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  • Question 1 - A 51 year old obese female, with a history of smoking, presents to...

    Incorrect

    • A 51 year old obese female, with a history of smoking, presents to the clinic with worsening dyspnoea. She is currently on oestrogen therapy for menopausal symptoms. Clinical examination, ECG and radiological findings correspond to right sided heart failure. There are no signs of left ventricular dysfunction. Which of the following is the most likely cause of cor pulmonale?

      Your Answer: Carcinoma of the lung

      Correct Answer: Recurrent small pulmonary embolisms

      Explanation:

      Postmenopausal oestrogen therapy and hormone therapy are associated with an increased risk of thromboembolism. The relative risk seems to be even greater if the treated population has pre-existing risk factors for thromboembolism, such as obesity, immobilization, and fracture. Cor pulmonale can occur secondary to small recurrent pulmonary embolisms. Pneumonias and bronchiectasis usually present with purulent sputum, and in case of carcinoma there may be other associated symptoms like weight loss, etc.

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      • Respiratory
      39.2
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  • Question 2 - A 50 year old woman with a 30 pack year history of smoking...

    Correct

    • 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: 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 3 - A 66 year old man visits the clinic because he has been experiencing...

    Correct

    • A 66 year old man visits the clinic because he has been experiencing increasing breathlessness for the past five months while doing daily tasks. His exercise tolerance is now limited to 75 metres while on a flat surface and walking up the stairs makes him breathless. He sleeps on four pillows and has swollen ankles in the morning. He occasionally coughs up phlegm. Past Medical history of importance: 36 pack year smoking history Hypertension Ischaemic heart disease Coronary artery stenting done 10 months ago Pulmonary function testing revealed: FEV1 0.90 L (1.80 – 3.02 predicted) FVC 1.87 L (2.16 – 3.58 predicted) Diffusion capacity 3.0 mmol/min/kPa (5.91 – 9.65 predicted) Total lung capacity 4.50 L (4.25 – 6.22 predicted) Residual volume 2.70 L (1.46 – 2.48 predicted)   Which condition does he have?

      Your Answer: Chronic obstructive pulmonary disease

      Explanation:

      Whilst asthma and COPD are different diseases they cause similar symptoms, which can present a challenge in identifying which of the two diseases a patient is suffering from. COPD causes chronic symptoms and narrowed airways which do not respond to treatment to open them up. In the case of asthma the constriction of the airways through inflammation tends to come and go and treatment to reduce inflammation and to open up the airways usually works well.

      COPD is more likely than asthma to cause a chronic cough with phlegm and is rare before the age of 35 whilst asthma is common in under-35s. Disturbed sleep caused by breathlessness and wheeze is more likely in cases of asthma, as is a history of allergies, eczema and hay fever. Differentiating between COPD and asthma requires a history of both symptoms and spirometry. The spirometry history should include post bronchodilator measurements, the degree of reversibility and, ideally, home monitoring which gives a history of diurnal variation.

      Airflow Obstruction: Both asthma and COPD are characterised by airflow obstruction. Airflow obstruction is defined as a reduced FEV1 and a reduced FEV1/FVC ratio, such that FEV1 is less than 80% of that predicted, and FEV1/FVC is less than 0.7.

      These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

      COPD: COPD is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. The airflow obstruction is not fully reversible.

      Spirometry COPD Asthma
      VC Reduced Nearly normal
      FEV1 Reduced Reduced in attack
      FVC (or FEV6) Reduced Nearly normal
      FEV1 Ratio
      (of VC/FVC/FEV6) Reduced in attack

      This man has a low FEV1 and FVC. His diffusions capacity is also low despite having a normal total lung capacity. These values confirm a diagnosis of COPD.

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  • Question 4 - A 51 year old smoker was recently diagnosed with non small cell lung...

    Correct

    • A 51 year old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread. What is the stage of this cancer?

      Your Answer: T2 N1 M0

      Explanation:

      The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.

