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  • Question 1 - An 80-year-old man comes to the clinic complaining of increasing shortness of breath...

    Correct

    • An 80-year-old man comes to the clinic complaining of increasing shortness of breath and dry cough over the past three months. He gets breathless after walking a few hundred metres. He is a non-smoker and takes medication for type II diabetes mellitus. During examination, his pulse is 80/minute and regular, blood pressure (BP) 130/70 mmHg, bilateral clubbing of digits, oxygen saturation (SpO2) in room air is 90%. Auscultation reveals bilateral, fine, late inspiratory crackles, more marked in the mid-zones and at the lung bases. Chest X-ray reveals patchy shadowing at the lung bases. What is the definitive investigation to guide his management?

      Your Answer: High-resolution computed tomography (HRCT) chest

      Explanation:

      High-resolution computed tomography (HRCT) chest is the most reliable test for diagnosing idiopathic pulmonary fibrosis (IPF). The radiological pattern seen in IPF is called usual interstitial pneumonia (UIP), which is characterized by honeycombing, reticular opacities, and lung architectural distortion. In advanced cases, there may be lobar volume loss, particularly in the lower lobes.

      Antinuclear antibody (ANA) and anti-cyclic citrullinated peptide (anti-CCP) tests are not useful for diagnosing IPF, as they are typically normal or only mildly elevated in this condition. These tests may be helpful in diagnosing interstitial lung disease associated with rheumatologic conditions, such as systemic lupus erythematosus or rheumatoid arthritis.

      Arterial blood gas (ABG) analysis can be performed in patients with IPF who are experiencing respiratory distress. This test typically shows type I respiratory failure with low oxygen levels and normal or decreased carbon dioxide levels. However, ABG analysis is not the definitive test for diagnosing IPF.

      Bronchoalveolar lavage may be considered if HRCT chest cannot detect the UIP pattern, but it is not typically necessary for diagnosing IPF.

      Pulmonary function tests (PFTs) can help differentiate between obstructive and restrictive lung diseases. In IPF, PFTs typically show a restrictive pattern, with decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), and a normal or increased FEV1/FVC ratio. While PFTs are a useful initial test for evaluating lung function in patients with suspected IPF, they are not definitive for establishing a diagnosis.

    • This question is part of the following fields:

      • Respiratory
      39.3
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  • Question 2 - A 31-year-old man and his wife, who have been trying to have a...

    Correct

    • A 31-year-old man and his wife, who have been trying to have a baby, visit a Fertility Clinic to receive the results of their tests. The man's semen sample has revealed azoospermia. Upon further inquiry, the man reports having a persistent cough that produces purulent sputum. What test would confirm the underlying condition?

      Your Answer: Cystic fibrosis transmembrane conductance regulator (CFTR) genetic screening and sweat test

      Explanation:

      Investigations for Male Infertility: A Case of Azoospermia and Bronchiectasis

      Azoospermia, or the absence of sperm in semen, can be caused by a variety of factors, including genetic disorders and respiratory diseases. In this case, a man presents with a longstanding cough productive of purulent sputum and is found to have azoospermia. The combination of azoospermia and bronchiectasis suggests a possible diagnosis of cystic fibrosis (CF), a genetic disorder that affects the respiratory and reproductive systems.

      CF is diagnosed via a sweat test showing high sweat chloride levels and genetic screening for two copies of disease-causing CFTR mutations. While most cases of CF are diagnosed in infancy, some are diagnosed later in life, often by non-respiratory specialties such as infertility clinics. Klinefelter syndrome, a genetic disorder characterized by an extra X chromosome in males, can also cause non-obstructive azoospermia and is diagnosed by karyotyping.

      Computed tomography (CT) thorax can be helpful in diagnosing bronchiectasis, but the underlying diagnosis in this case is likely to be CF. Testicular biopsy and testing FSH and testosterone levels can be used to investigate the cause of azoospermia, but in this case, investigating for CF is the most appropriate next step. Nasal biopsy can diagnose primary ciliary dyskinesia, another cause of bronchiectasis and subfertility, but it is not relevant in this case.

      In conclusion, a thorough evaluation of male infertility should include a comprehensive medical history, physical examination, and appropriate investigations to identify any underlying conditions that may be contributing to the problem.

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      • Respiratory
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  • Question 3 - A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses...

    Correct

    • A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses concern about feeling excessively tired during the day and experiencing frequent episodes of sleepiness.
      Her husband reports that she snores heavily at night and sometimes stops breathing. Additionally, her work performance has been declining, and she is at risk of losing her job.
      What is the most suitable initial step in managing this patient's condition?

      Your Answer: Continuous Positive Airways Pressure (CPAP)

      Explanation:

      Obstructive Sleep Apnoea and its Treatment

      The presence of heavy snoring, apnoea attacks at night, and daytime somnolence suggests the possibility of obstructive sleep apnoea. The recommended treatment for this condition is continuous positive airway pressure (CPAP), which helps maintain airway patency during sleep. In addition to CPAP, weight loss and smoking cessation are also helpful measures. Surgery is not necessary for this condition.

      Long-term oxygen therapy is indicated for individuals with chronic hypoxia associated with chronic respiratory disease to prevent the development of pulmonary hypertension. However, bronchodilators are not useful in this case. It is important to seek medical attention if any of these symptoms are present to receive proper diagnosis and treatment.

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      • Respiratory
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  • Question 4 - A 61-year-old electrician presents with a 4-month history of cough and weight loss....

    Incorrect

    • A 61-year-old electrician presents with a 4-month history of cough and weight loss. On further questioning, the patient reports experiencing some episodes of haemoptysis. He has a long-standing history of hypothyroidism, which is well managed with thyroxine 100 µg daily. The patient smokes ten cigarettes a day and has no other significant medical history. Blood tests and an X-ray are carried out, which reveal possible signs of asbestosis. A CT scan is ordered to investigate further.
      What is the typical CT scan finding of asbestosis in the lung?

