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  • Question 1 - A 23 year old male medical student presents to the A&E department with...

    Incorrect

    • A 23 year old male medical student presents to the A&E department with pleuritic chest pain. He does not have productive cough nor is he experiencing shortness of breath. He has no past medical history. A chest x-ray which was done shows a right-sided pneumothorax with a 1 cm rim of air and no mediastinal shift. What is the most appropriate treatment option?

      Your Answer: Immediate 14G cannula into 2nd intercostal space, mid-clavicular line

      Correct Answer: Discharge with outpatient chest x-ray

      Explanation:

      Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Patients are typically aged 18-40 years, tall, thin, and, often, are smokers.

      In small pneumothoraxes with minimal symptoms, no active treatment is required. These patients can be safely discharged with early outpatient review and should be given written advice to return if breathlessness worsens. Patients who have been discharged without intervention should be advised that air travel should be avoided until a radiograph has confirmed resolution of the pneumothorax.

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      • Respiratory
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  • Question 2 - A 54 year old male, with a smoking history of 15 pack years...

    Incorrect

    • A 54 year old male, with a smoking history of 15 pack years presents with worsening dyspnoea, fever and cough. He works at a foundry. Vitals are as follows: Respiratory rate: 28/min Heart rate: 80 bpm Temp: 37.6C Chest auscultation reveals bilateral crepitations throughout the lung fields. Calcified hilar nodules are visible on the chest X-ray. Further evaluation shows an eggshell calcification on HRCT. Which of the following is the most likely diagnosis?

      Your Answer: Sarcoidosis

      Correct Answer: Silicosis

      Explanation:

      Silicosis is a common occupational lung disease that is caused by the inhalation of crystalline silica dust. Silica is the most abundant mineral on earth. Workers that are involved for example in construction, mining, or glass production are among the individuals with the highest risk of developing the condition. Acute silicosis causes severe symptoms (e.g., exertional dyspnoea, cough with sputum) and has a very poor prognosis.
      Chronic silicosis has a very variable prognosis and affected individuals may remain asymptomatic for several decades. However, radiographic signs are usually seen early on. Typical radiographic findings are calcifications of perihilar lymph nodes, diffuse ground glass opacities, large numbers of rounded, solitary nodules or bigger, confluent opacities. Avoiding further exposure to silica is crucial, especially since the only treatment available is symptomatic (e.g., bronchodilators). Silicosis is associated with an increased risk of tuberculosis and lung cancer. Berylliosis typically affects individuals who are exposed to aerospace industry. Histoplasmosis and tuberculosis do not form eggshell calcifications.

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      • Respiratory
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  • Question 3 - A 23 year old female is admitted with acute severe asthma. Treatment is...

    Correct

    • A 23 year old female is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone. There is no improvement despite initial treatment. What is the next step in management?

      Your Answer: IV magnesium sulphate

      Explanation:

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy. Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

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  • Question 4 - A 70 year old thyroid cancer patient is admitted due to dyspnoea. Which...

    Incorrect

    • A 70 year old thyroid cancer patient is admitted due to dyspnoea. Which investigation should be done to assess for possible compression of the upper airways?

      Your Answer: Peak expiratory flow rate

      Correct Answer: Flow volume loop

      Explanation:

      Flow-volume loop is an easy, non-invasive diagnostic tool that can be used even in severely-ill patients. It can provide information about the location of the obstruction and can differentiate between obstructive pulmonary disease and upper-airway obstruction. Therefore, it is recommended to obtain a flow-volume loop during the assessment of patients with upper airway obstruction.

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      • Respiratory
      92.3
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  • Question 5 - A 14 year old known asthmatic presents to the A&E department with difficulty...

