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  • Question 1 - A 33-year-old woman presents to the Emergency Department with sudden shortness of breath...

    Correct

    • A 33-year-old woman presents to the Emergency Department with sudden shortness of breath and right-sided pleuritic chest pain along with dizziness. Upon examination, there is no tenderness in the chest wall and no abnormal sounds on auscultation. The calves appear normal. The electrocardiogram shows sinus tachycardia with a heart rate of 130 bpm. The D-dimer level is elevated at 0.85 mg/l. The chest X-ray is normal, and the oxygen saturation is 92% on room air. The ventilation/perfusion (V/Q) scan indicates a low probability of pulmonary embolism. What is the most appropriate next step?

      Your Answer: Request a computed tomography (CT) pulmonary angiogram

      Explanation:

      The Importance of Imaging in Diagnosing Pulmonary Embolism

      Pulmonary embolism is a common medical issue that requires accurate diagnosis to initiate appropriate treatment. While preliminary investigations such as ECG, ABG, and D-dimer can raise clinical suspicion, imaging plays a crucial role in making a definitive diagnosis. V/Q imaging is often the first step, but if clinical suspicion is high, a computed tomography pulmonary angiogram (CTPA) may be necessary. This non-invasive imaging scan can detect a filling defect in the pulmonary vessel, indicating the presence of an embolus. Repeating a V/Q scan is unlikely to provide additional information. Bronchoscopy is not useful in detecting pulmonary embolism, and treating as an LRTI is not appropriate without evidence of infection. Early and accurate diagnosis is essential in managing pulmonary embolism effectively.

    • This question is part of the following fields:

      • Respiratory
      34.8
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  • Question 2 - A 38-year-old man from Somalia presents at your general practice surgery as a...

    Incorrect

    • A 38-year-old man from Somalia presents at your general practice surgery as a temporary resident. He has noticed some lumps on the back of his neck recently. He reports having a productive cough for the last 3 months, but no haemoptysis. He has lost 3 kg in weight in the last month. He is a non-smoker and lives with six others in a flat. His chest X-ray shows several large calcified, cavitating lesions bilaterally.
      What is the GOLD standard investigation for active disease, given the likely diagnosis?

      Your Answer: Tissue biopsy

      Correct Answer: Sputum culture

      Explanation:

      The patient in question has several risk factors for tuberculosis (TB), including being from an ethnic minority and living in overcrowded accommodation. The presence of symptoms and chest X-ray findings of bilateral large calcified, cavitating lesions strongly suggest a diagnosis of TB. The gold standard investigation for TB is to send at least three spontaneous sputum samples for culture and microscopy, including one early morning sample. Treatment should be initiated without waiting for culture results if clinical symptoms and signs of TB are present. Treatment involves a 6-month course of antibiotics, with the first 2 months consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampicin. Even if culture results are negative, the full course of antibiotics should be completed. Public health must be notified of the diagnosis for contact tracing and surveillance. Pulmonary function testing is useful for assessing the severity of lung disease but is not used in the diagnosis of TB. Tissue biopsy is not recommended as the gold standard investigation for TB, but may be useful in some cases of extrapulmonary TB. The tuberculin skin test is used to determine if a patient has ever been exposed to TB, but is not the gold standard investigation for active TB. Interferon-γ release assays measure a person’s immune reactivity to TB and can suggest the likelihood of M tuberculosis infection.

    • This question is part of the following fields:

      • Respiratory
      53.6
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  • Question 3 - You have a telephone consultation with a 28-year-old male who wants to start...

    Incorrect

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

      Your Answer: Take folic acid 400 mcg once daily from before conception until 12 weeks of pregnancy

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

      Explanation:

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

      Folic Acid: Importance, Deficiency, and Prevention

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

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

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

    • This question is part of the following fields:

      • Respiratory
      146.2
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  • Question 4 - 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: Lung cancer

      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.

    • This question is part of the following fields:

      • Respiratory
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  • Question 5 - 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: Full pulmonary function tests

      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.

    • This question is part of the following fields:

      • Respiratory
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  • Question 6 - You are reviewing a patient who attends the clinic with a respiratory disorder.
    Which...

    Correct

    • You are reviewing a patient who attends the clinic with a respiratory disorder.
      Which of the following conditions would be suitable for long-term oxygen therapy (LTOT) for an elderly patient?

      Your Answer: Chronic obstructive pulmonary disease (COPD)

      Explanation:

      Respiratory Conditions and Oxygen Therapy: Guidelines for Treatment

      Chronic obstructive pulmonary disease (COPD), opiate toxicity, asthma, croup, and myasthenia gravis are respiratory conditions that may require oxygen therapy. The British Thoracic Society recommends assessing the need for home oxygen therapy in COPD patients with severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, or oxygen saturation of 92% or below when breathing air. Opiate toxicity can cause respiratory compromise, which may require naloxone, but this needs to be considered carefully in palliative patients. Asthmatic patients who are acutely unwell and require oxygen should be admitted to hospital for assessment, treatment, and ventilation support. Croup, a childhood respiratory infection, may require hospital admission if oxygen therapy is needed. Myasthenia gravis may cause neuromuscular respiratory failure during a myasthenic crisis, which is a life-threatening emergency requiring intubation and ventilator support and not amenable to home oxygen therapy.

    • This question is part of the following fields:

      • Respiratory
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  • Question 7 - The blood gases with pH 7.38, pO2 6.2 kPa, pCO2 9.2 kPa, and...

    Correct

    • The blood gases with pH 7.38, pO2 6.2 kPa, pCO2 9.2 kPa, and HCO3– 44 mmol/l are indicative of a respiratory condition. Which respiratory condition is most likely responsible for these blood gas values?

      Your Answer: Chronic obstructive pulmonary disease (COPD)

      Explanation:

      Respiratory Failure in Common Lung Conditions

      When analyzing blood gases, it is important to consider the type of respiratory failure present in order to determine the underlying cause. In cases of low oxygen and high carbon dioxide, known as type 2 respiratory failure, chronic obstructive pulmonary disease (COPD) is the most likely culprit. Asthma, on the other hand, typically causes type 1 respiratory failure, although severe cases may progress to type 2 as the patient tires. Pulmonary embolism and pneumonia are also more likely to cause type 1 respiratory failure, while pulmonary fibrosis is associated with this type of failure as well. Understanding the type of respiratory failure can aid in the diagnosis and management of these common lung conditions.

    • This question is part of the following fields:

      • Respiratory
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  • Question 8 - 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: Brachiocephalic

      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.