      Your Answer: Diffuse fibrotic bands with ground glass opacity

      Correct Answer: Honeycombing of the lung with parenchymal bands and pleural plaques

      Explanation:

      Differentiating Lung Diseases: Radiological Findings

      Asbestosis is a lung disease characterized by interstitial pneumonitis and fibrosis, resulting in honeycombing of the lungs with parenchymal bands and pleural plaques. Smoking can accelerate its presentation. On a chest X-ray, bilateral reticulonodular opacities in the lower zones are observed, while a CT scan shows increased interlobular septae, parenchymal bands, and honeycombing. Silicosis, on the other hand, presents with irregular linear shadows and hilar lymphadenopathy, which can progress to PMF with compensatory emphysema. Tuberculosis is characterized by cavitation of upper zones, while pneumoconiosis shows parenchymal nodules and lower zone emphysema. Proper diagnosis is crucial in determining the appropriate treatment and management of these lung diseases.

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      • Respiratory
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  • Question 5 - A 50-year-old farmer presents to his general practitioner (GP) with gradually progressive shortness...

    Incorrect

    • A 50-year-old farmer presents to his general practitioner (GP) with gradually progressive shortness of breath over the last year, along with an associated cough. He has no significant past medical history to note except for a previous back injury and is a non-smoker. He occasionally takes ibuprofen for back pain but is on no other medications. He has worked on farms since his twenties and acquired his own farm 10 years ago.
      On examination, the patient has a temperature of 36.9oC and respiratory rate of 26. Examination of the chest reveals bilateral fine inspiratory crackles. His GP requests a chest X-ray, which shows bilateral reticulonodular shadowing.
      Which one of the following is the most likely underlying cause of symptoms in this patient?

      Your Answer: Silicosis

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

      Causes of Pulmonary Fibrosis: Extrinsic Allergic Alveolitis

      Pulmonary fibrosis is a condition characterized by shortness of breath and reticulonodular shadowing on chest X-ray. It can be caused by various factors, including exposure to inorganic dusts like asbestosis and beryllium, organic dusts like mouldy hay and avian protein, certain drugs, systemic diseases, and more. In this scenario, the patient’s occupation as a farmer suggests a possible diagnosis of extrinsic allergic alveolitis or hypersensitivity pneumonitis, which is caused by exposure to avian proteins or Aspergillus in mouldy hay. It is important to note that occupational lung diseases may entitle the patient to compensation. Non-steroidal anti-inflammatory drugs, silicosis, crocidolite exposure, and beryllium exposure are less likely causes in this case.

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      • Respiratory
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  • Question 6 - A 35-year-old male patient presented to the Emergency department with sudden onset chest...

    Correct

    • A 35-year-old male patient presented to the Emergency department with sudden onset chest pain and shortness of breath that had been ongoing for six hours. The symptoms appeared out of nowhere while he was watching TV, and lying flat made the breathlessness worse. The patient denied any recent history of infection, cough, fever, leg pain, swelling, or travel.
      Upon examination, the patient was apyrexial and showed no signs of cyanosis. Respiratory examination revealed reduced breath sounds and hyperresonance in the right lung.
      What is the most likely diagnosis?

      Your Answer: Primary spontaneous pneumothorax

      Explanation:

      Diagnosis and Management of a Primary Spontaneous Pneumothorax

      Given the sudden onset of shortness of breath and reduced breath sounds from the right lung, the most likely diagnosis for this patient is a right-sided primary spontaneous pneumothorax (PSP). Primary pneumothoraces occur in patients without chronic lung disease, while secondary pneumothoraces occur in patients with existing lung disease. To rule out a pulmonary embolism, a D-dimer test should be performed. A positive D-dimer does not necessarily mean a diagnosis of pulmonary embolism, but a negative result can rule it out. If the D-dimer is positive, imaging would be the next step in management.

      A 12-lead ECG should also be performed to check for any ischaemic or infarcted changes, although there is no clinical suspicion of acute coronary syndrome in this patient. Bornholm disease, a viral infection causing myalgia and severe pleuritic chest pain, is unlikely given the examination findings. An asthma attack would present similarly, but there is no history to suggest this condition in this patient.

      In summary, a primary spontaneous pneumothorax is the most likely diagnosis for this patient. A D-dimer test should be performed to rule out a pulmonary embolism, and a 12-lead ECG should be done to check for any ischaemic or infarcted changes. Bornholm disease and asthma are unlikely diagnoses.

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      • Respiratory
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  • Question 7 - You have a telephone consultation with a 28-year-old male who wants to start...

    Correct

    • You have a telephone consultation with a 28-year-old male who wants to start trying to conceive. He has a history of asthma and takes salbutamol 100mcg as needed.
      Which of the following would be most important to advise?

      Your Answer: Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy

      Explanation:

      Women who are taking antiepileptic medication and are planning to conceive should be prescribed a daily dose of 5mg folic acid instead of the standard 400mcg. This high-dose folic acid should be taken from before conception until the 12th week of pregnancy to reduce the risk of neural tube defects. It is important to refer these women to specialist care, but they should continue to use effective contraception until they have had a full assessment. Despite the medication, it is still likely that they will have a normal pregnancy and healthy baby. If trying to conceive, women should start taking folic acid as soon as possible, rather than waiting for a positive pregnancy test.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

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      • Respiratory
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  • Question 8 - A 50-year-old woman is admitted to hospital with fever, dyspnoea and consolidation at...

    Incorrect

    • A 50-year-old woman is admitted to hospital with fever, dyspnoea and consolidation at the left lower base. She is commenced on antibiotics. A few days later, she deteriorates and a chest X-ray reveals a large pleural effusion, with consolidation on the left side.
      What is the most important investigation to perform next?

      Your Answer: Computed tomography (CT) scan

      Correct Answer: Pleural aspiration

      Explanation:

      Appropriate Investigations for a Unilateral Pleural Effusion

      When a patient presents with a unilateral pleural effusion, the recommended first investigation is pleural aspiration. This procedure allows for the analysis of the fluid, including cytology, biochemical analysis, Gram staining, and culture and sensitivity. By classifying the effusion as a transudate or an exudate, further management can be guided.

