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  • Question 1 - A 65-year-old man presents with haemoptysis over the last 2 days. He has...

    Correct

    • A 65-year-old man presents with haemoptysis over the last 2 days. He has had a productive cough for 7 years, which has gradually worsened. Over the last few winters, he has been particularly bad and required admission to hospital. Past medical history includes pulmonary tuberculosis (TB) at age 20. On examination, he is cyanotic and clubbed, and has florid crepitations in both lower zones.
      What is the most likely diagnosis?

      Your Answer: Bronchiectasis

      Explanation:

      Diagnosing Respiratory Conditions: Bronchiectasis vs. Asthma vs. Pulmonary Fibrosis vs. COPD vs. Lung Cancer

      Bronchiectasis is the most probable diagnosis for a patient who presents with copious sputum production, recurrent chest infections, haemoptysis, clubbing, cyanosis, and florid crepitations at both bases that change with coughing. This condition is often exacerbated by a previous history of tuberculosis.

      Asthma, on the other hand, is characterized by reversible obstruction of airways due to bronchial muscle contraction in response to various stimuli. The absence of wheezing, the patient’s age, and the presence of haemoptysis make asthma an unlikely diagnosis in this case.

      Pulmonary fibrosis involves parenchymal fibrosis and interstitial remodelling, leading to shortness of breath and a non-productive cough. Patients with pulmonary fibrosis may develop clubbing, basal crepitations, and a dry cough, but the acute presentation and haemoptysis in this case would not be explained.

      Chronic obstructive pulmonary disease (COPD) is a progressive disorder characterized by airway obstruction, chronic bronchitis, and emphysema. However, the absence of wheezing, smoking history, and acute new haemoptysis make COPD a less likely diagnosis.

      Lung cancer is a possibility given the haemoptysis and clubbing, but the long history of productive cough, florid crepitations, and previous history of TB make bronchiectasis a more likely diagnosis. Overall, a thorough evaluation of symptoms and medical history is necessary to accurately diagnose respiratory conditions.

    • This question is part of the following fields:

      • Respiratory
      68
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  • Question 2 - A 50-year-old man, with a history of chronic obstructive pulmonary disease (COPD), is...

    Correct

    • A 50-year-old man, with a history of chronic obstructive pulmonary disease (COPD), is admitted to hospital with sudden-onset shortness of breath. His oxygen saturation levels are 82%, respiratory rate (RR) 25 breaths/min (normal 12–18 breaths/min), his trachea is central, he has reduced breath sounds in the right lower zone. Chest X-ray reveals a 2.5 cm translucent border at the base of the right lung.
      Given the likely diagnosis, what is the most appropriate management?

      Your Answer: Intrapleural chest drain

      Explanation:

      Management of Spontaneous Pneumothorax in a Patient with COPD

      When a patient with COPD presents with a spontaneous pneumothorax, prompt intervention is necessary. Smoking is a significant risk factor for pneumothorax, and recurrence rates are high for secondary pneumothorax. In deciding between needle aspiration and intrapleural chest drain, the size of the pneumothorax is crucial. In this case, the patient’s pneumothorax was >2 cm, requiring an intrapleural chest drain. Intubation and NIV are not necessary interventions at this time. Observation alone is not sufficient, and the patient requires urgent intervention due to low oxygen saturation, high respiratory rate, shortness of breath, and reduced breath sounds.

    • This question is part of the following fields:

      • Respiratory
      43.2
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  • Question 3 - A 28-year-old man with cystic fibrosis (CF) arrives at the Emergency Department (ED)...

    Incorrect

    • A 28-year-old man with cystic fibrosis (CF) arrives at the Emergency Department (ED) with haemoptysis. During his stay in the ED, he experiences another episode of frank haemoptysis, which measures 180 ml.
      A prompt computed tomography (CT) aortogram is conducted, revealing dilated and tortuous bronchial arteries.
      What action could potentially harm the management of this patient?

      Your Answer: Bronchial artery embolisation

      Correct Answer: Non-invasive ventilation

      Explanation:

      Treatment options for massive haemoptysis in cystic fibrosis patients

      Massive haemoptysis in cystic fibrosis (CF) patients can be a life-threatening complication. Non-invasive ventilation is not recommended as it may increase the risk of aspiration of blood and disturb clot formation. IV antibiotics should be given to treat acute inflammation related to pulmonary infection. Tranexamic acid, an anti-fibrinolytic drug, can be given orally or intravenously up to four times per day until bleeding is controlled. CF patients have impaired absorption of fat-soluble vitamins, including vitamin K, which may lead to prolonged prothrombin time. In such cases, IV vitamin K should be given. Bronchial artery embolisation is often required to treat massive haemoptysis, particularly when larger hypertrophied bronchial arteries are seen on CT. This procedure is performed by an interventional vascular radiologist and may be done under sedation or general anaesthetic if the patient is in extremis.

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      • Respiratory
      43.3
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  • Question 4 - A morbidly obese 32-year-old man presents to his General Practitioner for review. His...

    Correct

    • A morbidly obese 32-year-old man presents to his General Practitioner for review. His main reason for attendance is that his wife is concerned about his loud snoring and the fact that he stops breathing during the night for periods of up to 8–10 seconds, followed by coughing, snoring or waking. Recently he has become hypertensive and is also on treatment for impotence. His 24-hour urinary free cortisol level is normal.
      Which diagnosis best fits this picture?

      Your Answer: Obstructive sleep apnoea

      Explanation:

      Distinguishing Between Obstructive Sleep Apnoea and Other Conditions

      Obstructive sleep apnoea (OSA) is a common sleep disorder that can have significant impacts on a person’s health and well-being. Symptoms of OSA include memory impairment, daytime somnolence, disrupted sleep patterns, decreased libido, and systemic hypertension. When investigating potential causes of these symptoms, it is important to rule out other conditions that may contribute to or mimic OSA.