    • This question is part of the following fields:

      • Respiratory
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  • Question 9 - A 62-year-old female patient complains of breathlessness and weight loss over the past...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Respiratory
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  • Question 10 - A 32-year-old man is referred to the Respiratory Outpatient clinic due to a...

    Incorrect

    • A 32-year-old man is referred to the Respiratory Outpatient clinic due to a chronic non-productive cough. He is a non-smoker and reports no other symptoms. Initial tests show a normal full blood count and C-reactive protein, normal chest X-ray, and normal spirometry. What is the next most suitable test to perform?

      Your Answer: Computed tomography (CT) thorax

      Correct Answer: Bronchial provocation testing

      Explanation:

      Investigating Chronic Cough: Recommended Tests and Procedures

      Chronic cough with normal chest X-ray and spirometry, and no ‘red flag’ symptoms in a non-smoker can be caused by cough-variant asthma, gastro-oesophageal reflux, and post-nasal drip. To investigate for bronchial hyper-reactivity, bronchial provocation testing is recommended using methacholine or histamine. A CT thorax may eventually be required to look for underlying structural lung disease, but in the first instance, investigating for cough-variant asthma is appropriate. Bronchoscopy is not a first-line investigation but may be used in specialist centres to investigate chronic cough. Sputum culture is unlikely to be useful in a patient with a dry cough. Maximal inspiratory and expiratory pressures are used to investigate respiratory muscle weakness.

    • This question is part of the following fields:

      • Respiratory
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  • Question 11 - A 24-year-old man, who is a known intravenous drug user, presented with progressive...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Respiratory
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  • Question 12 - A 47-year-old woman has been hospitalized with haemoptysis and epistaxis. On her chest...

    Correct

    • A 47-year-old woman has been hospitalized with haemoptysis and epistaxis. On her chest X-ray, there are several rounded lesions with alveolar shadowing. Her serum test shows a positive result for cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA). What is the probable diagnosis?

      Your Answer: Granulomatosis with polyangiitis (GPA)

      Explanation:

      Differential Diagnosis for Pulmonary Granulomas and Positive c-ANCA: A Case Study

      Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease that often presents with granulomatous lung disease and alveolar capillaritis. Symptoms include cough, dyspnea, hemoptysis, and chest pain. Chest X-ray and computed tomography can show rounded lesions that may cavitate, while bronchoscopy can reveal granulomatous inflammation. In this case study, the chest radiograph appearances, epistaxis, and positive c-ANCA are more indicative of GPA than lung cancer, echinococcosis, systemic lupus erythematosus, or tuberculosis. While SLE can also cause pulmonary manifestations, cavitating lesions are not typical. Positive c-ANCA is associated with GPA, while SLE is associated with positive antinuclear antibodies, double-stranded DNA antibodies, and extractable nuclear antigens.

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      • Respiratory
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  • Question 13 - A previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the...

    Correct

    • A previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the broken hip that she sustained as a result of falling down stairs. Upon discharge to a nursing home 10 days later, she is unable to ambulate fully and, about a month later, she dies suddenly.
      Which of the following is most likely to be the immediate cause of death found at post-mortem examination?

      Your Answer: Pulmonary embolism

      Explanation:

      Likely Cause of Sudden Death in an Elderly Patient with Fracture

      Immobilisation after a fracture in elderly patients increases the risk of developing deep vein thrombosis (DVT), which can lead to pulmonary embolism. In the case of a sudden death, pulmonary embolism is the most likely cause. Pneumonia with pneumococcus is also a risk for elderly patients in hospital, but the absence of signs and symptoms of infection makes it less likely. Tuberculosis is also unlikely as there were no signs of an infectious disease. Congestive heart failure is a possibility in the elderly, but it is unlikely to cause sudden death in this scenario. While malignancy is a risk for older patients, immobilisation leading to pulmonary thromboembolism is the most likely cause of sudden death in this case.

    • This question is part of the following fields:

      • Respiratory
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  • Question 14 - A 50-year-old woman is brought to the Emergency Department after falling down the...

    Correct

    • A 50-year-old woman is brought to the Emergency Department after falling down the stairs at home. She complains of ‘rib pain’ and is moved to the resus room from triage, as she was unable to complete full sentences due to shortness of breath. Sats on room air were 92%. You are asked to see her urgently as the nursing staff are concerned about her deterioration.
      On examination, she appears distressed; blood pressure is 85/45, heart rate 115 bpm, respiratory rate 38 and sats 87% on air. Her left chest does not appear to be moving very well, and there are no audible breath sounds on the left on auscultation.
      What is the most appropriate next step in immediate management of this patient?

      Your Answer: Needle thoracocentesis of left chest

      Explanation:

      Needle Thoracocentesis for Tension Pneumothorax

      Explanation:
      In cases of traumatic chest pain, it is important to keep an open mind regarding other injuries. However, if a patient rapidly deteriorates with signs of shock, hypoxia, reduced chest expansion, and no breath sounds audible on the affected side of the chest, a tension pneumothorax should be suspected. This is an immediately life-threatening condition that requires immediate intervention.

      There is no time to wait for confirmation on a chest X-ray or to set up a chest drain. Instead, needle thoracocentesis should be performed on the affected side of the chest. A large-bore cannula is inserted in the second intercostal space, mid-clavicular line, on the affected side. This can provide rapid relief and should be followed up with the insertion of a chest drain.

      It is important to note that there is no role for respiratory consultation or nebulisers in this scenario. Rapid intervention is key to preventing cardiac arrest and improving patient outcomes.

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      • Respiratory
      57.5
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  • Question 15 - A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a...

    Correct

    • A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a sudden ‘pop’ followed by the onset of pain and shortness of breath.
      Upon examination, the patient appears to be struggling to breathe with a respiratory rate of 40 breaths per minute. Diminished breath sounds are heard on the right side of the chest during auscultation.
      Diagnostic tests reveal a PaO2 of 8.2 kPa (normal range: 10.5-13.5 kPa) and a PaCO2 of 3.3 kPa (normal range: 4.6-6.0 kPa). A chest X-ray shows a 60% right-sided pneumothorax.
      What is the most appropriate course of treatment for this patient?

      Your Answer: 14F chest drain insertion over a Seldinger wire

      Explanation:

      Safe and Effective Chest Drain Insertion Techniques for Pneumothorax Management

      Pneumothorax, the presence of air in the pleural cavity, can cause significant respiratory distress and requires prompt management. Chest drain insertion is a common procedure used to treat pneumothorax, but the technique used depends on the size and cause of the pneumothorax. Here are some safe and effective chest drain insertion techniques for managing pneumothorax:

      1. Narrow-bore chest drain insertion over a Seldinger wire: This technique is appropriate for large spontaneous pneumothorax without trauma. It involves inserting a narrow-bore chest drain over a Seldinger wire, which is a minimally invasive technique that reduces the risk of complications.