      While a blood culture may be helpful if the patient has a fever, pleural aspiration is still the more appropriate next investigation. A CT scan may be useful at some point to outline the extent of the consolidation and effusion, but it would not change management at this stage.

      Bronchoscopy may be necessary if a tumour is suspected, but it is not required based on the information provided. Thoracoscopy may be used if pleural aspiration is inconclusive, but it is a more invasive procedure. Therefore, pleural aspiration should be performed first.

      In summary, pleural aspiration is the recommended first investigation for a unilateral pleural effusion, as it provides valuable information for further management. Other investigations may be necessary depending on the specific case.

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      • Respiratory
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  • Question 9 - A 42-year-old man presents to the Emergency Department with complaints of severe breathlessness...

    Incorrect

    • A 42-year-old man presents to the Emergency Department with complaints of severe breathlessness after being exposed to smoke during a house fire. He reports vomiting twice and experiencing a headache and dizziness.
      Upon examination, the patient is found to be tachypnoeic with good air entry, and his oxygen saturations are at 100% on air. He appears drowsy, but his Glasgow Coma Scale (GCS) score is 15, and there are no signs of head injury on his neurological examination.
      What is the initial step in managing this patient's condition?

      Your Answer:

      Correct Answer: High-flow oxygen

      Explanation:

      Treatment Options for Smoke Inhalation Injury

      Smoke inhalation injury can lead to carbon monoxide (CO) poisoning, which is characterized by symptoms such as headache, dizziness, and vomiting. It is important to note that normal oxygen saturation may be present despite respiratory distress due to the inability of a pulse oximeter to differentiate between carboxyhaemoglobin and oxyhaemoglobin. Therefore, any conscious patient with suspected CO poisoning should be immediately treated with high-flow oxygen, which can reduce the half-life of carboxyhaemoglobin from up to four hours to 90 minutes.

      Cyanide poisoning, which is comparatively rare, can also be caused by smoke inhalation. The treatment of choice for cyanide poisoning is a combination of hydroxocobalamin and sodium thiosulphate.

      Hyperbaric oxygen may be beneficial for managing patients with CO poisoning, but high-flow oxygen should be provided immediately while waiting for initiation. Indications for hyperbaric oxygen include an unconscious patient, COHb > 25%, pH < 7.1, and evidence of end-organ damage due to CO poisoning. Bronchodilators such as nebulised salbutamol and ipratropium may be useful as supportive care in cases of inhalation injury where signs of bronchospasm occur. However, in this case, compatible signs such as wheeze and reduced air entry are not present. Metoclopramide may provide symptomatic relief of nausea, but it does not replace the need for immediate high-flow oxygen. Therefore, it is crucial to prioritize the administration of high-flow oxygen in patients with suspected smoke inhalation injury. Managing Smoke Inhalation Injury: Treatment Options and Priorities

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      • Respiratory
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  • Question 10 - A 75-year-old woman presents to a respiratory outpatient clinic with a dry cough...

    Incorrect

    • A 75-year-old woman presents to a respiratory outpatient clinic with a dry cough and shortness of breath that has been ongoing for 6 months. Despite being a non-smoker, her husband is a pigeon breeder. Upon examination, she has an SpO2 of 95% on room air and clubbing is present. Chest examination reveals symmetrical and bilateral reduced chest expansion with fine end-inspiratory crepitations. A chest radiograph shows increased interstitial markings in the lower zones of both lungs. High-resolution computed tomography (HRCT) confirms these findings and also shows bibasal honeycombing. There is no lymphadenopathy present on CT. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Idiopathic pulmonary fibrosis (usual interstitial pneumonia)

      Explanation:

      Differential Diagnosis for Interstitial Lung Disease: A Case Study

      Interstitial lung disease (ILD) is a group of lung disorders that affect the interstitium, the tissue and space surrounding the air sacs in the lungs. Idiopathic pulmonary fibrosis (IPF) is the most common type of ILD, characterized by chronic inflammation of the lung interstitium with lower zone predominance. This article discusses the differential diagnosis for ILD, using a case study of a patient presenting with subacute dry cough, exertional dyspnea, and general malaise and fatigue.

      Idiopathic Pulmonary Fibrosis (IPF)
      IPF is characterized by chronic inflammation of the lung interstitium with lower zone predominance. Patients present with subacute dry cough, exertional dyspnea, and general malaise and fatigue. Clinical examination reveals fine end-inspiratory crepitations throughout the chest with lower zone predominance. Radiological findings include reduced lung volumes and bilateral increased interstitial markings with lower zone predominance on chest X-ray (CXR), and honeycombing and microcyst formation in the lung bases on high-resolution CT (HRCT). Lung transplantation is the only definitive treatment, while steroids are not indicated.

      Tuberculosis
      Tuberculosis presents with chronic cough, haemoptysis, fever, and night sweats. Imaging shows cavitating lesions ± lymphadenopathy.

      Bronchiectasis
      Bronchiectasis presents with productive cough, recurrent chest infections, and haemoptysis. CXR findings are often non-specific, but dilated, thick-walled (ectatic) bronchi are easily seen on HRCT.

      Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)
      Hypersensitivity pneumonitis may be caused by airborne irritants to lung parenchyma, such as pigeon breeding. Changes are classically found in lung apices, making it less likely than IPF/UIP.

      Sarcoidosis
      End-stage sarcoidosis may present with lung fibrosis, but this does not spare the apices and typically affects the middle and upper zones of the lung.

      In conclusion, the differential diagnosis for ILD includes IPF, tuberculosis, bronchiectasis, hypersensitivity pneumonitis, and sarcoidosis. Accurate diagnosis is crucial for appropriate treatment and management of these conditions.

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  • Question 11 - A 65-year-old known alcoholic is brought by ambulance after being found unconscious on...