      For example, thyroid function testing should be conducted to rule out hypothyroidism, and the uvula and tonsils should be assessed for mechanical obstruction that may be treatable with surgery. Diagnosis of OSA is typically made using overnight oximetry. The mainstay of management for OSA is weight loss, along with the use of continuous positive airway pressure (CPAP) ventilation during sleep.

      When considering potential diagnoses for a patient with symptoms of OSA, it is important to distinguish between other conditions that may contribute to or mimic OSA. For example, Cushing’s disease can be identified through elevated 24-hour urinary free cortisol levels. Essential hypertension may contribute to OSA, but it does not fully explain the symptoms described. Simple obesity may be a contributing factor, but it does not account for the full clinical picture. Finally, simple snoring can be ruled out if apnoeic episodes are present. By carefully considering all potential diagnoses, healthcare providers can provide the most effective treatment for patients with OSA.

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      • Respiratory
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  • Question 5 - A 68-year-old man with chronic obstructive pulmonary disease (COPD) visits his general practitioner...

    Incorrect

    • A 68-year-old man with chronic obstructive pulmonary disease (COPD) visits his general practitioner (GP) complaining of increased wheezing, breathlessness, and a dry cough. He is able to speak in complete sentences.
      During the examination, the following observations are made:
      Temperature 37.2 °C
      Respiratory rate 18 breaths per minute
      Blood pressure 130/70 mmHg
      Heart rate 90 bpm
      Oxygen saturations 96% on room air
      He has diffuse expiratory wheezing.
      What is the most appropriate course of action for this patient?

      Your Answer: Request chest X-ray before prescribing any treatment

      Correct Answer: Prednisolone

      Explanation:

      Treatment Options for Acute Exacerbation of COPD

      When a patient presents with evidence of an acute non-infective exacerbation of COPD, treatment with oral corticosteroids is appropriate. Short-acting bronchodilators may also be necessary. If the patient’s observations are not grossly deranged, they can be managed in the community with instructions to seek further medical input if their symptoms worsen.

      Antibiotics are not indicated for non-infective exacerbations of COPD. However, if the patient has symptoms of an infective exacerbation, antibiotics may be prescribed based on the Anthonisen criteria.

      Referral to a hospital medical team for admission is not necessary unless the patient is haemodynamically unstable, hypoxic, or experiencing respiratory distress.

      A chest X-ray is not required unless there is suspicion of underlying pneumonia or pneumothorax. If the patient fails to respond to therapy or develops new symptoms, a chest X-ray may be considered at a later stage.

    • This question is part of the following fields:

      • Respiratory
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  • Question 6 - 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: Emphysema

      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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      • Respiratory
      60.7
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  • Question 7 - An 80-year-old known alcoholic is brought by ambulance after being found unconscious on...

    Incorrect

    • An 80-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 bank holiday weekend. Admission chest X-ray is normal. Before discharge on Tuesday morning, he is noted to be febrile and dyspnoeic. Blood tests reveal neutrophilia and elevated C-reactive protein (CRP) levels. A chest X-ray demonstrates consolidation in the right lower zone of the lung.
      What is the most likely diagnosis for this patient?

      Your Answer: Staphylococcal pneumonia

      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 occurs when someone inhales foreign material, such as vomit, into their lungs. If an alcoholic is found unconscious and has a consolidation in the lower zone of their lungs, it is highly likely that they have aspiration pneumonia. Antibiotics should be prescribed accordingly.

      Allergic bronchopulmonary aspergillosis is another condition that can cause breathlessness and consolidation on chest X-ray. However, it is unlikely to develop in a hospital setting and does not typically cause a fever. Treatment involves prednisolone and sometimes itraconazole.

      Tuberculosis (TB) is becoming more common in the UK and Europe, especially among immunosuppressed individuals like alcoholics. However, TB usually affects the upper lobes of the lungs, and the patient’s chest X-ray from two days prior makes it an unlikely diagnosis.

      Staphylococcal pneumonia can occur in alcoholics, but it is characterized by cavitating lesions and often accompanied by empyema.

      Pneumocystis jiroveci pneumonia is also common in immunosuppressed individuals and causes bilateral perihilar consolidations, sometimes with pneumatocele formation.

    • This question is part of the following fields:

      • Respiratory
      56.9
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  • Question 8 - A 45-year-old man presents to his GP with persistent wheezing and difficulty breathing....

    Incorrect

    • A 45-year-old man presents to his GP with persistent wheezing and difficulty breathing. Despite being prescribed a salbutamol inhaler, his symptoms continue and he is forced to take time off work. His GP increases his treatment by adding oral prednisolone, which initially helps but his symptoms return upon returning to work. However, during a two-week vacation, his wheezing significantly improves. Upon returning to work, he suffers an acute asthma attack and is taken to the hospital by ambulance. Which diagnostic test is most likely to confirm the diagnosis?

      Your Answer: Lung biopsy

      Correct Answer: Peak flow rates measured at home and in work

      Explanation:

      Occupational Asthma and its Causes

      Occupational asthma (OA) is a type of asthma that develops in adulthood and is caused by exposure to allergens in the workplace. Symptoms improve significantly when the affected person is away from their work environment. OA can be triggered by immunologic or non-immunologic stimuli. Immunologic stimuli have a latency period between exposure and symptom onset, while non-immunologic stimuli do not. Non-immunologic stimuli that trigger OA are referred to as reactive airways dysfunction syndrome (RADS) or irritant-induced asthma.