      2. Portex chest drain insertion: Portex chest drains are a safer alternative to surgical chest drains in traumatic cases. This technique involves inserting a less traumatic chest drain that is easier to manage and less likely to cause complications.

      3. Avoid chest drain insertion using a trochar: Chest drain insertion using a trochar is a dangerous technique that can cause significant pressure damage to surrounding tissues. It should be avoided.

      4. Avoid repeated air aspiration: Although needle aspiration is a management option for symptomatic pneumothorax, repeated air aspiration is not recommended. It can cause complications and is less effective than chest drain insertion.

      In conclusion, chest drain insertion is an effective technique for managing pneumothorax, but the technique used should be appropriate for the size and cause of the pneumothorax. Narrow-bore chest drain insertion over a Seldinger wire and Portex chest drain insertion are safer alternatives to more invasive techniques. Chest drain insertion using a trochar and repeated air aspiration should be avoided.

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      • Respiratory
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  • Question 16 - After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the...

    Incorrect

    • After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the respiratory consultant discusses the anatomy of the lungs with a group of undergraduate students.
      With regard to the lungs, which one of the following statements is accurate?

      Your Answer: Each lung has eight bronchopulmonary segments

      Correct Answer: The lungs receive a dual blood supply

      Explanation:

      Facts about the Anatomy of the Lungs

      The lungs are a vital organ responsible for respiration. Here are some important facts about their anatomy:

      – The lungs receive a dual blood supply from the pulmonary artery and the bronchial arteries. A pulmonary embolus may only result in infarction when the circulation is already inadequate.
      – The left lung has two lobes, while the right lung has three. The horizontal fissure is present only in the right lung.
      – Each lung has ten bronchopulmonary segments, which can be selectively removed surgically if diseased.
      – The right bronchus is shorter, wider, and more vertical than the left bronchus, making it more likely for foreign bodies to enter it. Aspiration pneumonia and abscess formation are common in the apical segment of the right lower lobe.

      Important Facts about the Anatomy of the Lungs

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      • Respiratory
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  • Question 17 - 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: Pulmonary function tests

      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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      • Respiratory
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  • Question 18 - A 28-year-old female patient presents to your clinic seeking help to quit smoking....

    Correct

    • A 28-year-old female patient presents to your clinic seeking help to quit smoking. Despite several attempts in the past, she has been unsuccessful. She has a medical history of bipolar disorder and well-managed epilepsy, for which she takes lamotrigine. She currently smokes 15 cigarettes per day and is especially interested in the health benefits of quitting smoking since she has recently found out that she is pregnant. As her physician, you decide to prescribe a suitable medication to assist her in her efforts. What would be the most appropriate treatment option?

      Your Answer: Nicotine gum

      Explanation:

      Standard treatments for nicotine dependence do not include amitriptyline, fluoxetine, or gabapentin. Nicotine replacement therapy (NRT) can be helpful for motivated patients, but it is not a cure for addiction and may require multiple attempts. Bupropion and varenicline are other smoking cessation aids, but they have multiple side effects and may not be suitable for all patients. NICE guidelines recommend discussing the best method of smoking cessation with the patient, but NRT is considered safer in pregnancy.

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      • Respiratory
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  • Question 19 - 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: Mycobacterium avium intracellulare

      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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      • Respiratory
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  • Question 20 - A 29-year-old electrician was referred to the hospital by his general practitioner. He...

    Incorrect

    • A 29-year-old electrician was referred to the hospital by his general practitioner. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for the past three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. On the day of referral, he reported mild dyspnea, a global headache, myalgia, and arthralgia. During the examination, a maculopapular rash was observed on his upper body, and fine crackles were audible in the left mid-zone of his chest. Mild neck stiffness was also noted. His vital signs showed a fever of 39°C and a blood pressure of 120/70 mmHg.

      The following investigations were conducted:
      - Hb: 84 g/L (130-180)
      - WBC: 8 ×109/L (4-11)
      - Platelets: 210 ×109/L (150-400)
      - Reticulocytes: 8% (0.5-2.4)
      - Na: 137 mmol/L (137-144)
      - K: 4.2 mmol/L (3.5-4.9)
      - Urea: 5.0 mmol/L (2.5-7.5)
      - Creatinine: 110 µmol/L (60-110)
      - Bilirubin: 19 µmol/L (1-22)
      - Alk phos: 130 U/L (45-105)
      - AST: 54 U/L (1-31)
      - GGT: 48 U/L (<50)

      The chest x-ray revealed patchy consolidation in both mid-zones. What is the most appropriate course of treatment?

      Your Answer: Co-trimoxazole

      Correct Answer: Clarithromycin

      Explanation:

      Mycoplasma Pneumonia: Symptoms, Complications, and Treatment

      Mycoplasma pneumonia is a type of pneumonia that commonly affects individuals aged 15-30 years. It is characterized by systemic upset, dry cough, and fever, with myalgia and arthralgia being common symptoms. Unlike other types of pneumonia, the white blood cell count is often within the normal range. In some cases, Mycoplasma pneumonia can also cause extrapulmonary manifestations such as haemolytic anaemia, renal failure, hepatitis, myocarditis, meningism and meningitis, transverse myelitis, cerebellar ataxia, and erythema multiforme.

      One of the most common complications of Mycoplasma pneumonia is haemolytic anaemia, which is associated with the presence of cold agglutinins found in up to 50% of cases. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies in paired sera. Treatment typically involves the use of macrolide antibiotics such as clarithromycin or erythromycin, with tetracycline or doxycycline being alternative options.

      In summary, Mycoplasma pneumonia is a type of pneumonia that can cause a range of symptoms and complications, including haemolytic anaemia and extrapulmonary manifestations. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies, and treatment typically involves the use of macrolide antibiotics.

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      • Respiratory
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  • Question 21 - A 35-year-old man visits his doctor seeking assistance in quitting smoking. He has...

    Incorrect

    • A 35-year-old man visits his doctor seeking assistance in quitting smoking. He has been smoking 20 cigarettes daily for the past six years and has a history of epilepsy. Which smoking cessation aid is most likely to result in adverse effects for this individual?