    Incorrect

    • A 14 year old known asthmatic presents to the A&E department with difficulty breathing. She was seen by her regular doctor the day before with a sore throat which he diagnosed as tonsillitis and was prescribed oral Amoxicillin for 5 days. Past medical history: Ulcerative colitis diagnosed four years ago. Current medications: Inhaled salbutamol and beclomethasone Mesalazine 400 mg TDS She was observed to be alert and oriented but she had laboured breathing. Inspiratory wheeze was noted. She was pale, sweaty and cyanosed. Her temperature was 36.7ºC, pulse 121/minute and blood pressure 91/40 mmHg. The lungs were clear and the remainder of the examination was normal. She was given high-flow oxygen through a face mask but despite this her breathing became increasingly difficult.   What is the most likely causative agent?

      Your Answer:

      Correct Answer: Haemophilus influenzae

      Explanation:

      Acute epiglottitis is a life-threatening disorder with serious implications to the anaesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. There is inflammatory oedema of the arytenoids, aryepiglottic folds and the epiglottis; therefore, supraglottitis may be used instead or preferred to the term acute epiglottitis.

      Acute epiglottitis can occur at any age. The responsible organism used to be Hemophilus influenzae type B (Hib), but infection with group A b-haemolytic Streptococci has become more frequent after the widespread use of Hemophilus influenzae vaccination.

      The typical presentation in epiglottitis includes acute occurrence of high fever, severe sore throat and difficulty in swallowing with the sitting up and leaning forward position in order to enhance airflow. There is usually drooling because of difficulty and pain on swallowing. Acute epiglottitis usually leads to generalized toxaemia. The most common differential diagnosis is croup and a foreign body in the airway. A late referral to an acute care setting with its serious consequences may result from difficulty in differentiation between acute epiglottitis and less urgent causes of a sore throat, shortness of breath and dysphagia.

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  • Question 6 - A 66-year-old man with newly-diagnosed small cell carcinoma discusses his further treatment options...

    Incorrect

    • A 66-year-old man with newly-diagnosed small cell carcinoma discusses his further treatment options with the team of doctors. Which statement is incorrect about small cell carcinoma?

      Your Answer:

      Correct Answer: Patients with small cell lung cancer always benefit from surgery

      Explanation:

      Small cell lung cancer (SCLC) is characterized by rapid growth and early dissemination. Prompt initiation of treatment is important.

      Patients with clinical stage Ia (T1N0) after standard staging evaluation may be considered for surgical resection, but combined treatment with chemotherapy and radiation therapy is the standard of care. Radiation therapy is often added at the second cycle of chemotherapy.

      Historically, patients undergoing surgery for small cell lung cancer (SCLC) had a dismal prognosis. However, more recent data suggest that patients with true stage I SCLC may benefit from surgical resection.

      Common sites of hematogenous metastases include the brain, bones, liver, adrenal glands, and bone marrow. The symptoms depend upon the site of spread.

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  • Question 7 - Which type of lung cancer is most commonly linked to cavitating lesions? ...

    Incorrect

    • Which type of lung cancer is most commonly linked to cavitating lesions?

      Your Answer:

      Correct Answer: Squamous cell

      Explanation:

      Squamous-cell carcinoma is the most common histological type of lung cancer to cavitate (82% of cavitary primary lung cancer), followed by adenocarcinoma and large cell carcinoma. Multiple cavitary lesions in primary lung cancer are rare, however, multifocal bronchoalveolar cell carcinoma can occasionally have multiple cavitary lesions. Small cell carcinoma is not known to cavitate.

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  • Question 8 - Which of the following statements about smoking is correct? ...

    Incorrect

    • Which of the following statements about smoking is correct?

      Your Answer:

      Correct Answer: Quitting is associated with average weight gain of 2 kg

      Explanation:

      A study conducted showed that the average post smoking cessation weight gain was about 2 kg.
      Withdrawal symptoms usually peak after 1–3 days and then decrease over a period of 3–4 weeks. After this time, the body has expelled most of the nicotine, and the withdrawal effects are mainly psychological.

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  • Question 9 - What does Caplan's syndrome refer to? ...

    Incorrect

    • What does Caplan's syndrome refer to?

      Your Answer:

      Correct Answer: Rheumatoid lung nodules and pneumoconiosis

      Explanation:

      Caplan’s syndrome is defined as the association between silicosis and rheumatoid arthritis (RA). It is rare and usually diagnosed in an advanced stage of RA. It generally affects patients with a prolonged exposure to silica.