    Incorrect

    • A 65-year-old known alcoholic is brought by ambulance after being found unconscious on the road on a Sunday afternoon. He has a superficial laceration in the right frontal region. He is admitted for observation over the weekend. The admission chest X-ray is normal. Before discharge on Tuesday morning, he is noted to be febrile and dyspnoeic. Blood tests reveal a neutrophilia and elevated C-reactive protein (CRP). A chest X-ray demonstrates consolidation in the lower zone of the right lung.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Aspiration pneumonia

      Explanation:

      Aspiration pneumonia is a type of pneumonia that typically affects the lower lobes of the lungs, particularly the right middle or lower lobes or left lower lobe. It is often seen in individuals who have consumed alcohol and subsequently vomited, leading to the aspiration of the contents into the lower bronchi. If an alcoholic is found unconscious with a lower zone consolidation, aspiration pneumonia should be considered when prescribing antibiotics. Hospital-acquired pneumonia (HAP) is unlikely to occur within the first 48 hours of admission. Tuberculosis (TB) is a rare diagnosis in this case as it typically affects the upper lobes and the patient’s chest X-ray from two days earlier was normal. Staphylococcal pneumonia may be seen in alcoholics but is characterized by cavitating lesions and empyema. Pneumocystis jiroveci pneumonia is common in immunosuppressed individuals and presents with bilateral perihilar consolidations and possible lung cyst formation.

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  • Question 12 - A 63-year-old man who used to work as a stonemason presents to the...

    Incorrect

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

      Your Answer:

      Correct Answer: Occupational interstitial lung disease

      Explanation:

      Possible Occupational Lung Diseases and Differential Diagnosis

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

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

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

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

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  • Question 13 - A 35-year-old man with acquired immune deficiency syndrome (AIDS) presents to the Emergency...

    Incorrect

    • A 35-year-old man with acquired immune deficiency syndrome (AIDS) presents to the Emergency Department with fever, dyspnea, and overall feeling unwell. The attending physician suspects Pneumocystis jirovecii pneumonia. What is the most characteristic clinical feature of this condition?

      Your Answer:

      Correct Answer: Desaturation on exercise

      Explanation:

      Understanding Pneumocystis jirovecii Pneumonia: Symptoms and Diagnosis

      Pneumocystis jirovecii pneumonia is a fungal infection that affects the lungs. While it is rare in healthy individuals, it is a significant concern for those with weakened immune systems, such as AIDS patients, organ transplant recipients, and individuals undergoing certain types of therapy. Here are some key symptoms and diagnostic features of this condition:

      Desaturation on exercise: One of the hallmark symptoms of P. jirovecii pneumonia is a drop in oxygen levels during physical activity. This can be measured using pulse oximetry before and after walking up and down a hallway.

      Cavitating lesions on chest X-ray: While a plain chest X-ray may show diffuse interstitial opacification, P. jirovecii pneumonia can also present as pulmonary nodules that cavitate. High-resolution computerised tomography (HRCT) is the preferred imaging modality.

      Absence of cervical lymphadenopathy: Unlike some other respiratory infections, P. jirovecii pneumonia typically does not cause swelling of the lymph nodes in the neck.

      Non-productive cough: Patients with P. jirovecii pneumonia may experience a dry, non-productive cough due to the thick, viscous nature of the secretions in the lungs.

      Normal pulmonary function tests: P. jirovecii pneumonia does not typically cause an obstructive pattern on pulmonary function tests.

      By understanding these symptoms and diagnostic features, healthcare providers can more effectively diagnose and treat P. jirovecii pneumonia in at-risk patients.

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  • Question 14 - A 32-year-old office worker attends Asthma Clinic for her annual asthma review. She...

    Incorrect

    • A 32-year-old office worker attends Asthma Clinic for her annual asthma review. She takes a steroid inhaler twice daily, which seems to control her asthma well. Occasionally, she needs to use her salbutamol inhaler, particularly if she has been exposed to allergens.
      What is the primary mechanism of action of the drug salbutamol in the treatment of asthma?

      Your Answer:

      Correct Answer: β2-adrenoceptor agonist

      Explanation:

      Pharmacological Management of Asthma: Understanding the Role of Different Drugs

      Asthma is a chronic inflammatory condition of the airways that causes reversible airway obstruction. The pathogenesis of asthma involves the release of inflammatory mediators due to IgE-mediated degranulation of mast cells. Pharmacological management of asthma involves the use of different drugs that target specific receptors and pathways involved in the pathogenesis of asthma.

      β2-adrenoceptor agonists are selective drugs that stimulate β2-adrenoceptors found in bronchial smooth muscle, leading to relaxation of the airways and increased calibre. Salbutamol is a commonly used short-acting β2-adrenoceptor agonist, while salmeterol is a longer-acting drug used in more severe asthma.

      α1-adrenoceptor antagonists, which mediate smooth muscle contraction in blood vessels, are not used in the treatment of asthma. β1-adrenoceptor agonists, found primarily in cardiac tissue, are not used in asthma management either, as they increase heart rate and contractility.

      β2-adrenoceptor antagonists, also known as β blockers, cause constriction of the airways and should be avoided in asthma due to the risk of bronchoconstriction. Muscarinic antagonists, such as ipratropium, are useful adjuncts in asthma management as they block the muscarinic receptors in bronchial smooth muscle, leading to relaxation of the airways.

      Other drugs used in asthma management include steroids (oral or inhaled), leukotriene receptor antagonists (such as montelukast), xanthines (such as theophylline), and sodium cromoglycate. Understanding the role of different drugs in asthma management is crucial for effective treatment and prevention of exacerbations.

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  • Question 15 - A 10-year-old boy visits his General Practitioner complaining of feeling unwell for the...

    Incorrect

    • A 10-year-old boy visits his General Practitioner complaining of feeling unwell for the past two days. He reports having a sore throat, general malaise, and nasal congestion, but no cough or fever. During the examination, his pulse rate is 70 bpm, respiratory rate 18 breaths per minute, and temperature 37.3 °C. The doctor notes tender, swollen anterior cervical lymph nodes. What investigation should the doctor consider requesting?

      Your Answer:

      Correct Answer: Throat swab

      Explanation:

      Investigations for Upper Respiratory Tract Infections: A Case Study

      When a patient presents with symptoms of an upper respiratory tract infection, it is important to consider appropriate investigations to differentiate between viral and bacterial causes. In this case study, a young boy presents with a sore throat, tender/swollen lymph nodes, and absence of a cough. A McIsaac score of 3 suggests a potential for streptococcal pharyngitis.