      Your Answer: Varenicline

      Correct Answer: Bupropion

      Explanation:

      Options for Smoking Cessation in Patients with Seizure History

      Patients with a predisposition or past history of seizures should avoid bupropion due to an increased risk of seizures. The Medicines and Health products Regulatory Authority (MHRA) warns against prescribing bupropion to patients who experience seizures. However, behavioural therapy is encouraged for all patients who wish to quit smoking. E-cigarettes can be a safer alternative and may eventually help patients quit entirely, but they are not currently funded by the NHS. Nicotine replacement therapy in the form of patches or gum can also be used. Varenicline is cautioned but not contraindicated for use in patients with seizures, so it should only be used if the benefits outweigh the risk.

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      • Respiratory
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  • Question 22 - A 55-year-old woman presents with 6 months of recurrent episodes of shortness of...

    Correct

    • A 55-year-old woman presents with 6 months of recurrent episodes of shortness of breath. She describes it as ‘coming on suddenly without warning’. They have woken her at night before. She describes the attacks as a ‘tightness’ in the chest and says that they are associated with tingling in her fingers. The episodes resolve in a few minutes by themselves. She is otherwise medically fit and well. She smokes 15 cigarettes per day and has a family history of asthma. Examination is normal, and the peak expiratory flow rate is normal for her age and height.
      Which of the following is the most likely diagnosis?

      Your Answer: Panic attacks

      Explanation:

      Differentiating between possible causes of acute shortness of breath: A medical analysis

      When a patient presents with acute shortness of breath, it is important to consider a range of possible causes. In this case, the patient’s symptoms suggest panic attacks rather than left ventricular failure, acute asthma attacks, COPD, or anaemia.

      Panic attacks are characterized by sudden onset and spontaneous resolution, numbness of extremities, and normal examination and peak flow measurement. They can be triggered or occur unexpectedly, and may be due to a disorder such as panic disorder or post-traumatic stress disorder, or secondary to medical problems such as thyroid disease. Treatment includes psychological therapies, breathing exercises, stress avoidance, and pharmacological therapies such as selective serotonin reuptake inhibitors.

      Left ventricular failure, on the other hand, would cause respiratory problems due to pulmonary congestion, leading to reduced pulmonary compliance and increased airway resistance. Examination of someone with left ventricular failure would reveal pulmonary crackles and possibly a small mitral regurgitation murmur. However, it is unlikely that a woman would experience acute episodes such as these due to heart failure.

      Acute asthma attacks are typically triggered by inhaled allergens or other factors such as cold/dry air, stress, or upper respiratory tract infections. The absence of triggers in this case suggests that asthma is not the diagnosis.

      COPD is a possible differential due to the patient’s smoking history, but it is unlikely to have worsened so acutely and resolved in a matter of minutes. The normal peak expiratory flow rate also suggests that COPD is not the cause.

      Finally, anaemia would not account for acute episodes of shortness of breath, which are present normally on exertion in anaemic patients. Signs of anaemia such as pallor, tachycardia, cardiac dilation, or oedema are not mentioned in the patient’s history.

      In conclusion, a careful analysis of the patient’s symptoms and medical history can help differentiate between possible causes of acute shortness of breath, leading to appropriate treatment and management.

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      • Respiratory
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  • Question 23 - A 35-year-old call centre operator with a 6-year history of sarcoidosis presents with...

    Incorrect

    • A 35-year-old call centre operator with a 6-year history of sarcoidosis presents with worsening shortness of breath during his visit to Respiratory Outpatients. This is his fifth episode of this nature since his diagnosis. In the past, he has responded well to tapered doses of oral steroids. What initial test would be most useful in evaluating his current pulmonary condition before prescribing steroids?

      Your Answer: Serum angiotensin-converting enzyme (ACE) level

      Correct Answer: Pulmonary function tests with transfer factor

      Explanation:

      Pulmonary Function Tests with Transfer Factor in Sarcoidosis: An Overview

      Sarcoidosis is a complex inflammatory disease that can affect multiple organs, with respiratory manifestations being the most common. Pulmonary function tests with transfer factor are a useful tool in assessing the severity of sarcoidosis and monitoring response to treatment. The underlying pathological process in sarcoidosis is interstitial fibrosis, leading to a restrictive pattern on pulmonary function tests with reduced transfer factor. While steroids are often effective in treating sarcoidosis, monitoring transfer factor levels can help detect exacerbations and assess response to treatment. Other diagnostic tests, such as arterial blood gas, chest X-ray, serum ACE levels, and HRCT of the chest, may also be useful in certain situations but are not always necessary as an initial test. Overall, pulmonary function tests with transfer factor play a crucial role in the management of sarcoidosis.

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  • Question 24 - A 68-year-old retired caretaker with a well-documented history of chronic obstructive pulmonary disease...

    Correct

    • A 68-year-old retired caretaker with a well-documented history of chronic obstructive pulmonary disease (COPD) is admitted, for his fourth time this year, with shortness of breath and a cough productive of green sputum. Examination findings are: respiratory rate (RR) 32 breaths/min, temperature 37.4 °C, SpO2 86% on room air, asterixis and coarse crepitations at the left base. A chest X-ray (CXR) confirms left basal consolidation.
      Which arterial blood gas (ABG) picture is likely to belong to the above patient?

      Your Answer: pH: 7.27, pa (O2): 7.1, pa (CO2): 8.9, HCO3–: 33.20, base excess (BE) 4.9 mmol

      Explanation:

      Interpreting Blood Gas Results in COPD Patients

      COPD is a common respiratory disease that can lead to exacerbations requiring hospitalization. In these patients, lower respiratory tract infections can quickly lead to respiratory failure and the need for respiratory support. Blood gas results can provide important information about the patient’s respiratory and metabolic status. In COPD patients, a type II respiratory failure with hypercapnia and acidosis is common, resulting in a low pH and elevated bicarbonate levels. However, blood gas results that show low carbon dioxide or metabolic acidosis are less likely to be in keeping with COPD. Understanding and interpreting blood gas results is crucial in managing COPD exacerbations and providing appropriate respiratory support.

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      • Respiratory
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  • Question 25 - A 65-year-old man with rheumatoid arthritis has been on long term therapy to...

    Incorrect

    • A 65-year-old man with rheumatoid arthritis has been on long term therapy to manage his condition. He complains of worsening shortness of breath and a chest x-ray reveals 'bilateral interstitial shadowing'. Which medication is the probable culprit for his symptoms?

      Your Answer: Azathioprine

      Correct Answer: Methotrexate

      Explanation:

      Methotrexate as a Cause and Treatment for Pulmonary Fibrosis

      Pulmonary fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. Methotrexate, a chemotherapy drug, is a known cause of pulmonary fibrosis. However, it is also sometimes used as a treatment for idiopathic pulmonary fibrosis as a steroid sparing agent.