      Caplan’s syndrome presents with rheumatoid lung nodules and pneumoconiosis. Originally described in coal miners with progressive massive fibrosis, it may also occur in asbestosis, silicosis and other pneumoconiosis. Chest radiology shows multiple, round, well defined nodules, usually 0.5 – 2.0 cm in diameter, which may cavitate and resemble tuberculosis.

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  • Question 10 - A 75 year old man was admitted to the hospital with worsening dyspnoea....

    Incorrect

    • A 75 year old man was admitted to the hospital with worsening dyspnoea. He was given a five day course of Amoxicillin. On examination, his blood pressure was 89/59 mmHg with a respiratory rate of 35/min. A chest x-ray revealed left lower lobe consolidation. Past medical history: Type 2 diabetes mellitus Arterial blood gas on air: pH 7.34 pCO2 5.4 kPa pO2 9.0 kPa Which antibiotic therapy is the most suitable?

      Your Answer:

      Correct Answer: Intravenous co-amoxiclav + clarithromycin

      Explanation:

      CURB Pneumonia Severity Score:
      – Confusion (abbreviated Mental Test Score <=8) (1 point)
      – Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
      – Respiratory Rate > 30 per minute (1 point)
      – Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) Based on the CURB Pneumonia Severity Score, the patient has severe pneumonia. According to the 2009 Centres for Medicare and Medicaid Services (CMS) and Joint Commission consensus guidelines, inpatient treatment of pneumonia should be given within four hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens, which are also in accordance with IDSA/ATS guidelines. For non-intensive care unit (ICU) patients:
      Beta-lactam (intravenous [IV] or intramuscular [IM] administration) plus macrolide (IV or oral [PO])
      Beta-lactam (IV or IM) plus doxycycline (IV or PO)
      Antipneumococcal quinolone monotherapy (IV or IM)

      If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO)

      For ICU patients:
      IV beta-lactam plus IV macrolide
      IV beta-lactam plus IV antipneumococcal quinolone

      If the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.

      The most suitable antibiotic therapy for this patient is therefore Intravenous co-amoxiclav + clarithromycin.

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  • Question 11 - A 20 year old woman presents to the hospital with sharp, left-sided chest...

    Incorrect

    • A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath. On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%. CXR reveals a left pneumothorax with a 4 cm rim of air visible. Which management strategy is appropriate in this patient?

      Your Answer:

      Correct Answer: Needle aspiration

      Explanation:

      Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
      Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.

      Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.

      Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
      Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.

      If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.

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  • Question 12 - A 60 year old man who has been complaining of increasing shortness of...

    Incorrect

    • A 60 year old man who has been complaining of increasing shortness of breath had a post-bronchodilator spirometry done. FEV1/FVC 0. 63 FEV1% predicted 63% What is the best interpretation of these results?

      Your Answer:

      Correct Answer: COPD (stage 2 - moderate)

      Explanation:

      Chronic obstructive pulmonary disease (COPD) is a complex and progressive chronic lung disease. Typically, COPD includes emphysema and chronic bronchitis. COPD is characterized by the restriction of airflow into and out of the lungs. The obstruction of airflow makes breathing difficult. The causes of COPD include smoking, long-term exposure to air pollutants and a rare genetic disorder.

      The Global Initiative for Chronic Obstructive Lung Disease (GOLD) developed the GOLD Staging System. In the GOLD System, the forced expiratory volume in one second (FEV1) measurement from a pulmonary function test is used to place COPD into stages. Often, doctors also consider your COPD symptoms.

      COPD has four stages. The stages of COPD range from mild to very severe. COPD affects everyone differently. Because COPD is a progressive lung disease, it will worsen over time.
      The Stages of COPD:
      Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
      Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
      Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
      Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

      This patient has a FEV1 percent of 63 which falls within the stage 2 or moderate COPD.

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  • Question 13 - A young man presents to the clinic with recurrent episodes of breathlessness. Past...

