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  • Question 1 - A 6-month-old girl is brought by her parents to see her pediatrician due...

    Incorrect

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

      Your Answer: <50% of usual feed intake over past 24 hours

      Correct Answer:

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      22.2
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  • Question 2 - A 14-month-old boy presents with a history of occasional wheezing and cough, which...

    Incorrect

    • A 14-month-old boy presents with a history of occasional wheezing and cough, which worsens at night. He recently had a cold and appears congested today. His mother reports that he often wheezes after a cold, and this can persist for several weeks after the infection has resolved. Both parents smoke, but his mother is trying to reduce her smoking, and neither parent smokes inside the house. There is no family history of asthma or allergies. Another doctor recently prescribed inhalers, but they have had little effect. On examination, he has a slight fever of 37.8°C, and there are scattered audible wheezes heard during chest examination.

      What is the SINGLE most likely diagnosis?

      Your Answer: Bronchiolitis

      Correct Answer: Viral induced wheeze

      Explanation:

      Viral induced wheeze is a common condition in childhood that is triggered by a viral infection, typically a cold. The wheezing occurs during the infection and can persist for several weeks after the infection has cleared. This condition is most commonly seen in children under the age of three, as their airways are smaller. It is also more prevalent in babies who were small for their gestational age and in children whose parents smoke. It is important to note that viral induced wheeze does not necessarily mean that the child has asthma, although a small percentage of children with this condition may go on to develop asthma. Asthma is more commonly seen in children with a family history of asthma or allergies. Inhalers are often prescribed for the management of viral induced wheeze, but they may not always be effective.

    • This question is part of the following fields:

      • Respiratory
      38.2
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  • Question 3 - A 70-year-old nursing home resident is brought to the Emergency Department because she...

    Incorrect

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

      What is the SINGLE most probable diagnosis?

      Your Answer: Klebsiella pneumonia

      Correct Answer: Aspiration pneumonia

      Explanation:

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

    • This question is part of the following fields:

      • Respiratory
      45.8
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  • Question 4 - You assess a 65-year-old woman with a history of progressively increasing shortness of...

    Incorrect

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

      Your Answer: Unilateral transudative pleural effusion

      Correct Answer: Unilateral exudative pleural effusion

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Respiratory
      54.5
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  • Question 5 - You review a 30-year-old man who presents with an acute exacerbation of asthma...

    Incorrect

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

      Your Answer: Requirement of ventilation

      Correct Answer: Acute severe asthma

      Explanation:

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

    • This question is part of the following fields:

      • Respiratory
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  • Question 6 - A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting,...

    Correct

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

      Your Answer: Isolation and culture from a sputum sample

      Explanation:

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

    • This question is part of the following fields:

      • Respiratory
      46.4
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  • Question 7 - You are working in the pediatric emergency department and are asked to review...

    Incorrect

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

      Your Answer: 6.6-8.0 kPa

      Correct Answer: 4.4-6.4 kPa

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      53.2
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  • Question 8 - A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Correct

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

      Your Answer: Pulmonary embolism

      Explanation:

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

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

    • This question is part of the following fields:

      • Respiratory
      18.6
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  • Question 9 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Incorrect

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

      Your Answer: Flucloxacillin

      Correct Answer: Amoxicillin

      Explanation:

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

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

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

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      • Respiratory
      40.8
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  • Question 10 - You evaluate a 47-year-old man with a history of increasing shortness of breath...

    Incorrect

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

      Your Answer: Chronic obstructive pulmonary disease (COPD)

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

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

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      • Respiratory
      64.3
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  • Question 11 - A 32-year-old patient with asthma is transferred to the resuscitation area of your...

    Correct

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

      Your Answer: 4-6 hours

      Explanation:

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

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

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      • Respiratory
      29.6
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  • Question 12 - A 35-year-old man who resides in a Traveller community comes in with a...

    Correct

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

      Your Answer: Erythromycin

      Explanation:

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

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

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      • Respiratory
      50.2
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  • Question 13 - A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18...

    Incorrect

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

      Your Answer: 22 mg

      Correct Answer: 30 mg

      Explanation:

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

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      • Respiratory
      15.6
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  • Question 14 - You are treating a 45-year-old patient with known COPD who has been brought...

    Incorrect

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

      Your Answer: 3.3-5.5 mmol/L

      Correct Answer: 0.5-2.2 mmol/L

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      37.7
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  • Question 15 - You evaluate a 32-year-old woman who has been diagnosed with Mycoplasma pneumoniae pneumonia.
    Which...

    Incorrect

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

      Your Answer: Acute glomerulonephritis

      Correct Answer: Infective endocarditis

      Explanation:

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

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      • Respiratory
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  • Question 16 - Following the passing of a young patient treated for an extended cardiac arrest...

    Incorrect

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

      Your Answer: Pneumonia following fresh water drowning is typically the result of streptococcus pneumoniae infection

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

      Explanation:

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

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

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

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

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

      Further Reading:

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

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

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

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

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

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

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

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      • Respiratory
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  • Question 17 - You assess a patient who came in with chest discomfort and difficulty breathing....

    Correct

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

      Your Answer: 5th intercostal space

      Explanation:

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

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

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

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      • Respiratory
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  • Question 18 - A 45-year-old Irish woman comes in with a complaint of increasingly severe shortness...