      According to medical research, other chemotherapy drugs such as alkylating agents, asparaginase, bleomycin, and procarbazine have also been linked to pulmonary parenchymal or pleural reactions in patients with malignant diseases. In addition, drug-related interstitial pneumonia should be considered in rheumatoid arthritis patients who are taking methotrexate or newer drugs like leflunomide.

      Despite its potential risks, methotrexate can be a useful treatment option for some patients with pulmonary fibrosis. However, it is important for healthcare providers to carefully monitor patients for any adverse reactions and adjust treatment plans accordingly.

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  • Question 26 - A 30-year-old woman comes to the General Practice Clinic complaining of feeling unwell...

    Correct

    • A 30-year-old woman comes to the General Practice Clinic complaining of feeling unwell for the past few days. She has been experiencing nasal discharge, sneezing, fatigue, and a cough. Her 3-year-old daughter recently recovered from very similar symptoms. During the examination, her pulse rate is 62 bpm, respiratory rate 18 breaths per minute, and temperature 37.2 °C. What is the probable causative organism for her symptoms?

      Your Answer: Rhinovirus

      Explanation:

      Identifying the Most Common Causative Organisms of the Common Cold

      The common cold is a viral infection that affects millions of people worldwide. Among the different viruses that can cause the common cold, rhinoviruses are the most common, responsible for 30-50% of cases annually. influenzae viruses can also cause milder symptoms that overlap with those of the common cold, accounting for 5-15% of cases. Adenoviruses and enteroviruses are less common causes, accounting for less than 5% of cases each. Respiratory syncytial virus is also a rare cause of the common cold, accounting for only 5% of cases annually. When trying to identify the causative organism of a common cold, it is important to consider the patient’s symptoms, recent exposure to sick individuals, and prevalence of different viruses in the community.

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      • Respiratory
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  • Question 27 - A 50-year-old woman presents to her General Practitioner with increasing shortness of breath....

    Correct

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

      Your Answer: Meig’s syndrome

      Explanation:

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

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

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

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

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

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

      Finally, cardiac failure can result in bilateral pleural effusions.

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  • Question 28 - A 50-year-old woman presents to the hospital with shortness of breath and lethargy...

    Incorrect

    • A 50-year-old woman presents to the hospital with shortness of breath and lethargy for the past two weeks.
      On clinical examination, there are reduced breath sounds, dullness to percussion and decreased vocal fremitus at the left base.
      Chest X-ray reveals a moderate left-sided pleural effusions. A pleural aspirate is performed on the ward. Analysis is shown:
      Aspirate Serum
      Total protein 18.5 g/l 38 g/l
      Lactate dehydrogenase (LDH) 1170 u/l 252 u/l
      pH 7.37 7.38
      What is the most likely cause of the pleural effusion?

      Your Answer: Bronchial carcinoma

      Correct Answer: Hypothyroidism

      Explanation:

      Understanding Pleural Effusions: Causes and Criteria for Exudates

      Pleural effusions, the accumulation of fluid in the pleural space surrounding the lungs, can be classified as exudates or transudates using Light’s criteria. While the traditional cut-off value of >30 g/l of protein to indicate an exudate and <30 g/l for a transudate is no longer recommended, Light's criteria still provide a useful framework for diagnosis. An exudate is indicated when the ratio of pleural fluid protein to serum protein is >0.5, the ratio of pleural fluid LDH to serum LDH is >0.6, or pleural fluid LDH is greater than 2/3 times the upper limit for serum.

      Exudate effusions are typically caused by inflammation and disruption to cell architecture, while transudates are often associated with systematic illnesses that affect oncotic or hydrostatic pressure. In the case of hypothyroidism, an endocrine disorder, an exudative pleural effusion is consistent with overstimulation of the ovaries.

      Other conditions that can cause exudative pleural effusions include pneumonia and pulmonary embolism. Mesothelioma, a type of cancer associated with asbestos exposure, can also cause an exudative pleural effusion, but is less likely in the absence of chest pain, persistent cough, and unexplained weight loss.

      Understanding the causes and criteria for exudative pleural effusions can aid in the diagnosis and treatment of various medical conditions.

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  • Question 29 - A 68-year-old man with known bronchial carcinoma presents to hospital with confusion. A...

    Incorrect

    • A 68-year-old man with known bronchial carcinoma presents to hospital with confusion. A computed tomography (CT) scan of the brain was reported as normal: no evidence of metastases. His serum electrolytes were as follows:
      Investigation Result Normal value
      Sodium (Na+) 114 mmol/l 135–145 mmol/l
      Potassium (K+) 3.9 mmol/l 3.5–5.0 mmol/l
      Urea 5.2 mmol/l 2.5–6.5 mmol/l
      Creatinine 82 μmol/l 50–120 µmol/l
      Urinary sodium 54 mmol/l
      Which of the subtype of bronchial carcinoma is he most likely to have been diagnosed with?

      Your Answer: Squamous cell

      Correct Answer: Small cell

      Explanation:

      Different Types of Lung Cancer and Their Association with Ectopic Hormones

      Lung cancer is a complex disease that can be divided into different types based on their clinical and biological characteristics. The two main categories are non-small cell lung cancers (NSCLCs) and small cell lung cancer (SCLC). SCLC is distinct from NSCLCs due to its origin from amine precursor uptake and decarboxylation (APUD) cells, which have an endocrine lineage. This can lead to the production of various peptide hormones, causing paraneoplastic syndromes such as the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and Cushing syndrome.

      Among NSCLCs, squamous cell carcinoma is commonly associated with ectopic parathyroid hormone, leading to hypercalcemia. Large cell carcinoma and bronchoalveolar cell carcinoma are NSCLCs that do not produce ectopic hormones. Adenocarcinoma, another type of NSCLC, also does not produce ectopic hormones.

      Understanding the different types of lung cancer and their association with ectopic hormones is crucial for proper management and treatment of the disease.

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  • Question 30 - A 67-year-old woman presents with right-sided pleural effusion. Thoracentesis is performed and the...

    Incorrect

    • A 67-year-old woman presents with right-sided pleural effusion. Thoracentesis is performed and the pleural fluid analysis reveals the following results:
      Pleural fluid Pleural fluid analysis Serum Normal value
      Protein 2.5 g/dl 7.3 g/dl 6-7.8 g/dl
      Lactate dehydrogenase (LDH) 145 IU/l 350 IU/l 100-250 IU/l
      What is the probable diagnosis for this patient?