      Throat swab is a useful investigation to differentiate between symptoms of the common cold and streptococcal pharyngitis. Sputum culture may be indicated if there is spread of the infection to the lower respiratory tract. A chest X-ray is not indicated as a first-line investigation, but may be later indicated if there is a spread to the lower respiratory tract. Full blood count is not routinely indicated, as it is only likely to show lymphocytosis for viral infections. Viral testing is not conducted routinely, unless required for public health research or data in the event of a disease outbreak.

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  • Question 16 - A 50-year-old woman presents to her General Practitioner with increasing shortness of breath....

    Incorrect

    • A 50-year-old woman presents to her General Practitioner with increasing shortness of breath. She has also suffered from dull right iliac fossa pain over the past few months. Past history of note includes tuberculosis at the age of 23 and rheumatoid arthritis. On examination, her right chest is dull to percussion, consistent with a pleural effusion, and her abdomen appears swollen with a positive fluid thrill test. She may have a right adnexal mass.
      Investigations:
      Investigation
      Result
      Normal value
      Chest X-ray Large right-sided pleural effusion
      Haemoglobin 115 g/l 115–155 g/l
      White cell count (WCC) 6.8 × 109/l 4–11 × 109/l
      Platelets 335 × 109/l 150–400 × 109/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 5.4 mmol/l 3.5–5.0 mmol/l
      Creatinine 175 μmol/l 50–120 µmol/l
      Bilirubin 28 μmol/l 2–17 µmol/l
      Alanine aminotransferase 25 IU/l 5–30 IU/l
      Albumin 40 g/l 35–55 g/l
      CA-125 250 u/ml 0–35 u/ml
      Pleural aspirate: occasional normal pleural cells, no white cells, protein 24 g/l.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Meig’s syndrome

      Explanation:

      Possible Causes of Pleural Effusion: Meig’s Syndrome, Ovarian Carcinoma, Reactivation of Tuberculosis, Rheumatoid Arthritis, and Cardiac Failure

      Pleural effusion is a condition where fluid accumulates in the pleural space, the area between the lungs and the chest wall. There are various possible causes of pleural effusion, including Meig’s syndrome, ovarian carcinoma, reactivation of tuberculosis, rheumatoid arthritis, and cardiac failure.

      Meig’s syndrome is characterized by the association of a benign ovarian tumor and a transudate pleural effusion. The pleural effusion resolves when the tumor is removed, although a raised CA-125 is commonly found.

      Ovarian carcinoma with lung secondaries is another possible cause of pleural effusion. However, if no malignant cells are found on thoracocentesis, this diagnosis becomes less likely.

      Reactivation of tuberculosis may also lead to pleural effusion, but this would be accompanied by other symptoms such as weight loss, night sweats, and fever.

      Rheumatoid arthritis can produce an exudative pleural effusion, but this presentation is different from the transudate seen in Meig’s syndrome. In addition, white cells would be present due to the inflammatory response.

      Finally, cardiac failure can result in bilateral pleural effusions.

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  • Question 17 - A 65-year-old woman presents to the Emergency Department with a productive cough, difficulty...

    Incorrect

    • A 65-year-old woman presents to the Emergency Department with a productive cough, difficulty breathing, and chills lasting for 4 days. Upon examination, bronchial breathing is heard at the left lower lung base. Inflammatory markers are elevated, and a chest X-ray shows consolidation in the left lower zone. What is the most frequently encountered pathogen linked to community-acquired pneumonia?

      Your Answer:

      Correct Answer: Streptococcus pneumoniae

      Explanation:

      Common Bacterial Causes of Pneumonia

      Pneumonia is a lung infection that can be categorized as either community-acquired or hospital-acquired, depending on the likely causative pathogens. The most common cause of community-acquired pneumonia is Streptococcus pneumoniae, a type of Gram-positive coccus. Staphylococcus aureus pneumonia typically affects older individuals, often after they have had the flu, and can result in cavitating lesions in the upper lobes of the lungs. Mycobacterium tuberculosis can also cause cavitating lung disease, which is characterized by caseating granulomatous inflammation. This type of pneumonia is more common in certain groups, such as Asians and immunocompromised individuals, and is diagnosed through sputum smears, cultures, or bronchoscopy. Haemophilus influenzae is a Gram-negative bacteria that can cause meningitis and pneumonia, but it is much less common now due to routine vaccination. Finally, Neisseria meningitidis is typically associated with bacterial meningitis.

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  • Question 18 - A 35-year-old woman had a productive cough due to upper respiratory tract infection...

    Incorrect

    • A 35-year-old woman had a productive cough due to upper respiratory tract infection two weeks ago. She experienced a burning sensation in her chest during coughing. About a week ago, she coughed up a teaspoonful of yellow sputum with flecks of blood. The next morning, she had a small amount of blood-tinged sputum but has not had any subsequent haemoptysis. Her cough is resolving, and she is starting to feel better. She has no history of respiratory problems and has never smoked cigarettes. On examination, there are no abnormalities found in her chest, heart, or abdomen. Her chest x-ray is normal.

      What would be your recommendation at this point?

      Your Answer:

      Correct Answer: Observation only

      Explanation:

      Acute Bronchitis

      Acute bronchitis is a type of respiratory tract infection that causes inflammation in the bronchial tubes. This condition is usually caused by viral infections, with up to 95% of cases being attributed to viruses such as adenovirus, coronavirus, and influenzae viruses A and B. While antibiotics are often prescribed for acute bronchitis, there is little evidence to suggest that they provide significant relief or shorten the duration of the illness.

      Other viruses that can cause acute bronchitis include parainfluenza virus, respiratory syncytial virus, coxsackievirus A21, rhinovirus, and viruses that cause rubella and measles. It is important to note that in cases where there is no evidence of bronchoconstriction or bacterial infection, and the patient is not experiencing respiratory distress, observation is advised.

      Overall, the causes and symptoms of acute bronchitis can help individuals take the necessary steps to manage their condition and prevent its spread to others.