    Incorrect

    • A young man presents to the clinic with recurrent episodes of breathlessness. Past medical history reveals recurrent episodes of colicky abdominal pain for the past three years. On examination, he has a productive cough with foul smelling sputum. Investigations show: Sputum culture with Heavy growth of Pseudomonas aeruginosa and Haemophilus influenzae. Chest x-ray: Tramline and ring shadows. What is his diagnosis?

      Your Answer:

      Correct Answer: Cystic fibrosis

      Explanation:

      Cystic fibrosis (CF) is a multisystemic, autosomal recessive disorder that predominantly affects infants, children, and young adults. CF is the most common life-limiting genetic disorder in whites, with an incidence of 1 case per 3200-3300 new-borns in the United States.

      People with CF can have a variety of symptoms, including:
      Very salty-tasting skin
      Persistent coughing, at times with phlegm
      Frequent lung infections including pneumonia or bronchitis
      Wheezing or shortness of breath
      Poor growth or weight gain in spite of a good appetite
      Frequent greasy, bulky stools or difficulty with bowel movements
      Male infertility

      Signs of bronchiectasis include the tubular shadows; tram tracks, or horizontally oriented bronchi; and the signet-ring sign, which is a vertically oriented bronchus with a luminal airway diameter that is 1.5 times the diameter of the adjacent pulmonary arterial branch.

      Bronchiectasis is characterized by parallel, thick, line markings radiating from hila (line tracks) in cylindrical bronchiectasis. Ring shadows represent dilated thick-wall bronchi seen in longitudinal section or on-end or dilated bronchi in varicose bronchiectasis.

      Pseudomonas aeruginosa is the key bacterial agent of cystic fibrosis (CF) lung infections, and the most important pathogen in progressive and severe CF lung disease. This opportunistic pathogen can grow and proliferate in patients, and exposure can occur in hospitals and other healthcare settings.

      Haemophilus influenzae is regularly involved in chronic lung infections and acute exacerbations of CF patients

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  • Question 14 - A 20 year old heroin addict is admitted following an overdose. She is...

    Incorrect

    • A 20 year old heroin addict is admitted following an overdose. She is drowsy and has a respiratory rate of 6 bpm. Which of the following arterial blood gas results (taken on room air) are most consistent with this?

      Your Answer:

      Correct Answer: pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa

      Explanation:

      In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis.

      The normal range for PaCO2 is 35-45 mmHg (4.67 to 5.99 kPa). Respiratory acidosis can be acute or chronic. In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (i.e., >45 mm Hg) with an accompanying academia (i.e., pH < 7.35). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal or near-normal pH secondary to renal compensation and an elevated serum bicarbonate levels (i.e., >30 mEq/L).

      Arterial blood gases with pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa would indicate respiratory acidosis.

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  • Question 15 - How should DVT during pregnancy be managed? ...

    Incorrect

    • How should DVT during pregnancy be managed?

      Your Answer:

      Correct Answer: Dalteparin

      Explanation:

      Subcutaneous low molecular weight heparin (LMWH) is the preferred treatment for most patients with acute DVT, including in pregnancy. A large meta-analyses comparing LMWH to unfractionated heparin (UFH) showed that LMWH decreased the risk of mortality, recurrent veno-thrombo embolism (VTE), and haemorrhage compared with heparin. Other advantages of LMWH may include more predictable therapeutic response, ease of administration and monitoring, and less heparin-induced thrombocytopenia. Disadvantages of LMWH include cost and longer half-life compared with heparin.

      Warfarin, which is administered orally, is used if long-term anticoagulation is needed. The international normalized ratio (INR) is followed, with a target range of 2-3. Warfarin crosses the placenta and is teratogenic, causing a constellation of anomalies known as warfarin embryopathy, with greatest risk between the sixth and twelfth week of gestation.
      Other options are not indicated for use.

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  • Question 16 - A 50 year old woman with a 30 pack year history of smoking...

    Incorrect

    • A 50 year old woman with a 30 pack year history of smoking presents with a persistent cough and occasional haemoptysis. A chest x-ray which is done shows no abnormality. What percentage of recent chest x-rays were reported as normal in patients who are subsequently diagnosed with lung cancer?