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  • Question 5 - A 28 year old woman presents with lethargy, arthralgia and cough. Over the...

    Incorrect

    • A 28 year old woman presents with lethargy, arthralgia and cough. Over the past three weeks she has also developed painful erythematous nodules on both shins. Respiratory examination is normal. A chest x-ray is performed which is reported as follows: Bilateral mediastinal nodal enlargement. No evidence of lung parenchymal disease. Normal cardiac size. Given the likely diagnosis, what would be the most appropriate course of action?

      Your Answer: Inhaled corticosteroids

      Correct Answer: Observation

      Explanation:

      Sarcoidosis is an inflammatory disease that affects one or more organs but most commonly affects the lungs and lymph glands. The inflammation may change the normal structure and possibly the function of the affected organ(s).
      The presentation in sarcoidosis varies with the extent and severity of organ involvement, as follows:
      Asymptomatic (incidentally detected on chest imaging): Approximately 5% of cases.
      Systemic complaints (fever, anorexia): 45% of cases
      Pulmonary complaints (dyspnoea on exertion, cough, chest pain, and haemoptysis [rare]): 50% of cases

      Löfgren syndrome (fever, bilateral hilar lymphadenopathy, and polyarthralgias): Common in Scandinavian patients, but uncommon in African-American and Japanese patients.

      Dermatologic manifestations may include the following:
      – Erythema nodosum
      – A lower-extremity panniculitis with painful, erythematous nodules (often with Löfgren syndrome)
      – Lupus pernio (the most specific associated cutaneous lesion)
      – Violaceous rash on the cheeks or nose (common)
      – Maculopapular plaques (uncommon)

      Staging of sarcoidosis is as follows:
      Stage 0: Normal chest radiographic findings
      Stage I: Bilateral hilar lymphadenopathy
      Stage II: Bilateral hilar lymphadenopathy and infiltrates
      Stage III: Infiltrates alone
      Stage IV: Fibrosis

      Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for the treatment of arthralgias and other rheumatic complaints. Patients with stage I sarcoidosis often require only occasional treatment with NSAIDs.

      Treatment in patients with pulmonary involvement is as follows:
      Asymptomatic patients may not require treatment
      In patients with minimal symptoms, serial re-evaluation is prudent
      Treatment is indicated for patients with significant respiratory symptoms
      Corticosteroids can produce small improvements in the functional vital capacity and in the radiographic appearance in patients with more severe stage II and III disease.

      This patient has Stage 1 Sarcoidosis so observation is the most appropriate action.

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  • Question 6 - 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: Berylliosis

      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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  • Question 7 - How should DVT during pregnancy be managed? ...

    Incorrect

    • How should DVT during pregnancy be managed?

      Your Answer: Warfarin

      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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      • Respiratory
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  • Question 8 - A husband visits the clinic with his wife because he wants to be...

    Incorrect

    • A husband visits the clinic with his wife because he wants to be screened for cystic fibrosis. His brother and wife had a child with cystic fibrosis so he is concerned. His wife is currently 10 weeks pregnant. When screened, he was found to be a carrier of the DF508 mutation for cystic fibrosis but despite this result, the wife declines testing. What are the chances that she will have a child with cystic fibrosis, given that the gene frequency for this mutation in the general population is 1/20?

      Your Answer: 1/4

      Correct Answer: 1/80

      Explanation:

      The chance of two carriers of a recessive gene having a child that is homozygous for that disease (that is both genes are transmitted to the child) is 25%. Therefore, the chances of this couple having a child with CF are 25%(1/4) x 1/20 = 1/80.

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      • Respiratory
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  • Question 9 - A 23 year old female presents to the hospital with worsening shortness of...