      Your Answer: Breast cancer

      Correct Answer: Heart failure

      Explanation:

      Causes of Transudative and Exudative Pleural Effusions

      Pleural effusion is the accumulation of fluid in the pleural space, which can be classified as transudative or exudative based on Light’s criteria. The most common cause of transudative pleural effusion is congestive heart failure, which can also cause bilateral or unilateral effusions. Other causes of transudative effusions include cirrhosis and nephrotic syndrome. Exudative pleural effusions are typically caused by pneumonia, malignancy, or pleural infections. Nephrotic syndrome can also cause transudative effusions, while breast cancer and viral pleuritis are associated with exudative effusions. Proper identification of the underlying cause is crucial for appropriate management of pleural effusions.

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  • Question 31 - A 50-year-old male smoker presented with chronic dyspnoea. He used to work in...

    Correct

    • A 50-year-old male smoker presented with chronic dyspnoea. He used to work in the shipyard but now has a retired life with his dogs. He was under treatment as a case of COPD, but maximal therapy for COPD failed to bring him any relief. On re-evaluation, his chest X-ray showed fine reticular opacities in the lower zones. A CT scan of his thorax showed interstitial thickening, with some ground glass opacity in the upper lungs.
      Pleural plaques were absent. What is the most likely diagnosis?

      Your Answer: Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD)

      Explanation:

      Differentiating Interstitial Lung Diseases: A Case Study

      The patient in question presents with dyspnoea and a history of smoking. While COPD is initially suspected, the radiograph and CT findings do not support this diagnosis. Instead, the patient may be suffering from an interstitial lung disease. RB-ILD is a possibility, given the presence of pigmented macrophages in the lung. Asbestosis is also considered, but the absence of pleural plaques makes this less likely. Pneumoconiosis and histoplasmosis are ruled out based on the patient’s history and imaging results. Treatment for interstitial lung diseases can be challenging, with steroids being the primary option. However, the effectiveness of this treatment is debatable. Ultimately, a lung biopsy may be necessary for a definitive diagnosis.

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  • Question 32 - A 35-year-old woman had a productive cough due to upper respiratory tract infection...

    Correct

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

      What would be your recommendation at this point?

      Your Answer: Observation only

      Explanation:

      Acute Bronchitis

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

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

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

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  • Question 33 - A 42-year-old man presents to the Emergency Department with complaints of severe breathlessness...

    Incorrect

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

      Your Answer: Nebulised salbutamol and ipratropium

      Correct Answer: High-flow oxygen

      Explanation:

      Treatment Options for Smoke Inhalation Injury

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

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

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

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  • Question 34 - A 50-year-old patient came in with worsening shortness of breath. A CT scan...

    Incorrect

    • A 50-year-old patient came in with worsening shortness of breath. A CT scan of the chest revealed a lesion in the right middle lobe of the lung. The radiologist described the findings as an area of ground-glass opacity surrounded by denser lung tissue.

      What is the more common name for this sign?

      Your Answer: Halo sign

      Correct Answer: Atoll sign

      Explanation:

      Radiological Signs in Lung Imaging: Atoll, Halo, Kerley B, Signet Ring, and Tree-in-Bud

      When examining CT scans of the lungs, radiologists look for specific patterns that can indicate various pathologies. One such pattern is the atoll sign, also known as the reversed halo sign. This sign is characterized by a region of ground-glass opacity surrounded by denser tissue, forming a crescent or annular shape that is at least 2 mm thick. It is often seen in cases of cryptogenic organizing pneumonia (COP), but can also be caused by tuberculosis or other infections.

      Another important sign is the halo sign, which is seen in angioinvasive aspergillosis. This sign appears as a ground-glass opacity surrounding a pulmonary nodule or mass, indicating alveolar hemorrhage.

      Kerley B lines are another pattern that can be seen on lung imaging, indicating pulmonary edema. These lines are caused by fluid accumulation in the interlobular septae at the periphery of the lung.

      The signet ring sign is a pattern seen in bronchiectasis, where a dilated bronchus and accompanying pulmonary artery branch are visible in cross-section. This sign is characterized by a marked dilation of the bronchus, which is not seen in the normal population.

      Finally, the tree-in-bud sign is a pattern seen in endobronchial tuberculosis or other endobronchial pathologies. This sign appears as multiple centrilobular nodules with a linear branching pattern, and can also be seen in cases of cystic fibrosis or viral pneumonia.

      Overall, understanding these radiological signs can help clinicians diagnose and treat various lung pathologies.

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  • Question 35 - Emily is a 6-year-old overweight girl brought in by concerned parents who are...

    Correct

    • Emily is a 6-year-old overweight girl brought in by concerned parents who are worried about her loud snoring and frequent interruptions in breathing which have been getting progressively worse. Her parents have been receiving complaints from the school teachers about her disruptive and inattentive behaviour in class. On examination, Emily has a short, thick neck and mildly enlarged tonsils but no other abnormalities.
      What is the next best step in management?

      Your Answer: Order an overnight polysomnographic study

      Explanation:

      Childhood Obstructive Sleep Apnoea: Diagnosis and Treatment Options

      Childhood obstructive sleep apnoea (OSA) is a pathological condition that requires prompt diagnosis and treatment. A polysomnographic study should be performed before booking for an operation, as adenotonsillectomy is the treatment of choice for childhood OSA.

      The clinical presentation of childhood OSA is non-specific but typically includes symptoms such as mouth breathing, abnormal breathing during sleep, poor sleep with frequent awakening or restlessness, nocturnal enuresis, nightmares, difficulty awakening, excessive daytime sleepiness or hyperactivity, and behavioural problems. However, parents should be reassured that snoring loudly is very normal in children his age and that his behaviour pattern will improve as he matures.

      Before any intervention is undertaken, the patient should be first worked up for OSA with a polysomnographic study. While dental splints may have a small role to play in OSA, they are not the ideal treatment option. Intranasal budesonide is an option for mild to moderate OSA, but it is only a temporising measure and not a proven effective long-term treatment.

      In conclusion, childhood OSA requires prompt diagnosis and treatment. Adenotonsillectomy is the treatment of choice, but a polysomnographic study should be performed before any intervention is undertaken. Parents should be reassured that snoring loudly is normal in children his age, and other treatment options such as dental splints and intranasal budesonide should be considered only after a thorough evaluation.

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      • Respiratory
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  • Question 36 - A 30-year-old woman with asthma presented with rapidly developing asthma and wheezing. She...

    Correct

    • A 30-year-old woman with asthma presented with rapidly developing asthma and wheezing. She was admitted, and during her treatment, she coughed out tubular gelatinous materials. A chest X-ray showed collapse of the lingular lobe.
      What is this clinical spectrum better known as?