      Your Answer:

      Correct Answer: 10%

      Explanation:

      A retrospective cohort study of the primary care records of 247 lung cancer patients diagnosed between 1998–2002 showed that 10% of the X-rays were reported as normal.
      Other tests may include:
      – Imaging tests: A CT scan can reveal small lesions in your lungs that might not be detected on an X-ray.
      – Sputum cytology: sputum may reveal the presence of lung cancer cells.
      – Tissue sample (biopsy): A sample of abnormal cells may be removed for histological analysis. A biopsy may be performed in a number of ways, including bronchoscopy, mediastinoscopy and needle biopsy. A biopsy sample may also be taken from adjacent lymph nodes.

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  • Question 17 - Which of the following is not a known cause of occupational asthma? ...

    Incorrect

    • Which of the following is not a known cause of occupational asthma?

      Your Answer:

      Correct Answer: Cadmium

      Explanation:

      Occupational asthma (OA) could be divided into a nonimmunological, irritant-induced asthma and an immunological, allergy-induced asthma. In addition, allergy-induced asthma can be caused by two different groups of agents: high molecular weight proteins (>5,000 Da) or low molecular weight agents (<5,000 Da), generally chemicals like the isocyanates.
      Isocyanates are very reactive chemicals characterized by one or more isocyanate groups (–N=C=O). The main reactions of this chemical group are addition reactions with ethanol, resulting in urethanes, with amines (resulting in urea derivates) and with water. Here, the product is carbamic acid which is not stable and reacts further to amines, releasing free carbon dioxide.

      Diisocyanates and polyisocyanates are, together with the largely nontoxic polyol group, the basic building blocks of the polyurethane (PU) chemical industry, where they are used solely or in combination with solvents or additives in the production of adhesives, foams, elastomers, paintings, coatings and other materials.

      The complex salts of platinum are one of the most potent respiratory sensitising agents having caused occupational asthma in more than 50% of exposed workers. Substitution of ammonium hexachlor platinate with platinum tetra amine dichloride in the manufacture of catalyst has controlled the problem in the catalyst industry. Ammonium hexachlorplatinate exposure still occurs in the refining process.

      Rosin based solder flux fume is produced when soldering. This fume is a top cause of occupational asthma.

      Bakeries, flour mills and kitchens where flour dust and additives in the flour are a common cause of occupational asthma.

      Cadmium was not found to cause occupational asthma.

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  • Question 18 - A 52 year old female, known case of rheumatoid arthritis presents to the...

    Incorrect

    • A 52 year old female, known case of rheumatoid arthritis presents to the clinic with dyspnoea, cough, and intermittent pleuritic chest pain. She was previously taking second line agents Salazopyrine and gold previously and has now started Methotrexate with folic acid replacement a few months back. Pulmonary function tests reveal restrictive lung pattern and CXR reveals pulmonary infiltrates. Which of the following treatments is most suitable in this case?

      Your Answer:

      Correct Answer: Stop methotrexate

      Explanation:

      Methotrexate lung disease (pneumonitis and fibrosis) is the specific etiological type of drug-induced lung disease. It can occur due to the administration of methotrexate which is an antimetabolite, which is given as disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxemia and tachypnoea are always present and crackles are frequently audible. Symptoms typically manifest within months of starting therapy. Methotrexate withdrawal is indicated in such cases.

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  • Question 19 - A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of...

    Incorrect

    • A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of the following tests would be most useful in aiding the diagnosis?

      Your Answer:

      Correct Answer: ANCA

      Explanation:

      Churg-Strauss disease (CSD) is one of three important fibrinoid, necrotizing, inflammatory leukocytoclastic systemic small-vessel vasculitides that are associated with antineutrophil cytoplasm antibodies (ANCAs).
      The first (prodromal) phase of Churg-Strauss disease (CSD) consists of asthma usually in association with other typical allergic features, which may include eosinophilia. During the second phase, the eosinophilia is characteristic (see below) and ANCAs with perinuclear staining pattern (pANCAs) are detected. The treatment would therefore be different from asthma. For most patients, especially those patients with evidence of active vasculitis, treatment with corticosteroids and immunosuppressive agents (cyclophosphamide) is considered first-line therapy

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  • Question 20 - A 35 year old factory worker presents with a history of episodic dyspnoea....

