer: IV aminophylline

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
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  • Question 15 - A 6-year-old girl has recently been diagnosed with whooping cough. Her parents would...

    Correct

    • A 6-year-old girl has recently been diagnosed with whooping cough. Her parents would like to ask you some questions.

      Which SINGLE statement about whooping cough is true?

      Your Answer: Encephalopathy is a recognised complication

      Explanation:

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

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

      The second stage, called the paroxysmal stage, is when the characteristic paroxysmal cough develops as the catarrhal symptoms begin to subside. During this stage, coughing occurs in spasms, often preceded by an inspiratory whoop and followed by a series of rapid expiratory coughs. Other symptoms may include vomiting, subconjunctival hemorrhages, and petechiae. Patients generally feel well between spasms, and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery during this period. The later stages are sometimes referred to as the convalescent stage.

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

      To diagnose whooping cough, nasopharyngeal swabs can be cultured in a medium called Bordet-Gengou agar, which contains blood, potato extract, glycerol, and an antibiotic to isolate Bordetella pertussis.

      Although antibiotics do not alter the clinical course of the infection, they can reduce the period of infectiousness and help prevent further spread.

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      • Respiratory
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  • Question 16 - A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
    Which...

    Correct

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

      Your Answer: Terbutaline 5mg via oxygen-driven nebuliser

      Explanation:

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

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

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

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

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

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  • Question 17 - A 6 month old girl is brought into the emergency department with a...

    Correct

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

      Your Answer: Results in peripheral vasoconstriction

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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  • Question 18 - A 35-year-old woman presents with difficulty breathing and coughing up blood after a...

    Incorrect

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

      Your Answer: The presence of haemoptysis scores 3 points

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

      Explanation:

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

      The allocation of points is as follows:

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

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  • Question 19 - You are managing a 72-year-old male patient who has been intubated as a...

    Incorrect

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

      Your Answer: End tidal CO2

      Correct Answer: PaO2/FiO2 ratio

      Explanation:

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

      Further Reading:

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

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

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

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  • Question 20 - A 62-year-old woman presents with a persistent cough that has been ongoing for...

    Incorrect

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

      What is the SINGLE most likely diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

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

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

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

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

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

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  • Question 21 - A 32-year-old woman presents with a history of increased cough and wheeze over...

    Correct

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

      Your Answer: Give oral prednisolone 40 mg

      Explanation:

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

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

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

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

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  • Question 22 - A 3-year-old boy is brought in by his parents with a history of...

    Incorrect

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

      What is the SINGLE most appropriate investigation?

      Your Answer: CT scan of chest

      Correct Answer: Nasopharyngeal aspirate

      Explanation:

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

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

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

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

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

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  • Question 23 - A 60-year-old woman comes in with a cough producing green sputum that has...

    Correct

    • A 60-year-old woman comes in with a cough producing green sputum that has been ongoing for the past two days. During the examination, she has a fever, with a temperature of 38.0°C, and exhibits coarse crackles in the lower right lung on chest examination.

      What is the MOST LIKELY single causative organism?

      Your Answer: Streptococcus pneumoniae

      Explanation:

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

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  • Question 24 - You are caring for a hypoxic patient in the resuscitation bay. One of...

    Correct

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

      Your Answer: MetHb

      Explanation:

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

      Further Reading:

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

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

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

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

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

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  • Question 25 - A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell...

    Incorrect

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

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

      What is the SINGLE most likely diagnosis?

      Your Answer: Allergic bronchopulmonary aspergillosis

      Correct Answer: Churg-Strauss syndrome

      Explanation:

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

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

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

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

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

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

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

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

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  • Question 26 - A toddler is brought to the hospital with bronchiolitis because of low oxygen...

    Incorrect

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

      Your Answer: Hypertonic saline nebuliser

      Correct Answer: Nasogastric feeding

      Explanation:

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

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

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

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

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

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  • Question 27 - A 25-year-old woman presents to the emergency department with a complaint of progressive...

    Correct

    • A 25-year-old woman presents to the emergency department with a complaint of progressive lip swelling that began 1 hour ago. Upon reviewing her medical history, it is noted that she has a previous diagnosis of hereditary angioedema (HAE). The following findings have been documented:

      - Blood pressure: 120/80 mmHg
      - Pulse rate: 90 beats per minute
      - Respiratory rate: 16 breaths per minute
      - Temperature: 37.5 degrees Celsius

      What is the primary concern regarding this patient?

      Your Answer: Airway obstruction

      Explanation:

      The primary concern regarding this patient is airway obstruction. The patient’s complaint of progressive lip swelling, along with her previous diagnosis of hereditary angioedema (HAE), suggests that she may be experiencing an allergic reaction. Angioedema can cause swelling in various parts of the body, including the lips, tongue, and throat. If the swelling progresses and affects the airway, it can lead to difficulty breathing and potentially block the airway completely. This can be a life-threatening emergency and requires immediate intervention to ensure the patient’s airway remains open and they can breathe properly.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

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  • Question 28 - A 45-year-old man presents with a severe exacerbation of his asthma. You have...

    Incorrect

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

      Your Answer: 500 mg over 5 minutes

      Correct Answer: 250 mg over 15 minutes

      Explanation:

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

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  • Question 29 - A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct...

    Incorrect

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

      Your Answer: Acute severe asthma

      Correct Answer: Near-fatal asthma

      Explanation:

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

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

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

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

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

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  • Question 30 - A 6-month-old infant is brought to the Emergency Department with a high fever...

    Incorrect

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

      Your Answer: RR >50 breaths/minute

      Correct Answer: RR >60 breaths/minute

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Respiratory
      59.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (13/30) 43%
Passmed