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  • Question 19 - A 75-year-old man presents to the Emergency Department with complaints of difficulty breathing....

    Incorrect

    • A 75-year-old man presents to the Emergency Department with complaints of difficulty breathing. Upon examination, you observe that his trachea is centralized and there is decreased chest expansion on the left side, accompanied by a dull percussion note and diminished breath sounds. What is the diagnosis?

      Your Answer:

      Correct Answer: Pleural effusion

      Explanation:

      Clinical Signs for Common Respiratory Conditions

      Pleural effusion, pneumothorax, pulmonary embolism, pneumonia, and pulmonary edema are common respiratory conditions that require accurate diagnosis for proper management. Here are the clinical signs to look out for:

      Pleural effusion: trachea central or pushed away from the affected side, reduced chest expansion on the affected side, reduced tactile vocal fremitus on the affected side, ‘stony dull’ or dull percussion note on the affected side, reduced air entry/breath sounds on the affected side, reduced vocal resonance on the affected side.

      Pneumothorax: trachea central or pushed away from the affected side, reduced chest expansion on the affected side, reduced tactile vocal fremitus on the affected side, hyper-resonant percussion note on the affected side, reduced air entry/breath sounds on the affected side, reduced vocal resonance on the affected side.

      Pulmonary embolism: respiratory examination is likely to be normal, there may be subtle signs related to the pulmonary embolism, eg pleural rub, or due to a chronic underlying chest disease.

      Pneumonia: trachea central, chest expansion likely to be normal, increased tactile vocal fremitus over area(s) of consolidation, dull percussion note over areas of consolidation, reduced air entry/bronchial breath sounds/crepitations on auscultation.

      Pulmonary edema: trachea central, chest expansion normal, normal vocal fremitus, resonant percussion note, likely to hear coarse basal crackles on auscultation.

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  • Question 20 - A 78-year-old man with known alcohol dependence presents to the Emergency Department with...

    Incorrect

    • A 78-year-old man with known alcohol dependence presents to the Emergency Department with a few weeks of productive cough, weight loss, fever and haemoptysis. He is a heavy smoker, consuming 30 cigarettes per day. On a chest X-ray, multiple nodules 1-3 mm in size are visible throughout both lung fields. What is the best treatment option to effectively address the underlying cause of this man's symptoms?

      Your Answer:

      Correct Answer: Anti-tuberculous (TB) chemotherapy

      Explanation:

      Choosing the Right Treatment: Evaluating Options for a Patient with Suspected TB

      A patient presents with a subacute history of fever, productive cough, weight loss, and haemoptysis, along with a chest X-ray description compatible with miliary TB. Given the patient’s risk factors for TB, such as alcohol dependence and smoking, anti-TB chemotherapy is the most appropriate response, despite the possibility of lung cancer. IV antibiotics may be used until sputum staining and culture results are available, but systemic chemotherapy would likely lead to overwhelming infection and death. Tranexamic acid may be useful for significant haemoptysis, but it will not treat the underlying diagnosis. acyclovir is not indicated, as the patient does not have a history of rash, and a diagnosis of miliary TB is more likely than varicella pneumonia. Careful evaluation of the patient’s history and symptoms is crucial in choosing the right treatment.

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  • Question 21 - A 75-year-old man with severe emphysema visits his General Practitioner (GP) for his...

    Incorrect

    • A 75-year-old man with severe emphysema visits his General Practitioner (GP) for his yearly check-up. He reports experiencing increasing breathlessness over the past six months and inquires about the potential benefits of long-term oxygen therapy. His recent routine blood work came back normal, and upon respiratory examination, there is a noticeable decrease in air entry. However, his cardiovascular examination appears to be normal. What would be an appropriate indication for prescribing this patient LTOT?

      Your Answer:

      Correct Answer:

      Explanation:

      When to Prescribe Oxygen Therapy for COPD Patients: Indications and Limitations

      Chronic obstructive pulmonary disease (COPD) is a progressive respiratory condition that can lead to hypoxia, or low oxygen levels in the blood. Oxygen therapy is a common treatment for COPD patients with hypoxia, but it is not appropriate for all cases. Here are some indications and limitations for prescribing oxygen therapy for COPD patients:

      Indication: PaO2 < 7.3 kPa when stable or PaO2 > 7.3 and < 8 kPa when stable with secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema, or pulmonary hypertension present. Patients should meet the criteria on at least two blood gases taken when stable at least three weeks apart. Limitation: Oxygen therapy would have no impact on the frequency of acute exacerbations and would not be appropriate to prescribe for this indication. Indication: Symptomatic desaturation on exertion. Ambulatory oxygen may be prescribed if the presence of oxygen results in an increase in exercise capacity and/or dyspnoea. Limitation: There is no evidence that oxygen therapy is of benefit in patients with severe breathlessness who are not significantly hypoxic at rest or on exertion. Management options would include investigating for other potential causes of breathlessness and treating as appropriate, or reviewing inhaled and oral medication for COPD and pulmonary rehabilitation. Indication: PaO2 < 8.5 kPa when stable with secondary polycythaemia, peripheral oedema, or pulmonary hypertension present. There is no evidence of survival benefit if patients with a PaO2 > 8 kPa are prescribed oxygen therapy.

      In summary, oxygen therapy is a valuable treatment for COPD patients with hypoxia, but it should be prescribed with caution and based on specific indications and limitations.

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  • Question 22 - A 62-year-old female patient complains of breathlessness and weight loss over the past...

    Incorrect

    • A 62-year-old female patient complains of breathlessness and weight loss over the past three months. She is a smoker who consumes 10 cigarettes per day. During the examination, you observe clubbing of the fingers and a few crackles in the chest. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Pulmonary fibrosis

      Explanation:

      Respiratory Causes of Clubbing

      Clubbing is a condition where the fingertips and nails become enlarged and rounded. It is often associated with respiratory and cardiovascular diseases. One of the respiratory causes of clubbing is pulmonary fibrosis, which is characterized by weight loss and breathlessness. Other respiratory causes include bronchiectasis, empyema, bronchial carcinoma, and mesothelioma. These conditions can also lead to weight loss and breathlessness, making it important to seek medical attention if these symptoms are present. On the other hand, cardiovascular causes of clubbing include cyanotic congenital heart disease and infective endocarditis. It is important to identify the underlying cause of clubbing in order to provide appropriate treatment and management.