    Incorrect

    • A 23 year old female presents to the hospital with worsening shortness of breath, increased volume of purulent sputum and left-sided chest pain. She has a history of cystic fibrosis. Medical notes state that she is under consideration for the transplant list and for some years has been colonised with pseudomonas. On examination she has a temperature of 38.4°C and FEV1 falling below 75% of the previous value that was recorded. She looks unwell and is tachycardic and hypotensive with a respiratory rate of 21/min. Burkholderia cepacia is confirmed as the pathogen in this case. What would be the most appropriate antibiotic regime?

      Your Answer: Vancomycin

      Correct Answer: Ceftazidime and aminoglycoside

      Explanation:

      Burkholderia cepacia is an aerobic gram-negative bacillus found in various aquatic environments. B cepacia is an organism of low virulence and is a frequent colonizer of fluids used in the hospital (e.g., irrigation solutions, intravenous fluids).
      B cepacia, as a non-aeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillin, and antipseudomonal third-generation cephalosporins and polymyxin B.
      B cepacia is often susceptible to trimethoprim plus sulfamethoxazole (TMP-SMX), cefepime, meropenem, minocycline, and tigecycline and has varying susceptibility to fluoroquinolones.
      Based on the options available, ceftazidime and aminoglycoside would be the best option.

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      • Respiratory
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  • Question 10 - A 32 year old primigravida, with a history of pulmonary hypertension, presents to...

    Incorrect

    • A 32 year old primigravida, with a history of pulmonary hypertension, presents to the clinic at 36 weeks gestation with worsening shortness of breath. Which of the following is the most accurate statements regarding her condition?

      Your Answer: Nifedipine is contraindicated in pregnancy

      Correct Answer: Risk of maternal mortality in patients with pulmonary hypertension is 30%

      Explanation:

      Historically, high rates of maternal and fetal death have been reported for pregnant women with pulmonary hypertension (30–56% and 11–28%, respectively). The causes of poor maternal outcomes are varied and include risk of death from right heart failure and stroke from intracardiac shunting. Furthermore, there is a high peri-/post-partum risk due to haemodynamic stress, bleeding complications and the use of general anaesthesia, which can all lead to right heart failure.
      The most common risk to the foetus is death, with premature birth and growth retardation being reported in successfully delivered children.
      CXR is not contraindicated in pregnancy. D-dimers are not used as a diagnostic aid as they are almost always elevated in pregnancy. Nifedipine, although contraindicated in pregnant women may be used judiciously if the need arises.

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  • Question 11 - A 23 year old female is admitted with acute severe asthma. Treatment is...

    Incorrect

    • 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:

      Correct 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 12 - 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 13 - A 64 year old woman with ankylosing spondylitis presents with cough, weight loss...

    Incorrect

    • A 64 year old woman with ankylosing spondylitis presents with cough, weight loss and tiredness. Her chest x-ray shows longstanding upper lobe fibrosis. Three sputum tests stain positive for acid fast bacilli (AFB) but are consistently negative for Mycobacterium tuberculosis on culture.   Which of the following is the most likely causative agent?

      Your Answer:

      Correct Answer: Mycobacterium avium intracellular complex

      Explanation:

      Pulmonary mycobacterium avium complex (MAC) infection in immunocompetent hosts generally manifests as cough, sputum production, weight loss, fever, lethargy, and night sweats. The onset of symptoms is insidious.
      In patients who may have pulmonary infection with MAC, diagnostic testing includes acid-fast bacillus (AFB) staining and culture of sputum specimens.

      The ATS/IDSA guidelines include clinical, radiographic, and bacteriologic criteria to establish a diagnosis of nontuberculous mycobacterial lung disease.

      Clinical criteria are as follows:

      Pulmonary signs and symptoms such as cough, fatigue, weight loss; less commonly, fever and weight loss; dyspnoea

      Appropriate exclusion of other diseases (e.g., carcinoma, tuberculosis).

      At least 3 sputum specimens, preferably early-morning samples taken on different days, should be collected for AFB staining and culture. Sputum AFB stains are positive for MAC in most patients with pulmonary MAC infection. Mycobacterial cultures grow MAC in about 1-2 weeks, depending on the culture technique and bacterial burden.