      Immunologic OA can be caused by high-molecular-weight or low-molecular-weight allergens. High-molecular-weight allergens include domestic and laboratory animals, fish and seafood, flour and cereals, and rubber. Low-molecular-weight allergens include metals, drugs, dyes and bleaches, isocyanates (naphthalene), and wood dust. It is important to identify the specific allergen causing OA in order to prevent further exposure and manage symptoms effectively.

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      • Respiratory
      41.8
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  • Question 9 - A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25...

    Incorrect

    • A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25 lb weight loss over the last 4 months. He reports a medical history significant for mild asthma controlled with an albuterol inhaler as needed. He takes no other medications and has no allergies. He has a 55 pack-year smoking history and has worked as a naval shipyard worker for 40 years. Examination reveals diffuse crackles in the posterior lung fields bilaterally and there is dullness to percussion one-third of the way up the right lung field. Ultrasound reveals free fluid in the pleural space.
      Which one of the following set of test values is most consistent with this patient’s presentation?
      (LDH: lactate dehydrogenase)
      Option LDH plasma LDH pleural Protein plasma Protein pleural
      A 180 100 7 3
      B 270 150 8 3
      C 180 150 7 4
      D 270 110 8 3
      E 180 100 7 2

      Your Answer:

      Correct Answer: Option C

      Explanation:

      Interpreting Light’s Criteria for Pleural Effusions

      When evaluating a patient with a history of occupational exposure and respiratory symptoms, it is important to consider the possibility of pneumoconiosis, specifically asbestosis. Chronic exposure to asbestos can lead to primary bronchogenic carcinoma and mesothelioma. Chest radiography may reveal radio-opaque pleural and diaphragmatic plaques. In this case, the patient’s dyspnea, hemoptysis, and weight loss suggest primary lung cancer, with a likely malignant pleural effusion observed under ultrasound.

      To confirm the exudative nature of the pleural effusion, Light’s criteria can be used. These criteria include a pleural:serum protein ratio >0.5, a pleural:serum LDH ratio >0.6, and pleural LDH more than two-thirds the upper limit of normal serum LDH. Meeting any one of these criteria indicates an exudative effusion.

      Option C is the correct answer as it satisfies Light’s criteria for an exudative pleural effusion. Options A, B, D, and E do not meet the criteria. Understanding Light’s criteria can aid in the diagnosis and management of pleural effusions, particularly in cases where malignancy is suspected.

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      • Respiratory
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  • Question 10 - 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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      • Respiratory
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  • Question 11 - A 45-year-old woman with known asthma presents to the Emergency Department with severe...

    Incorrect

    • A 45-year-old woman with known asthma presents to the Emergency Department with severe breathlessness and wheeze.
      Which of the following is the most concerning finding on examination and initial investigations?

      Your Answer:

      Correct Answer: PaCO2 5.5 kPa

      Explanation:

      Assessing the Severity of an Acute Asthma Exacerbation

      When assessing the severity of an acute asthma exacerbation, several factors must be considered. A PaCO2 level of 5.5 kPa in an acutely exacerbating asthmatic is a worrying sign and is a marker of a life-threatening exacerbation. A respiratory rate of 30 breaths per minute or higher is a sign of acute severe asthma, while poor respiratory effort is a sign of life-threatening asthma. Peak expiratory flow rate (PEFR) can also be used to help assess the severity of an acute exacerbation of asthma. A PEFR of 33-35% best or predicted is a sign of acute severe asthma, while a PEFR < 33% best or predicted is a sign of life-threatening asthma. A heart rate of 140 bpm or higher is a feature of acute severe asthma, while arrhythmia and/or hypotension are signs of life-threatening asthma. Inability to complete sentences in one breath is a sign of acute severe asthma, while an altered conscious level is a sign of life-threatening asthma. By considering these factors, healthcare professionals can accurately assess the severity of an acute asthma exacerbation and provide appropriate treatment.

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      • Respiratory
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  • Question 12 - A 56-year-old man has just been admitted to the medical ward. Two days...

    Incorrect

    • A 56-year-old man has just been admitted to the medical ward. Two days ago, he returned from a business trip and his history suggests he may have caught an atypical pneumonia. While examining the patient’s chest clinically, you try to determine whether the pneumonia is affecting one lobe in particular or is affecting the whole lung.
      On the right side of the patient’s chest, which one of the following surface landmarks would be most likely to mark the boundary between the middle and lower lobes?

      Your Answer:

      Correct Answer: Sixth rib

      Explanation:

      Surface Landmarks for Lung Lobes and Abdominal Planes

      The human body has several surface landmarks that can be used to locate important anatomical structures. In the case of the lungs, the position of the lobes can be estimated using the oblique and horizontal fissures. The sixth rib is the most likely surface landmark to mark the boundary between the right middle and lower lobes, while the fourth costal cartilage indicates the level of the horizontal fissure separating the superior from the middle lobes of the right lung.

      In the abdomen, the tip of the ninth costal cartilage is a useful landmark as it marks the position of the transpyloric plane. This imaginary axial plane is important as it is where many anatomical structures, such as the pylorus of the stomach and the neck of the pancreas, are located. Additionally, the horizontal line passing through the centre of the nipple, known as the mammillary line, can also be used as a surface landmark for certain procedures.

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      • Respiratory
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  • Question 13 - A 25-year-old male graduate student comes to the clinic complaining of shortness of...

    Incorrect

    • A 25-year-old male graduate student comes to the clinic complaining of shortness of breath during physical activity for the past two months. He denies any other symptoms and is a non-smoker. Upon examination, there are no abnormalities found, and his full blood count and chest x-ray are normal. What diagnostic test would be most useful in confirming the suspected diagnosis?