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  • Question 23 - A 67-year-old man comes to the Chest Clinic after being referred by his...

    Incorrect

    • A 67-year-old man comes to the Chest Clinic after being referred by his GP for a chronic cough. He complains of a dry cough that has been ongoing for 10 months and is accompanied by increasing shortness of breath. Despite multiple rounds of antibiotics, he has not experienced significant improvement. He has never smoked and denies any coughing up of blood. He used to work as a teacher and has not been exposed to any environmental dust or chemicals.

      His GP ordered a chest X-ray, which reveals reticular shadowing affecting both lung bases. Upon examination, he has clubbed fingers and fine-end inspiratory crackles. His heart sounds are normal, and he is saturating at 94% on room air with a regular heart rate of 80 bpm and regular respiratory rate of 20. There is no peripheral oedema.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Differential Diagnosis for Shortness of Breath and Clubbing: Idiopathic Pulmonary Fibrosis as the Likely Diagnosis

      Shortness of breath and clubbing can be indicative of various respiratory and cardiac conditions. In this case, the most likely diagnosis is idiopathic pulmonary fibrosis, as evidenced by fine-end inspiratory crackles on examination, X-ray findings of bi-basal reticulonodular shadowing in a typical distribution, and the presence of clubbing. Bronchiectasis is another possible diagnosis, but the lack of purulent phlegm and coarse crackles, as well as chest X-ray findings inconsistent with dilated, thick-walled bronchi, make it less likely. Carcinoma of the lung is also a consideration, but the absence of a smoking history and chest X-ray findings make it less probable. Chronic obstructive pulmonary disease (COPD) is unlikely without a smoking history and the absence of wheeze on examination. Congestive cardiac failure (CCF) can cause shortness of breath, but clubbing is typically only present in cases of congenital heart disease with right to left shunts, which is not demonstrated in this case. Overall, idiopathic pulmonary fibrosis is the most likely diagnosis based on the clinical presentation and diagnostic findings.

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  • Question 24 - A 72-year-old woman is admitted with renal failure. She has a history of...

    Incorrect

    • A 72-year-old woman is admitted with renal failure. She has a history of congestive heart failure and takes ramipril 10 mg daily and furosemide 80 mg daily.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 102 g/l 115–155 g/l
      Platelets 180 × 109/l 150–400 × 109/l
      White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
      Sodium (Na+) 143 mmol/l 135–145 mmol/l
      Potassium (K+) 6.2 mmol/l 3.5–5.0 mmol/l
      Creatinine 520 μmol/l 50–120 µmol/l
      Chest X-ray: no significant pulmonary oedema
      Peripheral fluid replacement is commenced and a right subclavian central line is inserted. She complains of pleuritic chest pain; saturations have decreased to 90% on oxygen via mask.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Iatrogenic pneumothorax

      Explanation:

      Differential Diagnosis for a Patient with Pleuritic Chest Pain and Desaturation after Subclavian Line Insertion

      Subclavian line insertion carries a higher risk of iatrogenic pneumothorax compared to other routes, such as the internal jugular route. Therefore, if a patient presents with pleuritic chest pain and desaturation after subclavian line insertion, iatrogenic pneumothorax should be considered as the most likely diagnosis. Urgent confirmation with a portable chest X-ray is necessary, and formal chest drain insertion is the management of choice.

      Other complications of central lines include local site and systemic infection, arterial puncture, haematomas, catheter-related thrombosis, air embolus, dysrhythmias, atrial wall puncture, lost guidewire, anaphylaxis, and chylothorax. However, these complications would not typically present with pleuritic chest pain and desaturation.

      Developing pulmonary oedema is an important differential, but it would not explain the pleuritic chest pain. Similarly, lower respiratory tract infection is a possibility, but the recent line insertion makes iatrogenic pneumothorax more likely. Costochondritis can cause chest pain worse on inspiration and chest wall tenderness, but it would not explain the desaturation.

      In conclusion, when a patient presents with pleuritic chest pain and desaturation after subclavian line insertion, iatrogenic pneumothorax should be the primary consideration, and urgent confirmation with a portable chest X-ray is necessary.

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  • Question 25 - A 21-year old patient is brought to the Emergency Department by paramedics following...

    Incorrect

    • A 21-year old patient is brought to the Emergency Department by paramedics following an assault. On examination, there are two puncture wounds on the posterior chest wall. The ambulance crew believe the patient was attacked with a screwdriver. He is currently extremely short of breath, haemodynamically unstable, and his oxygen saturations are falling despite high-flow oxygen. There are reduced breath sounds in the right hemithorax.
      What is the most appropriate first step in managing this patient?

      Your Answer:

      Correct Answer: Needle decompression of right hemithorax

      Explanation:

      Management of Tension Pneumothorax in Penetrating Chest Trauma

      Tension pneumothorax is a life-threatening condition that requires immediate intervention in patients with penetrating chest trauma. The following steps should be taken:

      1. Clinical Diagnosis: Falling oxygen saturations, cardiovascular compromise, and reduced breath sounds in the affected hemithorax are suggestive of tension pneumothorax. This is a clinical diagnosis.

      2. Needle Decompression: Immediate needle decompression with a large bore cannula placed into the second intercostal space, mid-clavicular line is required. This is a temporizing measure to provide time for placement of a chest drain.

      3. Urgent Chest Radiograph: A chest radiograph may be readily available, but it should not delay decompression of the tension pneumothorax. It should be delayed until placement of the chest drain.

      4. Placement of Chest Drain: This is the definitive treatment of a tension pneumothorax, but immediate needle decompression should take place first.

      5. Contact On-Call Anaesthetist: Invasive ventilation by an anaesthetist will not improve the patient’s condition.

      6. Avoid Non-Invasive Ventilation: Non-invasive ventilation would worsen the tension pneumothorax and should be avoided.

      In summary, prompt recognition and management of tension pneumothorax are crucial in patients with penetrating chest trauma. Needle decompression followed by chest drain placement is the definitive treatment.