      Your Answer: Plastic bronchitis

      Explanation:

      Respiratory Conditions: Plastic Bronchitis, Loeffler Syndrome, Lofgren Syndrome, Cardiac Asthma, and Croup

      Plastic Bronchitis: Gelatinous or rigid casts form in the airways, leading to coughing. It is associated with asthma, bronchiectasis, cystic fibrosis, and respiratory infections. Treatment involves bronchial washing, sputum induction, and preventing infections. Bronchoscopy may be necessary for therapeutic removal of the casts.

      Loeffler Syndrome: Accumulation of eosinophils in the lungs due to parasitic larvae passage. Charcot-Leyden crystals may be present in the sputum.

      Lofgren Syndrome: Acute presentation of sarcoidosis with hilar lymphadenopathy and erythema nodosum. Usually self-resolving.

      Cardiac Asthma: Old term for acute pulmonary edema, causing peribronchial fluid collection and wheezing. Pink frothy sputum is produced.

      Croup: Acute pharyngeal infection in children aged 6 months to 3 years, presenting with stridor.

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  • Question 37 - A 61-year-old electrician presents with a 4-month history of cough and weight loss....

    Correct

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

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

      Explanation:

      Differentiating Lung Diseases: Radiological Findings

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

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  • Question 38 - 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: Stop metformin

      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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      • Respiratory
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  • Question 39 - A 25-year-old lady with a history of asthma is brought to the Emergency...

    Incorrect

    • A 25-year-old lady with a history of asthma is brought to the Emergency Department with an acute asthma attack. She has previously been admitted to the intensive therapy unit (ITU) with the same problem. Treatment is commenced with high-flow oxygen and regular nebulisers.
      Which of the following is a feature of life-threatening asthma?

      Your Answer: Respiratory alkalosis

      Correct Answer: Normal PaCO2

      Explanation:

      Assessment of Severity in Acute Asthma Attacks

      Acute asthma is a serious medical emergency that can lead to fatalities. To assess the severity of an asthma attack, several factors must be considered. Severe asthma is characterized by a peak flow of 33-50% of predicted or best, a respiratory rate of over 25 breaths per minute, a heart rate of over 110 beats per minute, and the inability to complete sentences. On the other hand, life-threatening asthma is indicated by a peak flow of less than 33% of predicted or best, a silent chest, cyanosis, and arterial blood gas showing high or normal PaCO2, which reflects reduced respiratory effort. Additionally, arterial blood gas showing hypoxia (PaO2 <8 kPa) or acidosis is also a sign of life-threatening asthma. Any life-threatening features require immediate critical care and senior medical review. A peak expiratory flow rate of less than 50% of predicted or best is a feature of an acute severe asthma attack. However, a pulse rate of 105 bpm is not a marker of severity in asthma due to its lack of specificity. Respiratory alkalosis, which is a condition characterized by low carbon dioxide levels, is actually a reassuring picture on the blood gas. In contrast, a normal carbon dioxide level would be a concern if the person is working that hard. Finally, the inability to complete full sentences is another feature of acute severe asthma.

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      • Respiratory
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  • Question 40 - A 68-year-old woman with a long history of rheumatoid arthritis presents to her...

    Incorrect

    • A 68-year-old woman with a long history of rheumatoid arthritis presents to her general practitioner complaining of a chronic cough, weight loss and haemoptysis. She smokes ten cigarettes a day. You understand that she has begun anti-tumour necrosis factor (TNF) antibody treatment around 9 months earlier. On examination, her rheumatoid appears quiescent at present.
      Investigations:
      Investigation Result Normal value
      Chest X-ray Calcified hilar lymph nodes,
      possible left upper lobe fibrosis
      Haemoglobin 109 g/l 115–155 g/l
      White cell count (WCC) 11.1 × 109/l 4–11 × 109/l
      Platelets 295 × 109/l 150–400 × 109/l
      Erythrocyte sedimentation rate (ESR) 61 mm/h 0–10mm in the 1st hour
      C-reactive protein (CRP) 55 mg/l 0–10 mg/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer: Rheumatoid lung disease

      Correct Answer: Active pulmonary tuberculosis

      Explanation:

      Differential diagnosis of calcified lymph nodes and upper lobe fibrosis in a patient with rheumatoid arthritis

      A patient with rheumatoid arthritis presents with calcified lymph nodes and upper lobe fibrosis on a chest X-ray. Several possible causes need to be considered, including active pulmonary tuberculosis, lymphoma, rheumatoid lung disease, bronchial carcinoma, and invasive aspergillosis. While anti-TNF antibody medication for rheumatoid arthritis may increase the risk of tuberculosis and aspergillosis, it is important to rule out other potential etiologies based on clinical examination, imaging studies, and laboratory tests. The presence of soft, fluffy, and ill-defined lesions on chest X-ray may suggest active tuberculosis, while the absence of upper lobe fibrosis may argue against lymphoma or radiotherapy-induced fibrosis. Pulmonary nodules and lung fibrosis at the lung bases are more typical of rheumatoid lung disease, but calcified nodes with upper lobe fibrosis are unusual. Bronchial carcinoma may be a concern given the patient’s age and smoking history, but typically lymph nodes are not calcified. Invasive aspergillosis is more likely in immunosuppressed patients and can be detected by a CT scan and a serum galactomannan test. A comprehensive differential diagnosis can guide further evaluation and management of this complex case.

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      • Respiratory
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  • Question 41 - A 67-year-old man comes to the Chest Clinic after being referred by his...

    Correct

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

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

      What is the most probable diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Explanation:

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

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

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      • Respiratory
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  • Question 42 - A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses...

    Correct

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

      Your Answer: Continuous Positive Airways Pressure (CPAP)

      Explanation:

      Obstructive Sleep Apnoea and its Treatment

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

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

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      • Respiratory
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  • Question 43 - A 50-year-old farmer presents to his general practitioner (GP) with gradually progressive shortness...

    Incorrect

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

      Your Answer: Silicosis

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

      Causes of Pulmonary Fibrosis: Extrinsic Allergic Alveolitis

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

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      • Respiratory
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  • Question 44 - A 32-year-old female with a 10 year history of asthma presents with increasing...

    Incorrect

    • A 32-year-old female with a 10 year history of asthma presents with increasing dyspnoea after returning from a trip to Australia. She has not had a period in three months. On examination, she has a fever of 37.5°C, a pulse rate of 110/min, a blood pressure of 106/74 mmHg, and saturations of 93% on room air. Her respiratory rate is 24/min and auscultation of the chest reveals vesicular breath sounds. Peak flow is 500 L/min and her ECG shows no abnormalities except for a heart rate of 110 bpm. A chest x-ray is normal. What is the most likely diagnosis?