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  • Question 14 - A 78 year old male presents to the emergency department with shortness of...

    Incorrect

    • A 78 year old male presents to the emergency department with shortness of breath that has developed gradually over the last 4 days. His symptoms include fever and cough productive of greenish sputum. Past history is notable for COPD for which he was once admitted to the ICU, 2 years back. He now takes nebulizers (ipratropium bromide) at home. The patient previously suffered from myocardial infarction 7 years ago. He also has Diabetes Mellitus type II controlled by lifestyle modification. On examination, the following vitals are obtained. BP : 159/92 mmHg Pulse: 91/min (regular) Temp: Febrile On auscultation, there are scattered ronchi bilaterally and right sided basal crackles. Cardiovascular and abdominal examinations are unremarkable. Lab findings are given below: pH 7.31 pa(O2) 7.6 kPa pa(CO2) 6.3 kPa Bicarbonate 30 mmol/L, Sodium 136 mmol/L, Potassium 3.7 mmol/L, Urea 7.0 mmol/L, Creatinine 111 ÎĽmol/L, Haemoglobin 11.3 g/dL, Platelets 233 x 109 /l Mean cell volume (MCV) 83 fl White blood cells (WBC) 15.2 x 109 /l. CXR shows an opacity obscuring the right heart border. Which of the following interventions should be started immediately while managing this patient?

      Your Answer:

      Correct Answer: Salbutamol and ipratropium bromide nebulisers

      Explanation:

      Acute exacerbations of chronic obstructive pulmonary disease (COPD) are immediately treated with inhaled beta2 agonists and inhaled anticholinergics, followed by antibiotics (if indicated) and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators.
      High flow oxygen would worsen his symptoms. Usually titrated oxygen (88 to 92 %) is given in such patients to avoid the risk of hyperoxic hypercarbia in which increasing oxygen saturation in a chronic carbon dioxide retainer can inadvertently lead to respiratory acidosis and death.

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  • Question 15 - 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 16 - A 35-year-old woman is referred to the acute medical unit with a 5...

    Incorrect

    • A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever. Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum. What is the most appropriate diagnosis?

      Your Answer:

      Correct Answer: Lofgren's syndrome

      Explanation:

      Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.

      Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.

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  • Question 17 - Which of the following statements regarding the clinical effects of long-term oxygen therapy...

    Incorrect

    • Which of the following statements regarding the clinical effects of long-term oxygen therapy (LTOT) is the most accurate?

      Your Answer:

      Correct Answer: Reduced sympathetic outflow

      Explanation:

      Studies have shown that benefits of Long-tern oxygen therapy (LTOT) include improved exercise tolerance, with improved walking distance, and ability to perform daily activities, reduction of secondary polycythaemia, improved sleep quality and reduced sympathetic outflow, with increased sodium and water excretion, leading to improvement in renal function.

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  • Question 18 - 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 19 - Which treatment of chronic obstructive pulmonary disease (COPD) increases the long-term prognosis in...

    Incorrect

    • Which treatment of chronic obstructive pulmonary disease (COPD) increases the long-term prognosis in patients?

      Your Answer:

      Correct Answer: Long-term domiciliary oxygen therapy

      Explanation:

      COPD is commonly associated with progressive hypoxemia. Oxygen administration reduces mortality rates in patients with advanced COPD because of the favourable effects on pulmonary hemodynamics.

      Long-term oxygen therapy improves survival 2-fold or more in hypoxemic patients with COPD, according to 2 landmark trials, the British Medical Research Council (MRC) study and the US National Heart, Lung and Blood Institute’s Nocturnal Oxygen Therapy Trial (NOTT). Hypoxemia is defined as PaO2 (partial pressure of oxygen in arterial blood) of less than 55 mm Hg or oxygen saturation of less than 90%. Oxygen was used for 15-19 hours per day.