    Correct

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

      Your Answer: Löfgren’s syndrome

      Explanation:

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

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

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

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

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      • Respiratory
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  • Question 19 - A 57-year-old man comes in with a fever, difficulty breathing, and a cough...

    Incorrect

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

      Your Answer: Age over 55 scores 1 point

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

      Explanation:

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

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      • Respiratory
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  • Question 20 - A 35-year-old dairy farmer presents with a flu-like illness that has been worsening...

    Incorrect

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

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

      What is the SINGLE most likely causative organism?

      Your Answer: Legionella pneumophila

      Correct Answer: Coxiella burnetii

      Explanation:

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

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

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

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      • Respiratory
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  • Question 21 - A 23 year old male is brought to the emergency department (ED) by...

    Incorrect

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

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

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

      What is the probable diagnosis?

      Your Answer: Right sided massive haemothorax

      Correct Answer: Right sided tension pneumothorax

      Explanation:

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

      Further Reading:

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

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

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

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

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      • Respiratory
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  • Question 22 - You are managing a young woman in the Emergency Department who is feeling...

    Incorrect

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

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

      Your Answer: Continue to manage the patient unless they develop a cardiac arrest

      Correct Answer: Summon the resuscitation team

      Explanation:

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

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

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      • Respiratory
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  • Question 23 - A 30-year-old man comes in with a cough and wheezing.
    What ONE clinical...

    Incorrect

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

      Your Answer: Heart rate of 120 bpm

      Correct Answer: Normal PaCO2

      Explanation:

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

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

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

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

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

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      • Respiratory
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  • Question 24 - A 45-year-old man presents with acute severe asthma. You initiate management for the...

    Correct

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

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

      Your Answer: 1 hourly ipratropium bromide nebulisers

      Explanation:

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

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

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

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

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

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

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

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      • Respiratory
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  • Question 25 - A 4-year-old girl presents with stridor and a barking cough. Her mother reports...

    Incorrect

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

      What is the SINGLE most probable causative organism?

      Your Answer: Corynebacterium diphtheriae

      Correct Answer: Parainfluenza virus

      Explanation:

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

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

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

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      • Respiratory
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  • Question 26 - A 45-year-old woman comes in with a one-week history of fatigue, fever, headache,...

    Incorrect

    • A 45-year-old woman comes in with a one-week history of fatigue, fever, headache, muscle aches, and a dry cough that has now started to produce a small amount of sputum. She has also been experiencing occasional episodes of diarrhea for the past two days. During the examination, audible crackles are heard at the base of her lungs. Her blood test results today show evidence of hemolytic anemia and the presence of cold agglutinins.

      What is the SINGLE most appropriate antibiotic to prescribe for this patient?

      Your Answer: Amoxicillin

      Correct Answer: Clarithromycin

      Explanation:

      This patient presents with symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection with Mycoplasma pneumoniae. The clinical features of Mycoplasma pneumoniae infection 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 typically develop later in the course of the illness.

      Mycoplasma pneumoniae infection is commonly associated with the development of erythema multiforme, a rash characterized by multiple red lesions on the limbs that evolve into target lesions a few days after the rash appears. Additionally, this infection can also cause Steven-Johnson syndrome. It is worth noting that haemolytic anaemia with cold agglutinins can complicate Mycoplasma pneumoniae infections, providing further evidence for the diagnosis.

      The recommended first-line antibiotic for treating this case would be a macrolide, such as clarithromycin. Doxycycline can also be used but is generally considered a second-line option.

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      • Respiratory
      18.2
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  • Question 27 - A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling...

    Incorrect

    • A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling in her arms and hands. Upon examination, you observe that her face is also swollen and she has multiple enlarged veins and telangiectasia on her chest. She has a history of long-term smoking.

      What is the SINGLE most probable diagnosis?

      Your Answer: Hereditary haemorrhagic telangiectasia

      Correct Answer: Superior vena cava syndrome

      Explanation:

      This patient has come in with worsening shortness of breath and coughing up blood. They have a long history of smoking, and the likely diagnosis is superior vena cava obstruction caused by a primary bronchial tumor.

      The typical symptoms of superior vena cava obstruction include breathlessness, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

      Given the severity of the symptoms, this man needs to be urgently referred and admitted to the hospital. To provide immediate relief, his head should be elevated and he should be given supplemental oxygen. Corticosteroids and diuretics may also be administered. Further investigation through CT scanning is necessary, and radiotherapy may be recommended as a treatment option.

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      • Respiratory
      30.9
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  • Question 28 - A 35-year-old dairy farmer presents with a flu-like illness that has been worsening...

    Incorrect

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

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

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

      Your Answer: Clarithromycin

      Correct Answer: Doxycycline

      Explanation:

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

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

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

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      • Respiratory
      154.6
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  • Question 29 - A 6-year-old child arrives in a deteriorated state with acute severe asthma. The...

    Incorrect

    • A 6-year-old child arrives in a deteriorated state with acute severe asthma. The child has a history of asthma and is currently on a daily maintenance dose of 5 mg prednisolone. The child weighs 18 kg.
      Based on the BTS guidelines, what is the recommended dosage of prednisolone for this child?

      Your Answer: 40 mg

      Correct Answer: 32 mg

      Explanation:

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

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      • Respiratory
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  • Question 30 - You are evaluating a 68-year-old patient with a known history of COPD who...

    Correct

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

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

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

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

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

      Your Answer: Non-invasive ventilation

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

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      • Respiratory
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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (8/30) 27%
Passmed