      Your Answer: Thyrotoxicosis

      Correct Answer: Pulmonary embolism

      Explanation:

      Risk Factors and Symptoms of Pulmonary Embolism

      This patient presents with multiple risk factors for pulmonary embolism, including air travel and likely pregnancy. She is experiencing tachycardia and hypoxia, which require further explanation. However, there are no indications of a respiratory tract infection or acute asthma. It is important to note that an ECG and CXR may appear normal in cases of pulmonary embolism or may only show baseline tachycardia on the ECG. Therefore, it is crucial to consider the patient’s risk factors and symptoms when evaluating for pulmonary embolism. Proper diagnosis and treatment are essential to prevent potentially life-threatening complications.

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      • Respiratory
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  • Question 45 - A 55-year-old woman comes to her doctor complaining of wheezing, chest tightness, cough,...

    Incorrect

    • A 55-year-old woman comes to her doctor complaining of wheezing, chest tightness, cough, and difficulty breathing for the past three days. She reports that this started shortly after being exposed to a significant amount of hydrogen sulfide at work. She has no prior history of respiratory issues and is a non-smoker. What would be the most suitable initial management approach to alleviate her symptoms?

      Your Answer: Inhaled corticosteroids

      Correct Answer: Inhaled bronchodilators

      Explanation:

      Management of Reactive Airway Dysfunction Syndrome (RADS)

      Reactive airway dysfunction syndrome (RADS) is a condition that presents with asthma-like symptoms within 24 hours of exposure to irritant gases, vapours or fumes. To diagnose RADS, pre-existing respiratory conditions must be absent, and symptoms must occur after a single exposure to high concentrations of irritants. A positive methacholine challenge test and possible airflow obstruction on pulmonary function tests are also indicative of RADS.

      Inhaled bronchodilators, such as salbutamol, are the first-line treatment for RADS. Cromolyn sodium may be added in select cases, while inhaled corticosteroids are used if bronchodilators are ineffective. Oral steroids are not as effective in RADS as they are in asthma. High-dose vitamin D may be useful in some cases, but it is not routinely recommended for initial management.

      In summary, the management of RADS involves the use of inhaled bronchodilators as the first-line treatment, with other medications added in if necessary. A proper diagnosis is crucial to ensure appropriate management of this condition.

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      • Respiratory
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  • Question 46 - A 75-year-old man presents to the Emergency Department with complaints of difficulty breathing....

    Correct

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

      Your Answer: Pleural effusion

      Explanation:

      Clinical Signs for Common Respiratory Conditions

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

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

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

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

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

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

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      • Respiratory
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  • Question 47 - A 65-year-old man presents with haemoptysis over the last 2 days. He has...

    Incorrect

    • 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: Chronic obstructive pulmonary disease (COPD)

      Correct 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.

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      • Respiratory
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  • Question 48 - A 45-year-old female patient complained of cough with heavy sputum production, shortness of...

    Correct

    • A 45-year-old female patient complained of cough with heavy sputum production, shortness of breath, and a low-grade fever. She has been smoking 20 cigarettes per day for the past 25 years. Upon examination, her arterial blood gases showed a pH of 7.4 (normal range: 7.36-7.44), pCO2 of 6 kPa (normal range: 4.5-6), and pO2 of 7.9 kPa (normal range: 8-12). Based on these findings, what is the most likely diagnosis for this patient?

      Your Answer: Chronic bronchitis

      Explanation:

      Diagnosis of Acute Exacerbation of Chronic Obstructive Airways Disease

      There is a high probability that the patient is experiencing an acute exacerbation of chronic obstructive airways disease (COAD), particularly towards the chronic bronchitic end of the spectrum. This conclusion is based on the patient’s symptoms and the relative hypoxia with high pCO2. The diagnosis suggests that the patient’s airways are obstructed, leading to difficulty in breathing and reduced oxygen supply to the body. The exacerbation may have been triggered by an infection or exposure to irritants such as cigarette smoke. Early intervention is crucial to manage the symptoms and prevent further complications.

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      • Respiratory
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  • Question 49 - A 65-year-old man with chronic obstructive pulmonary disease (COPD) continues to be breathless...

    Correct

    • A 65-year-old man with chronic obstructive pulmonary disease (COPD) continues to be breathless at rest despite maximal inhaler therapy, pulmonary rehabilitation and home oxygen therapy. He has been reviewed for lung volume reduction surgery but was deemed unsuitable. He is referred for consideration of lung transplantation.
      His FEV1 is 30% predicted, he has not smoked for 12 years, and his past medical history includes bowel cancer, for which he underwent partial colectomy and adjunctive chemotherapy six years previously without evidence of recurrence on surveillance, and pulmonary tuberculosis age 37, which was fully sensitive and treated with six months of anti-tuberculous therapy. The patient’s body mass index (BMI) is 29 kg/m2.
      What feature in this patient’s history would make him ineligible for listing for lung transplantation at this time?

      Your Answer: FEV1 30% predicted

      Explanation:

      Contraindications for Lung Transplantation in a Patient with COPD

      Lung transplantation is a potential treatment option for patients with end-stage chronic obstructive pulmonary disease (COPD). However, certain factors may make a patient ineligible for the procedure.

      One important factor is the patient’s forced expiratory volume in one second (FEV1) percentage predicted. The International Society for Heart and Lung Transplantation recommends a minimum FEV1 of less than 25% predicted for lung transplantation. In addition, patients must have a Body mass index, airflow Obstruction, Dyspnea and Exercise capacity (BODE) index of 5 to 6, a PaCO2 > 6.6 kPa and/or a PaO2 < 8 kPa. A previous history of pulmonary tuberculosis is also a contraindication to lung transplantation, as active infection with Mycobacterium tuberculosis can complicate the procedure. The patient’s body mass index (BMI) is another important consideration. A BMI greater than 35 kg/m2 is an absolute contraindication to transplant, while a BMI between 30 and 35 kg/m2 is a relative contraindication. Age is also a factor, with patients over 65 years old being considered a relative contraindication to lung transplantation. However, there is no absolute age limit for the procedure. Finally, a previous history of malignancy may also impact a patient’s eligibility for lung transplantation. If the malignancy has a low risk of recurrence, such as basal cell carcinoma, patients may be considered for transplant after two years. For most other cancers, a five-year period without recurrence is required. In this case, the patient’s previous malignancy occurred six years ago and would not be an absolute contraindication to transplantation.

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      • Respiratory
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  • Question 50 - 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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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (25/50) 50%
Passmed