      Therefore, specialists recommend long-term oxygen therapy for patients with a PaO2 of less than 55 mm Hg, a PaO2 of less than 59 mm Hg with evidence of polycythaemia, or cor pulmonale. Patients should be evaluated after 1-3 months after initiating therapy, because some patients may not require long-term oxygen.

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  • Question 20 - Which of the following regarding malignant mesothelioma is correct? ...

    Incorrect

    • Which of the following regarding malignant mesothelioma is correct?

      Your Answer:

      Correct Answer: is treated with radiotherapy

      Explanation:

      Malignant mesothelioma is a type of cancer that occurs in the thin layer of tissue that covers the majority of the internal organs (mesothelium).
      Malignant Mesothelioma (MM) is a rare but rapidly fatal and aggressive tumour of the pleura and peritoneum. Aetiology of all forms of mesothelioma is strongly associated with industrial pollutants, of which asbestos is the principal carcinogen.

      Thoracoscopically guided biopsy should be performed if mesothelioma is suggested; the results are diagnostic in 98% of cases. No specific treatment has been found to be of benefit, except radiotherapy, which reduces seeding and invasion through percutaneous biopsy sites.

      Median survival for patients with malignant mesothelioma is 11 months. It is almost always fatal.

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  • Question 21 - 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 22 - A 35 year old male who has smoked 20 cigarettes per day was...

    Incorrect

    • A 35 year old male who has smoked 20 cigarettes per day was referred to the National Chest Hospital because he has had a nine month history of shortness of breath which is getting worse. Tests revealed that he had moderate emphysema. His family history showed that his father died from COPD at the age of 52. Genetic testing found the PiSZ genotype following the diagnosis of alpha-1 antitrypsin (A1AT) deficiency. What levels of alpha-1 antitrypsin would be expected if they were to be measured?

      Your Answer:

      Correct Answer: 40% of normal

      Explanation:

      Alpha1-antitrypsin (AAT) deficiency, first described in 1963, is one of the most common inherited disorders amongst white Caucasians. Its primary manifestation is early-onset of pan acinar emphysema. In adults, alpha1-antitrypsin deficiency leads to chronic liver disease in the fifth decade. As a cause of emphysema, it is seen in non-smokers in the fifth decade of life and during the fourth decade of life in smokers.

      Symptoms of alpha1-antitrypsin (AAT) deficiency emphysema are limited to the respiratory system. Dyspnoea is the symptom that eventually dominates alpha1-antitrypsin deficiency. Similar to other forms of emphysema, the dyspnoea of alpha1-antitrypsin deficiency is initially evident only with strenuous exertion. Over several years, it eventually limits even mild activities.
      The serum levels of some of the common genotypes are:
      •PiMM: 100% (normal)
      •PiMS: 80% of normal serum level of A1AT
      •PiSS: 60% of normal serum level of A1AT
      •PiMZ: 60% of normal serum level of A1AT, mild deficiency
      •PiSZ: 40% of normal serum level of A1AT, moderate deficiency
      •PiZZ: 10–15% (severe alpha 1-antitrypsin deficiency)

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  • Question 23 - 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 24 - Which of the following measurements is a poor prognostic factor in patients suffering...

    Incorrect

    • Which of the following measurements is a poor prognostic factor in patients suffering from pneumonia?

      Your Answer:

      Correct Answer: Respiratory rate 35/min

      Explanation:

      CURB Pneumonia Severity Score estimates the mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.
      Select Criteria:
      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) The CURB-65 scores range from 0 to 5. Clinical management decisions can be made based on the score:
      Score Risk Disposition
      0 or 1 – 1.5% mortality – Outpatient care
      2 – 9.2% mortality – Inpatient vs. observation admission
      ≥ 3 – 22% mortality – Inpatient admission with consideration for ICU admission with score of 4 or 5

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  • Question 25 - A patient with a history of asthma presents with worsening of her symptoms...