    Incorrect

    • A 35 year old factory worker presents with a history of episodic dyspnoea. The complaint worsens when he is working. He starts to feel wheezy, with a tendency to cough. Which diagnostic investigation would be the most useful in this case?

      Your Answer:

      Correct Answer: Serial peak flow measurements at work and at home

      Explanation:

      Serial Peak Expiratory Flow measurement at work and home is a feasible, sensitive, and specific test for the diagnosis of occupational asthma. For a diagnosis of occupational asthma, it is important to establish a relationship objectively between the workplace exposure and asthma symptoms and signs. Physiologically, this can be achieved by monitoring airflow limitation in relation to occupational exposure(s). If there is an effect of a specific workplace exposure, airflow limitation should be more prominent on work days compared with days away from work (or days away from the causative agent). Airflow limitation can be measured by spirometry, with peak expiratory flow (PEF) and/or forced expiratory volume in 1 s(FEV1) being the most useful for observing changes in airway calibre. Other tests mentioned are less reliable and would not help in establishing a satisfactory diagnosis of occupational asthma.

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  • Question 21 - An 80 year old woman is admitted with a right lower lobe pneumonia....

    Incorrect

    • An 80 year old woman is admitted with a right lower lobe pneumonia. There is consolidation and a moderate sized pleural effusion on the same side. An ultrasound guided pleural fluid aspiration is performed. The appearance of the fluid is clear and is sent off for culture. Whilst awaiting the culture results, which one of the following is the most important factor when determining whether a chest tube should be placed?

      Your Answer:

      Correct Answer: pH of the pleural fluid

      Explanation:

      In adult practice, biochemical analysis of pleural fluid plays an important part in the management of pleural effusions. Protein levels or Light’s criteria differentiate exudates from transudates, while infection is indicated by pleural acidosis associated with raised LDH and low glucose levels. In terms of treatment, the pH may even guide the need for tube drainage, suggested by pH <7.2 in an infected effusion, although the absolute protein values are of no value in determining the likelihood of spontaneous resolution or chest drain requirements. pH is therefore the most important factor.

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  • Question 22 - A female in her early 20's who has been diagnosed with asthma for...

    Incorrect

    • A female in her early 20's who has been diagnosed with asthma for the past four years visits the office for a review. She has been using Beclomethasone dipropionate inhaler 200mcg bd along with Salbutamol inhaler 100mcg prn and her asthma is still uncontrolled. Her chest examination is clear and she has good inhaler technique. What would be the most appropriate next step in the management of her asthma?

      Your Answer:

      Correct Answer: Add a leukotriene receptor antagonist

      Explanation:

      The NICE 2017 guidelines state that in patients who are uncontrolled with a SABA (Salbutamol) and ICS (Inhaled corticosteroid e.g. Beclomethasone), a leukotriene receptor antagonist (LTRA) should be added.
      If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.

      This recommendation is also stated in NICE 2019 guidelines.

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  • Question 23 - A 14 year old girl with cystic fibrosis (CF) presents with abdominal pain....

    Incorrect

    • A 14 year old girl with cystic fibrosis (CF) presents with abdominal pain. Which of the following is the pain most likely linked to?

      Your Answer:

      Correct Answer: Meconium ileus equivalent syndrome

      Explanation:

      Meconium ileus equivalent (MIE) can be defined as a clinical manifestation in cystic fibrosis (CF) patients caused by acute intestinal obstruction by putty-like faecal material in the cecum or terminal ileum. A broader definition includes a more chronic condition in CF patients with abdominal pain and a coecal mass which may eventually pass spontaneously. The condition occurs only in CF patients with exocrine pancreatic insufficiency (EPI). It has not been seen in other CF patients nor in non-CF patients with EPI. The frequency of these symptoms has been reported as 2.4%-25%.