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  • Question 26 - A 29-year-old electrician was referred to the hospital by his doctor. He had...

    Incorrect

    • A 29-year-old electrician was referred to the hospital by his doctor. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. At the time of referral, he was experiencing mild dyspnea, a global headache, myalgia, and arthralgia. On examination, he appeared unwell, had a fever of 39°C, and had a maculopapular rash on his upper body. Fine crackles were audible in the left mid-zone of his chest, and mild neck stiffness was noted.

      The following investigations were conducted: Hb 84 g/L (130-180), WBC 8 ×109/L (4-11), Platelets 210 ×109/L (150-400), Reticulocytes 8% (0.5-2.4), Na 129 mmol/L (137-144), K 4.2 mmol/L (3.5-4.9), Urea 5.0 mmol/L (2.5-7.5), Creatinine 110 µmol/L (60-110), Bilirubin 89 µmol/L (1-22), Alk phos 130 U/L (45-105), AST 54 U/L (1-31), and GGT 48 U/L (<50). A chest x-ray revealed patchy consolidation in both mid-zones.

      What is the most likely cause of his abnormal blood count?

      Your Answer:

      Correct Answer: IgM anti-i antibodies

      Explanation:

      The patient has pneumonia, hepatitis, and haemolytic anaemia, which can be caused by Mycoplasma pneumonia. This condition can also cause extrapulmonary manifestations such as renal failure, myocarditis, and meningitis. Haemolysis is associated with the presence of IgM antibodies, and sepsis may cause microangiopathic haemolytic anaemia. Clavulanic acid can cause hepatitis, and some drugs can induce haemolysis in patients with G6PD deficiency.

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  • Question 27 - A 72-year-old smoker with a pack year history of 80 years was admitted...

    Incorrect

    • A 72-year-old smoker with a pack year history of 80 years was admitted with haemoptysis and weight loss. A chest X-ray shows a 4-cm cavitating lung lesion in the right middle lobe.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Squamous cell carcinoma

      Explanation:

      Types of Lung Cancer and Cavitating Lesions

      Lung cancer can be classified into different subtypes based on their histology and response to treatments. Among these subtypes, squamous cell carcinoma is the most common type that causes cavitating lesions on a chest X-ray. This occurs when the tumour outgrows its blood supply and becomes necrotic, forming a cavity. Squamous cell carcinomas are usually centrally located and can also cause ectopic hormone production, leading to hypercalcaemia.

      Other causes of cavitating lesions include pulmonary tuberculosis, bacterial pneumonia, rheumatoid nodules, and septic emboli. Bronchoalveolar cell carcinoma is an uncommon subtype of adenocarcinoma that does not commonly cavitate. Small cell carcinoma and large cell carcinoma also do not commonly cause cavitating lesions.

      Adenocarcinoma, on the other hand, is the most common type of lung cancer and is usually caused by smoking. It typically originates in the peripheral lung tissue and can also cavitate, although it is less common than in squamous cell carcinoma. Understanding the different types of lung cancer and their characteristics can aid in diagnosis and treatment.

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  • Question 28 - A 65-year-old man with chronic obstructive pulmonary disease (COPD) is brought to Accident...

    Incorrect

    • A 65-year-old man with chronic obstructive pulmonary disease (COPD) is brought to Accident and Emergency with difficulty breathing. On arrival, his saturations were 76% on air, pulse 118 bpm and blood pressure 112/72 mmHg. He was given nebulised bronchodilators and started on 6 litres of oxygen, which improved his saturations up to 96%. He is more comfortable now, but a bit confused.
      What should be the next step in the management of this patient?

      Your Answer:

      Correct Answer: Arterial blood gas

      Explanation:

      Management of Acute Exacerbation of COPD: Considerations and Interventions

      When managing a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD), it is important to consider various interventions based on the patient’s clinical presentation. In this case, the patient has increased oxygen saturations, which may be contributing to confusion. It is crucial to avoid over-administration of oxygen, as it may worsen breathing function. An arterial blood gas can guide oxygen therapy and help determine the appropriate treatment, such as reducing oxygen concentration or initiating steroid therapy.

      IV aminophylline may be considered if nebulisers and steroids have not been effective, but it is not necessary in this case. Pulmonary function testing is not beneficial in immediate management. Intubation is not currently indicated, as the patient’s confusion is likely due to excessive oxygen administration.

      Antibiotics may be necessary if there is evidence of infection, but in this case, an arterial blood gas is the most important step. Overall, management of acute exacerbation of COPD requires careful consideration of the patient’s clinical presentation and appropriate interventions based on their individual needs.

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  • Question 29 - As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed....

    Incorrect

    • As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed. You learn that he spent all his working life in a factory. The following results are available:
      Measured Expected
      FEV1 (L) 2.59 3.46
      FVC (L) 3.16 4.21
      Ratio (%) 82 81
      Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Asbestosis

      Explanation:

      Possible Respiratory Diagnoses Based on Pulmonary Function Testing Results

      Based on the patient’s age and history of factory work, along with a restrictive defect on pulmonary function testing, asbestosis is the most likely diagnosis. Other possible respiratory diagnoses include allergic bronchopulmonary aspergillosis (ABPA), asthma, emphysema, and bronchiectasis. ABPA and asthma are associated with an obstructive picture on pulmonary function tests, while emphysema and bronchiectasis are also possible differentials based on the history but are associated with an obstructive lung defect. However, it would be unusual for an individual to have their first presentation of asthma at 72 years old. Therefore, a thorough evaluation of the patient’s medical history, physical examination, and additional diagnostic tests may be necessary to confirm the diagnosis.

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  • Question 30 - A 65-year-old man snores at night and his wife reports it is so...

    Incorrect

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

      Your Answer:

      Correct Answer: Compensated respiratory acidosis

      Explanation:

      Understanding Compensated and Uncompensated Acid-Base Disorders

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

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

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

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

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

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

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

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (5/8) 63%
Passmed