    Incorrect

    • A patient with a history of asthma presents with worsening of her symptoms and dyspnoea. She recently started taking a new medicine and she feels it might have aggravated her symptoms. Which of the following is likely responsible for her symptoms?

      Your Answer:

      Correct Answer: Timolol eye drops

      Explanation:

      β-blockers are the class of drug most often chosen to treat glaucoma, although other medical therapies are available. Systemic absorption of timolol eye drops can cause unsuspected respiratory impairment and exacerbation of asthma. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with β-blockers. Leukotriene antagonists and salbutamol are used in asthma treatment. HRT and ferrous sulphate do not lead to the exacerbation of asthma.

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  • Question 26 - 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:

      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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  • Question 27 - A 68 year old man is admitted with an infective exacerbation of chronic...

    Incorrect

    • A 68 year old man is admitted with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Investigations: blood gas taken whilst breathing 28% oxygen on admission: pH 7.30 p(O2) 7.8 kPa p(CO2) 7.4 kPa Which condition best describes the blood gas picture?

      Your Answer:

      Correct Answer: Decompensated type-2 respiratory failure

      Explanation:

      The normal partial pressure reference values are:
      – PaO2 more than 80 mmHg (11 kPa)
      – PaCO2 less than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 (7.4kPa)
      Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa).
      The pH is also lower than 7.35 at 7.3

      Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the build-up of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. The underlying causes include:
      – Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
      – Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
      – A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis)
      – Neuromuscular problems (Guillain–BarrĂ© syndrome, motor neuron disease)
      – Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest.

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  • Question 28 - A number of tests have been ordered for a 49 year old male...

    Incorrect

    • A number of tests have been ordered for a 49 year old male who has systemic lupus erythematosus (SLE). He was referred to the clinic because he has increased shortness of breath. One test in particular is transfer factor of the lung for carbon monoxide (TLCO), which is elevated. Which respiratory complication of SLE is associated with this finding?

      Your Answer:

      Correct Answer: Alveolar haemorrhage

      Explanation:

      Alveolar haemorrhage (AH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution. Extrapulmonary disease may be minimal and may be masked in patients who are already receiving immunosuppressants for other symptoms of SLE.

      DLCO or TLCO (diffusing capacity or transfer factor of the lung for carbon monoxide (CO)) is the extent to which oxygen passes from the air sacs of the lungs into the blood.
      Factors that can increase the DLCO include polycythaemia, asthma (can also have normal DLCO) and increased pulmonary blood volume as occurs in exercise. Other factors are left to right intracardiac shunting, mild left heart failure (increased blood volume) and alveolar haemorrhage (increased blood available for which CO does not have to cross a barrier to enter).

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  • Question 29 - 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 30 - A phrenic nerve palsy is caused by which of the following? ...

    Incorrect

    • A phrenic nerve palsy is caused by which of the following?

      Your Answer:

      Correct Answer: Aortic aneurysm

      Explanation:

      Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm.

      Thoracic aortic aneurysms are usually asymptomatic however chest pain is most commonly reported symptom. Left hemidiaphragm paralysis, because of left phrenic nerve palsy, is a very rare presentation of thoracic aortic aneurysm.
      Thoracic aortic aneurysm may present atypical symptoms such as dysphagia due to compression of the oesophagus; hoarseness due to vocal cord paralysis or compression of the recurrent laryngeal nerve; superior vena cava syndrome due to compression of the superior vena cava; cough, dyspnoea or both due to tracheal compression; haemoptysis due to rupture of the aneurysm into a bronchus; and shock due to rupture of the aneurysm.
      Common causes of phrenic nerve palsy include malignancy such as bronchogenic carcinoma, as well as mediastinal and neck tumours. Phrenic nerve palsy can also occur due to a penetrating injury or due to iatrogenic causes arising, for example, during cardiac surgery and central venous catheterization. Many cases or phrenic nerve palsy are idiopathic.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (3/10) 30%
Passmed