      Your Answer:

      Correct Answer: Spirometry before and after exercise

      Explanation:

      Confirming Exercise-Induced Asthma Diagnosis

      To confirm the suspected diagnosis of exercise-induced asthma, the most appropriate investigation would be spirometry before and after exercise. This patient is likely to have exercise-induced asthma, which means that his asthma symptoms are triggered by physical activity. Spirometry is a lung function test that measures how much air a person can inhale and exhale. By performing spirometry before and after exercise, doctors can compare the results and determine if there is a significant decrease in lung function after physical activity. If there is a significant decrease, it confirms the diagnosis of exercise-induced asthma. This test is important because it helps doctors develop an appropriate treatment plan for the patient. With the right treatment, patients with exercise-induced asthma can still participate in physical activity and lead a healthy lifestyle.

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      • Respiratory
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  • Question 14 - A 38-year-old male presents with complaints of difficulty breathing. During the physical examination,...

    Incorrect

    • A 38-year-old male presents with complaints of difficulty breathing. During the physical examination, clubbing of the fingers is observed. What medical condition is commonly associated with clubbing?

      Your Answer:

      Correct Answer: Pulmonary fibrosis

      Explanation:

      Respiratory and Other Causes of Clubbing of the Fingers

      Clubbing of the fingers is a condition where the tips of the fingers become enlarged and the nails curve around the fingertips. This condition is often associated with respiratory diseases such as carcinoma of the lung, bronchiectasis, mesothelioma, empyema, and pulmonary fibrosis. However, it is not typically associated with chronic obstructive airway disease (COAD). Other causes of clubbing of the fingers include cyanotic congenital heart disease, inflammatory bowel disease, and infective endocarditis.

      In summary, clubbing of the fingers is a physical manifestation of various underlying medical conditions. It is important to identify the underlying cause of clubbing of the fingers in order to provide appropriate treatment and management.

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      • Respiratory
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  • Question 15 - A 30-year-old man is brought to the Emergency Department after he suddenly collapsed...

    Incorrect

    • A 30-year-old man is brought to the Emergency Department after he suddenly collapsed while playing soccer, complaining of pleuritic chest pain and difficulty in breathing. Upon examination, the patient appears pale and short of breath. His pulse rate is 120 bpm and blood pressure is 105/60 mmHg. Palpation reveals a deviated trachea to the right, without breath sounds over the left lower zone on auscultation. Percussion of the left lung field is hyper-resonant.
      What would be the most appropriate immediate management for this patient?

      Your Answer:

      Correct Answer: Oxygen and aspirate using a 16G cannula inserted into the second anterior intercostal space mid-clavicular line

      Explanation:

      A pneumothorax is a condition where air accumulates in the pleural space between the parietal and visceral pleura. It can be primary or secondary, with the latter being more common in patients over 50 years old, smokers, or those with underlying lung disease. Symptoms include sudden chest pain, breathlessness, and, in severe cases, pallor, tachycardia, and hypotension. Primary spontaneous pneumothorax is more common in young adult smokers and often recurs. Secondary pneumothorax is associated with various lung diseases, including COPD and α-1-antitrypsin deficiency. A tension pneumothorax is a medical emergency that can lead to respiratory or cardiovascular compromise. Diagnosis is usually made through chest X-ray, but if a tension pneumothorax is suspected, treatment should be initiated immediately. Management varies depending on the size and type of pneumothorax, with larger pneumothoraces requiring aspiration or chest drain insertion. The safest location for chest drain insertion is the fifth intercostal space mid-axillary line within the safe triangle.

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      • Respiratory
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  • Question 16 - A 40-year-old Romanian smoker presents with a 3-month history of cough productive of...

    Incorrect

    • A 40-year-old Romanian smoker presents with a 3-month history of cough productive of blood-tinged sputum, fever, night sweats and weight loss. At presentation he is haemodynamically stable, has a fever of 37.7°C and appears cachectic. On examination, there are coarse crepitations in the right upper zone of lung. Chest radiograph reveals patchy, non-specific increased upper zone interstitial markings bilaterally together with a well-defined round opacity with a central lucency in the right upper zone and bilateral enlarged hila.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Tuberculosis

      Explanation:

      Differential Diagnosis for a Subacute Presentation of Pulmonary Symptoms

      Tuberculosis is a growing concern, particularly in Eastern European countries where multi-drug resistant strains are on the rise. The initial infection can occur anywhere in the body, but often affects the lung apices and forms a scarred granuloma. Latent bacteria can cause reinfection years later, leading to post-primary TB. Diagnosis is based on identifying acid-fast bacilli in sputum. Treatment involves a 6-month regimen of antibiotics. Staphylococcal and Klebsiella pneumonia can also present with pneumonia symptoms and cavitating lesions, but patients would be expected to be very ill with signs of sepsis. Squamous cell bronchial carcinoma is a possibility but less likely in this case. Primary pulmonary lymphoma is rare and typically occurs in HIV positive individuals, with atypical presentation and radiographic findings. Contact screening is essential for TB.

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      • Respiratory
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  • Question 17 - A 38-year-old woman presents to the Emergency department with a two-week history of...

    Incorrect

    • A 38-year-old woman presents to the Emergency department with a two-week history of palpitations and breathlessness. She has a past medical history of diabetes mellitus, which is well controlled on metformin 850 mg bd, and longstanding hypertension for which she has been on therapy for several years. Her current medications include captopril 50 mg bd, furosemide 40 mg od, and nifedipine 20 mg bd. She recently consulted her GP with symptoms of breathlessness, and he increased the dose of furosemide to 80 mg od.

      On examination, the patient is overweight and appears distressed. She is afebrile, with a pulse of 120, regular, and a blood pressure of 145/95 mmHg. Heart sounds 1 and 2 are normal without added sounds or murmurs. Respiratory rate is 28/minute, and the chest is clear to auscultation. The rest of the examination is normal.