      The treatment should primarily be non-operative. Specific treatment with N-acetylcysteine, administrated orally and/or as an enema is recommended. Enemas with the water soluble contrast medium, meglucamine diatrizoate (Gastrografin), provide an alternative form for treatment and can also serve diagnostic purposes. It is important that the physician is familiar with this disease entity and the appropriate treatment with the above mentioned drugs. Non-operative treatment is often effective, and dangerous complications following surgery can thus be avoided.

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  • Question 24 - A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is...

    Incorrect

    • A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is not on any medication at the moment. Her PEFR diary shows wide diurnal variations and she also gives a past history of eczema.   Which of the following is correct?

      Your Answer:

      Correct Answer: Low dose inhaled corticosteroids would be considered acceptable

      Explanation:

      The following drugs should be used as normal during pregnancy:
      short acting β2 -agonists
      long acting β2- agonists
      inhaled corticosteroids
      oral and intravenous theophyllines

      Use steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy.
      If leukotriene receptor antagonists are required to achieve adequate control of asthma then they should not be withheld during pregnancy.

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  • Question 25 - An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP)....

    Incorrect

    • An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP). Her medical notes state that she developed a skin rash after taking penicillin a few years ago. She has a CURB score of 4 and adverse prognostic features. Which of the following would be an appropriate empirical antibiotic choice?

      Your Answer:

      Correct Answer: Cefotaxime and erythromycin

      Explanation:

      Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is an important cause of mortality and morbidity worldwide. Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
      The CURB-65 is used as a means of deciding the action that is needed to be taken for that patient.
      Score 3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

      Recent studies have suggested that the use of a beta-lactam alone may be noninferior to a beta-lactam/macrolide combination or fluoroquinolone therapy in hospitalized patients.

      Therapy in ICU patients includes the following:
      – Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) plus either a macrolide or respiratory fluoroquinolone
      – For patients with penicillin allergy, a respiratory fluoroquinolone and aztreonam

      Therefore the appropriate treatment would be Cefotaxime and erythromycin.

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  • Question 26 - A 27-year-old man with a history of asthma presents for review. He has...

    Incorrect

    • A 27-year-old man with a history of asthma presents for review. He has recently been discharged from hospital following an acute exacerbation and reports generally poor control with a persistent night time cough and exertional wheeze. His current asthma therapy is: salbutamol inhaler 100mcg prn Clenil (beclomethasone dipropionate) inhaler 800mcg bd salmeterol 50mcg bd He has a history of missing appointments and requests a prescription with as few side-effects as possible. What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Leukotriene receptor antagonist

      Explanation:

      The NICE 2019 guidelines states that in patients who are uncontrolled with a SABA (Salbutamol) and ICS (Beclomethasone), LTRA should be added.
      If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.

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  • Question 27 - An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes...

    Incorrect

    • An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes seven cigarettes per day. Her exercise tolerance is only a few yards around the house now. Her FEV1 is 37% of predicted. What is the most appropriate intervention for this patient?

      Your Answer:

      Correct Answer: Give regular high-dose inhaled fluticasone and inhaled long-acting β-agonist

      Explanation:

      The Stages of COPD:
      Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
      Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
      Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
      Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

      This patient has a FEV1 percent of 37 which falls within the stage 3 or severe COPD.
      During stage 3 COPD, you will likely experience significant lung function impairment. Many patients will experience an increase in COPD flare-ups or exacerbations. For some people, the increase in flare-ups means they could need to be hospitalized at times as well.

      Inhaled corticosteroid (ICS) use in combination with long-acting β2-agonists (LABAs) was shown to provide improved reductions in exacerbations, lung function, and health status. ICS-LABA combination therapy is currently recommended for patients with a history of exacerbations despite treatment with long-acting bronchodilators alone. The presence of eosinophilic bronchial inflammation, detected by high blood eosinophil levels or a history of asthma or asthma–COPD overlap, may define a population of patients in whom ICSs may be of particular benefit.