      Investigations:
      - Hb: 134 g/L (normal range: 115-165)
      - WBC: 8.9 ×109/L (normal range: 4-11)
      - Platelets: 199 ×109/L (normal range: 150-400)
      - Sodium: 139 mmol/L (normal range: 137-144)
      - Potassium: 4.4 mmol/L (normal range: 3.5-4.9)
      - Urea: 5.8 mmol/L (normal range: 2.5-7.5)
      - Creatinine: 110 µmol/L (normal range: 60-110)
      - Glucose: 5.9 mmol/L (normal range: 3.0-6.0)
      - Arterial blood gases on air:
      - pH: 7.6 (normal range: 7.36-7.44)
      - O2 saturation: 99%
      - PaO2: 112 mmHg/15 kPa (normal range: 75-100)
      - PaCO2: 13.7 mmHg/1.8 kPa (normal range: 35-45)
      - Standard bicarbonate: 20 mmol/L (normal range: 20-28)
      - Base excess: -7.0 mmol/L (normal range: ±2)

      What is the appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Calming reassurance

      Explanation:

      Managing Respiratory Alkalosis in Patients with Panic Attacks

      Patients experiencing hyperventilation may develop respiratory alkalosis, which can be managed by creating a calming atmosphere and providing reassurance. However, the traditional method of breathing into a paper bag is no longer recommended. Instead, healthcare providers should focus on stabilizing the patient’s breathing and addressing any underlying anxiety or panic.

      It’s important to note that panic attacks can cause deranged ABG results, including respiratory alkalosis. Therefore, healthcare providers should be aware of this potential complication and take appropriate measures to manage the patient’s symptoms. While paper bag rebreathing may be effective in some cases, it should be administered with caution, especially in patients with respiratory or cardiac pathology.

      In summary, managing respiratory alkalosis in patients with panic attacks requires a holistic approach that addresses both the physical and emotional aspects of the condition. By creating a calming environment and providing reassurance, healthcare providers can help stabilize the patient’s breathing and prevent further complications.

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  • Question 18 - A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath,...

    Incorrect

    • A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath, unable to speak in complete sentences, tachypnoeic and with a tachycardia of 122 bpm. Severe inspiratory wheeze is noted on examination. The patient is given nebulised salbutamol and ipratropium bromide, and IV hydrocortisone is administered. After 45 minutes of IV salbutamol infusion, there is no improvement in tachypnea and oxygen saturation has dropped to 80% at high flow oxygen. An ABG is taken, showing a pH of 7.50, pO2 of 10.3 kPa, pCO2 of 5.6 kPa, and HCO3− of 28.4 mmol/l. What is the next most appropriate course of action?

      Your Answer:

      Correct Answer: Request an anaesthetic assessment for the Intensive Care Unit (ICU)

      Explanation:

      Why an Anaesthetic Assessment is Needed for a Severe Asthma Attack in ICU

      When a patient is experiencing a severe asthma attack, it is important to take the appropriate steps to provide the best care possible. In this scenario, the patient has already received nebulisers, an iv salbutamol infusion, and hydrocortisone, but their condition has not improved. The next best step is to request an anaesthetic assessment for ICU, as rapid intubation may be required and the patient may need ventilation support.

      While there are other options such as CPAP and NIPPV, these should only be used in a controlled environment with anaesthetic backup. Administering oral magnesium is also not recommended, and iv aminophylline should only be considered after an anaesthetic review. By requesting an anaesthetic assessment for ICU, the patient can receive the best possible care for their severe asthma attack.

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  • Question 19 - A 60-year-old man comes to you with complaints of increasing shortness of breath...

    Incorrect

    • A 60-year-old man comes to you with complaints of increasing shortness of breath on exertion over the past year. During the examination, you observe early finger clubbing and bibasal fine crackles on auscultation. You suspect that he may have pulmonary fibrosis.
      What is the imaging modality considered the gold standard for diagnosing pulmonary fibrosis?

      Your Answer:

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

      Explanation:

      Imaging Modalities for Pulmonary Fibrosis and Pulmonary Embolus

      When it comes to diagnosing pulmonary fibrosis and pulmonary embolus, there are several imaging modalities available. High-resolution computed tomography (HRCT) chest is considered the gold standard for suspected pulmonary fibrosis as it provides detailed images of the lung parenchyma. On the other hand, computed tomography pulmonary angiogram (CTPA) is the gold standard for suspected pulmonary embolus. A chest X-ray may be useful initially for investigating patients with suspected pulmonary fibrosis, but HRCT provides more detail. Ventilation-perfusion (V/Q) chest scan is used for certain patients with suspected pulmonary embolus, but not for pulmonary fibrosis. Magnetic resonance imaging (MRI) chest is not commonly used for either condition, as HRCT remains the preferred imaging modality for pulmonary fibrosis.

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  • Question 20 - A 24-year-old man, who is a known intravenous drug user, presented with progressive...

    Incorrect

    • A 24-year-old man, who is a known intravenous drug user, presented with progressive dyspnoea. On examination, his respiratory rate was 31 breaths per minute and his chest X-ray showed diffuse infiltrates in a bat-wing pattern. However, chest auscultation was normal. While staying in hospital, he developed sudden severe dyspnoea, and an emergency chest X-ray showed right-sided pneumothorax.
      What is the underlying disease of this patient?

      Your Answer:

      Correct Answer: Pneumocystis jirovecii infection

      Explanation:

      Differential Diagnosis for a Young Injection Drug User with Dyspnea and Chest X-ray Findings

      A young injection drug user presenting with gradually progressive dyspnea and a typical chest X-ray finding is likely to have Pneumocystis jirovecii infection, an opportunistic fungal infection that predominantly affects the lungs. This infection is often seen in individuals with underlying human immunodeficiency virus (HIV) infection-related immunosuppression. Other opportunistic infections should also be ruled out. Pneumocystis typically resides in the alveoli of the lungs, resulting in extensive exudation and formation of hyaline membrane. Lung biopsy shows foamy vacuolated exudates. Extrapulmonary sites involved include the thyroid, lymph nodes, liver, and bone marrow.

      Other potential diagnoses, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pneumoconiosis, and pulmonary histoplasmosis, are less likely. COPD and pneumoconiosis are typically seen in individuals with a history of smoking or occupational exposure to dust, respectively. Cystic fibrosis would present with a productive cough and possible hemoptysis, while pulmonary histoplasmosis is not commonly found in Europe.

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  • Question 21 - A 65-year-old woman presents to the Emergency Department with shortness of breath after...

    Incorrect

    • A 65-year-old woman presents to the Emergency Department with shortness of breath after being sat at home.
      An arterial blood gas (ABG) is performed and shows the following results:
      Investigation Result Normal value
      pH 7.48 7.35–7.45
      pO2 7.3 kPa 10.5–13.5 kPa
      pCO2 3.9 kPa 4.6–6 kPa
      HCO3 24 mmol/l 24–30 mmol/l
      Which one of the following conditions is most likely to account for these investigation results?

      Your Answer:

      Correct Answer: Pulmonary embolism

      Explanation:

      Understanding Respiratory Failure: Causes and ABG Interpretation

      Respiratory failure is a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide. There are two types of respiratory failure: type I and type II. Type I respiratory failure is characterized by low levels of oxygen and normal or low levels of carbon dioxide, resulting in respiratory alkalosis. Type II respiratory failure, on the other hand, is characterized by low levels of oxygen and high levels of carbon dioxide, resulting in respiratory acidosis.

      Pulmonary embolism is the only cause of type I respiratory failure. This condition results in reduced oxygenation of the blood due to a blockage in the pulmonary artery. The ABG of a patient with pulmonary embolism would show low levels of oxygen and carbon dioxide, as well as respiratory alkalosis.

      Hypothyroidism, Guillain–Barré syndrome, and myasthenia gravis are all causes of type II respiratory failure. Hypothyroidism can result in decreased ventilatory drive, while Guillain–Barré syndrome and myasthenia gravis can cause respiratory muscle weakness, leading to hypoventilation and respiratory acidosis.

      Opiate overdose is another cause of type II respiratory failure. Opiates act on the respiratory centers in the brain, reducing ventilation and causing respiratory acidosis.

      In summary, understanding the causes and ABG interpretation of respiratory failure is crucial in identifying and managing this potentially life-threatening condition.

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  • Question 22 - A 65-year-old lady is admitted with severe pneumonia and, while on the ward,...

    Incorrect

    • A 65-year-old lady is admitted with severe pneumonia and, while on the ward, develops a warm, erythematosus, tender and oedematous left leg. A few days later, her breathing, which was improving with antibiotic treatment, suddenly deteriorated.
      Which one of the following is the best diagnostic test for this patient?

      Your Answer:

      Correct Answer: Computed tomography (CT) pulmonary angiogram

      Explanation:

      The Best Imaging Method for Dual Pathology: Resolving Pneumonia and Pulmonary Embolus

      Computed tomography (CT) pulmonary angiography is the best imaging method for a patient with dual pathology of resolving pneumonia and a pulmonary embolus secondary to a deep vein thrombosis. This method uses intravenous contrast to image the pulmonary vessels and can detect a filling defect within the bright pulmonary arteries, indicating a pulmonary embolism.

      A V/Q scan, which looks for a perfusion mismatch, may indicate a pulmonary embolism, but would not be appropriate in this case due to the underlying pneumonia making interpretation difficult.

      A D-dimer test should be performed, but it is non-specific and may be raised due to the pneumonia. It should be used together with the Wells criteria to consider imaging.

      A chest X-ray should be performed to ensure there is no worsening pneumonia or pneumothorax, but in this case, a pulmonary embolism is the most likely diagnosis and therefore CTPA is required.

      An arterial blood gas measurement can identify hypoxia and hypocapnia associated with an increased respiratory rate, but this is not specific to a pulmonary embolism and many pulmonary diseases can cause this arterial blood gas picture.

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  • Question 23 - A 55-year old complains of difficulty breathing. A CT scan of the chest...

    Incorrect

    • A 55-year old complains of difficulty breathing. A CT scan of the chest reveals the presence of an air-crescent sign. Which microorganism is commonly linked to this sign?

      Your Answer:

      Correct Answer: Aspergillus

      Explanation:

      Radiological Findings in Pulmonary Infections: Air-Crescent Sign and More

      Different pulmonary infections can cause distinct radiological findings that aid in their diagnosis and management. Here are some examples:

      – Aspergillosis: This fungal infection can lead to the air-crescent sign, which shows air filling the space left by necrotic lung tissue as the immune system fights back. It indicates a sign of recovery and is found in about half of cases. Aspergilloma, a different form of aspergillosis, can also present with a similar radiological finding called the monad sign.
      – Mycobacterium avium intracellulare: This organism causes non-tuberculous mycobacterial infection in the lungs, which tends to affect patients with pre-existing chronic obstructive pulmonary disease or immunocompromised states.
      – Staphylococcus aureus: This bacterium can cause cavitating lung lesions and abscesses, which appear as round cavities with an air-fluid level.
      – Pseudomonas aeruginosa: This bacterium can cause pneumonia in patients with chronic lung disease, and CT scans may show ground-glass attenuation, bronchial wall thickening, peribronchial infiltration, and pleural effusions.
      – Mycobacterium tuberculosis: This bacterium may cause cavitation in the apical regions of the lungs, but it does not typically lead to the air-crescent sign.