      The Towards a Revolution in COPD Health (TORCH) trial was a pivotal, double-blind, placebo-controlled, randomized study comparing salmeterol plus fluticasone propionate (50 and 500 µg, respectively, taken twice daily) with each component alone and placebo over 3 years.26 Patients with COPD were enrolled if they had at least a 10-pack-year smoking history, FEV1 <60% predicted, and an FEV1:FVC ratio ≤0.70.26 Among 6,184 randomized patients, the risk of death was reduced by 17.5% with the ICS-LABA combination vs placebo (P=0.052). ICS-LABA significantly reduced the rate of exacerbations by 25% compared with placebo (P<0.001) and improved health status and FEV1 compared with either component alone or placebo.

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  • Question 28 - Which virus is severe acute respiratory syndrome (SARS) caused by? ...

    Incorrect

    • Which virus is severe acute respiratory syndrome (SARS) caused by?

      Your Answer:

      Correct Answer: A coronavirus

      Explanation:

      Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003.
      In general, SARS begins with a high fever (temperature greater than 38.0°C). Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also have mild respiratory symptoms at the outset. About 10 to 20 percent of patients have diarrhoea. After 2 to 7 days, SARS patients may develop a dry cough. Most patients develop pneumonia. 

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  • Question 29 - A 50 year old retired coal miner with simple silicosis presented with shortness...

    Incorrect

    • A 50 year old retired coal miner with simple silicosis presented with shortness of breath. He had been short of breath for 3 months. Around 3 months ago he began keeping turtle doves as pets. On auscultation he had basal crepitations and chest x-ray showed fine nodular shadowing in the apices.   What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

      Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:

      ‘extrinsic’ – caused by something originating outside the body
      ‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
      ‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)

      Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.

      EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.

      Examples of EAA include:

      Bird fancier’s lung (BFL) is a type of hypersensitivity pneumonitis (HP). It is triggered by exposure to avian proteins present in the dry dust of the droppings and sometimes in the feathers of a variety of birds. The lungs become inflamed, with granuloma formation. Birds such as pigeons, parakeets, cockatiels, shell parakeets (budgerigars), parrots, turtle doves, turkeys and chickens have been implicated.

      People who work with birds or own many birds are at risk. Bird hobbyists and pet store workers may also be at risk. This disease is an inflammation of the alveoli in the lungs caused by an immune response to inhaled allergens from birds. Initial symptoms include shortness of breath (dyspnoea), especially after sudden exertion or when exposed to temperature change, which can resemble asthma, hyperventilation syndrome or pulmonary embolism. Chills, fever, non-productive cough and chest discomfort may also occur.

      A definitive diagnosis can be difficult without invasive testing, but extensive exposure to birds combined with reduced diffusing capacity are strongly suggestive of this disease. X-ray or CT scans will show physical changes to the lung structure (a ground glass appearance) as the disease progresses. Precise distribution and types of tissue damage differ among similar diseases, as does response to treatment with Prednisone.

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  • Question 30 - A 63 year old man presents to the clinic complaining of a 6-month history...

    Incorrect

    • A 63 year old man presents to the clinic complaining of a 6-month history of shortness of breath on exertion and a non-productive cough.   On examination there is clubbing, and crepitations heard at the lung bases. Lung function tests show a reduced vital capacity and an increased FEV1/FVC ratio.   What is his diagnosis?

      Your Answer:

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Idiopathic pulmonary fibrosis (IPF) is a condition in which the lungs become scarred and breathing becomes increasingly difficult.
      The most common signs and symptoms of idiopathic pulmonary fibrosis are shortness of breath and a persistent dry, hacking cough. Many affected individuals also experience a loss of appetite and gradual weight loss.

      The clinical findings of IPF are bibasilar reticular abnormalities, ground glass opacities, or diffuse nodular lesions on high-resolution computed tomography and abnormal pulmonary function studies that include evidence of restriction (reduced VC with an increase in FEV1/FVC ratio) and/or impaired gas exchange (increased P(A-a)O2 with rest or exercise or decreased diffusion capacity of the lung for carbon monoxide [DLCO]).

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (1/4) 25%
Passmed