      Understanding these radiological findings can help clinicians narrow down the possible causes of pulmonary infections and tailor their treatment accordingly.

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  • Question 24 - A 10-year-old boy comes to the GP clinic with his father for an...

    Incorrect

    • A 10-year-old boy comes to the GP clinic with his father for an asthma check-up. He is currently on Clenil® Modulite® (beclomethasone) 100 μg twice daily as a preventer inhaler, but still needs to use his salbutamol inhaler 2-3 times a day. During the examination, he is able to complete sentences, not using any accessory muscles of respiration, his oxygen saturation is 99%, his chest is clear, and PEFR is 85% of his predicted value. What is the recommended next step in managing this patient according to the latest BTS guidelines?

      Your Answer:

      Correct Answer: Add formoterol a long-acting beta agonist (LABA)

      Explanation:

      Managing Pediatric Asthma: Choosing the Next Step in Treatment

      When treating pediatric asthma, it is important to follow guidelines to ensure the best possible outcomes for the patient. According to the 2019 SIGN/BTS guidelines, the next step after low-dose inhaled corticosteroid (ICS) should be to add a long-acting beta agonist (LABA) or leukotriene receptor antagonist (LTRA) in addition to ICS. However, it is important to note that the NICE guidelines differ in that LTRA is recommended before LABA.

      If the patient does not respond adequately to LABA and a trial of LTRA does not yield benefit, referral to a pediatrician is advised. Increasing the dose of ICS should only be considered after the addition of LTRA or LABA.

      It is crucial to never stop ICS therapy, as adherence to therapy is a guiding principle in managing pediatric asthma. LABAs should never be used alone without ICS, as this has been linked to life-threatening asthma exacerbations. Always follow guidelines and consult with a pediatrician for the best possible treatment plan.

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  • Question 25 - A 72-year-old retired boiler maker presents to his General Practitioner with increasing shortness...

    Incorrect

    • A 72-year-old retired boiler maker presents to his General Practitioner with increasing shortness of breath and non-specific dull right-sided chest ache. He has a 35-pack-year history and has recently lost a little weight. On examination, there is evidence of a large right-sided pleural effusion.
      Investigations:
      Investigation
      Result
      Normal value
      Sodium (Na+) 132 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 120 μmol/l 50–120 µmol/l
      Haemoglobin 115 g/l 135–175 g/l
      Platelets 170 × 109/l 150–400 × 109/l
      Chest X-ray: large right-sided pleural effusion.
      Pleural tap: pleural effusion contains occasional red blood cells, white blood cells and abnormal-looking cells which look of a sarcomatous type.
      Which of the following statements fits best with the underlying condition?

      Your Answer:

      Correct Answer: The vast majority of cases are associated with a history of asbestos exposure

      Explanation:

      Understanding Mesothelioma: Causes, Treatment, and Prognosis

      Mesothelioma is a type of cancer that has three major histological subtypes: sarcomatous, epithelial, and mixed. The vast majority of cases are associated with a history of direct exposure to asbestos, particularly in industries such as ship building, boiler manufacture, paper mill working, and insulation work. Patients often present with shortness of breath and chest pain on the affected side.

      While smoking increases the risk of malignancy, it does not directly play a role in the development of malignant pleural effusion. Treatment often includes a combination of chemotherapy, radiotherapy, and surgery, but even with these approaches, the result is not curative. Median survival is short, with a life expectancy of around two years.

      In early stages of cancer, radiation therapy combined with surgical treatment can be very effective, but in later stages, it is only effective in providing symptom relief. Radiation therapy alone will not be curative in 40% of cases. Understanding the causes, treatment options, and prognosis of mesothelioma is crucial for patients and their families.

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  • Question 26 - A 20-year-old male presents to the Emergency department with left-sided chest pain and...

    Incorrect

    • A 20-year-old male presents to the Emergency department with left-sided chest pain and difficulty breathing that started during a football game.

      Which diagnostic test is most likely to provide a conclusive diagnosis?

      Your Answer:

      Correct Answer: Chest x ray

      Explanation:

      Diagnosis of Pneumothorax

      A pneumothorax is suspected based on the patient’s medical history. To confirm the diagnosis, a chest x-ray is the only definitive test available. An ECG is unlikely to show any abnormalities, while blood gas analysis may reveal a slightly elevated oxygen level and slightly decreased carbon dioxide level, even if the patient is not experiencing significant respiratory distress.

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  • Question 27 - A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing,...

    Incorrect

    • A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing, with an AMTS score of 9. During the examination, his respiratory rate is 32 breaths/minute, and his blood pressure is 100/70 mmHg. His blood test shows a urea level of 6 mmol/l. What is a predictive factor for increased mortality in this pneumonia patient?

      Your Answer:

      Correct Answer: Respiratory rate >30 breaths/minute

      Explanation:

      Prognostic Indicators in Pneumonia: Understanding the CURB 65 Score

      The CURB 65 score is a widely used prognostic tool for patients with pneumonia. It consists of five indicators, including confusion, urea levels, respiratory rate, blood pressure, and age. A respiratory rate of >30 breaths/minute and new-onset confusion with an AMTS score of <8 are two of the indicators that make up the CURB 65 score. However, in the case of a patient with a respiratory rate of 32 breaths/minute and an AMTS score of 9, these indicators still suggest a poor prognosis. A urea level of >7 mmol/l and a blood pressure of <90 mmHg systolic and/or 60 mmHg diastolic are also indicators of a poor prognosis. Finally, age >65 is another indicator that contributes to the CURB 65 score. Understanding these indicators can help healthcare professionals assess the severity of pneumonia and determine appropriate treatment plans.

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  • Question 28 - A 68-year-old man with lung cancer presents to the Emergency Department complaining of...

    Incorrect

    • A 68-year-old man with lung cancer presents to the Emergency Department complaining of chest pain and shortness of breath. He reports no cough or sputum production. Upon auscultation, his chest is clear. His pulse is irregularly irregular and measures 110 bpm, while his oxygen saturation is 86% on room air. He is breathing at a rate of 26 breaths per minute. What diagnostic investigation is most likely to be effective in this scenario?

      Your Answer:

      Correct Answer: Computerised tomography pulmonary angiogram (CTPA)

      Explanation:

      Diagnostic Tests for Pulmonary Embolism in Cancer Patients

      Pulmonary embolism (PE) and deep vein thrombosis (DVT) are common in cancer patients due to their hypercoagulable state. When a cancer patient presents with dyspnea, tachycardia, chest pain, and desaturation, PE should be suspected. The gold standard investigation for PE is a computerised tomography pulmonary angiogram (CTPA), which has a high diagnostic yield.

      An electrocardiogram (ECG) can also be helpful in diagnosing PE, as sinus tachycardia is the most common finding. However, in this case, the patient’s irregularly irregular pulse is likely due to atrial fibrillation with a rapid ventricular rate, which should be treated alongside investigation of the suspected PE.

      A D-dimer test may not be helpful in diagnosing PE in cancer patients, as it has low specificity and may be raised due to the underlying cancer. An arterial blood gas (ABG) should be carried out to help treat the patient, but the cause of hypoxia will still need to be determined.

      Bronchoscopy would not be useful in diagnosing PE and should not be performed in this case.

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  • Question 29 - A 65-year-old man presents to the Emergency Department with sudden breathlessness and haemoptysis....

    Incorrect

    • A 65-year-old man presents to the Emergency Department with sudden breathlessness and haemoptysis. He had just returned from a trip to Thailand and had been complaining of pain in his left leg. His oxygen saturation is 88% on room air, blood pressure is 95/70 mmHg, and heart rate is 120 bpm. He has a history of hypertension managed with lifestyle measures only and used to work as a construction worker. While receiving initial management, the patient suddenly becomes unresponsive, stops breathing, and has no pulse. Despite prolonged resuscitation efforts, the patient is declared dead after 40 minutes. Which vessel is most likely to be affected, leading to this patient's death?

      Your Answer:

      Correct Answer: Pulmonary artery

      Explanation:

      Differentiating Thrombosis in Varicose Veins: Symptoms and Diagnosis

      Pulmonary artery thrombosis is a serious condition that can cause sudden-onset breathlessness, haemoptysis, pleuritic chest pain, and cough. It is usually caused by a deep vein thrombosis that travels to the pulmonary artery. Computed tomography pulmonary angiogram (CTPA) is the preferred imaging modality for diagnosis.

      Pulmonary vein thrombosis is a rare condition that is typically associated with lobectomy, metastatic carcinoma, coagulopathies, and lung transplantation. Patients usually present with gradual onset dyspnoea, lethargy, and peripheral oedema.

      Azygos vein thrombosis is a rare occurrence that is usually associated with azygos vein aneurysms and hepatobiliary pathologies. It is rarely fatal.

      Brachiocephalic vein thrombosis is usually accompanied by arm swelling, pain, and limitation of movement. It is less likely to progress to a pulmonary embolus than lower limb deep vein thrombosis.

      Coronary artery thrombus resulting in myocardial infarction (MI) is characterised by cardiac chest pain, hypotension, and sweating. Haemoptysis is not a feature of MI. Electrocardiographic changes and serum troponin and cardiac enzyme levels are typically seen in MI, but not in pulmonary embolism.

      In summary, the symptoms and diagnosis of thrombosis vary depending on the affected vein. It is important to consider the patient’s medical history and perform appropriate imaging and laboratory tests for accurate diagnosis and treatment.

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  • Question 30 - A 28-year-old Afro-Caribbean lady undergoes a routine chest X-ray during a career-associated medical...

    Incorrect

    • A 28-year-old Afro-Caribbean lady undergoes a routine chest X-ray during a career-associated medical examination. The chest X-ray report reveals bilateral hilar lymphadenopathy. On closer questioning the patient admits to symptoms of fatigue and weight loss and painful blue-red nodules on her shins.
      What is the most likely diagnosis in this case?

      Your Answer:

      Correct Answer: Sarcoidosis

      Explanation:

      Differential Diagnosis for a Patient with Hilar Lymphadenopathy and Erythema Nodosum

      Sarcoidosis is a condition characterized by granulomas affecting multiple systems, with lung involvement being the most common. It typically affects young adults, especially females and Afro-Caribbean populations. While the cause is unknown, infections and environmental factors have been suggested. Symptoms include weight loss, fatigue, and fever, as well as erythema nodosum and anterior uveitis. Acute sarcoidosis usually resolves without treatment, while chronic sarcoidosis requires steroids and monitoring of lung function, ESR, CRP, and serum ACE levels.

      Tuberculosis is a potential differential diagnosis, as it can also present with erythema nodosum and hilar lymphadenopathy. However, the absence of a fever and risk factors make it less likely.

      Lung cancer is rare in young adults and typically presents as a mass or pleural effusion on X-ray.

      Pneumonia is an infection of the lung parenchyma, but the absence of infective symptoms and consolidation on X-ray make it less likely.

      Mesothelioma is a cancer associated with asbestos exposure and typically presents in older individuals. The absence of exposure and the patient’s age make it less likely.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (3/8) 38%
Passmed