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  • Question 1 - A 35-year-old dairy farmer presents with a flu-like illness that has been worsening...

    Incorrect

    • A 35-year-old dairy farmer presents with a flu-like illness that has been worsening for the past two weeks. He has high fevers, a pounding headache, and muscle aches. He has now also developed a dry cough, stomach pain, and diarrhea. During the examination, there are no notable chest signs, but a liver edge can be felt 4 cm below the costal margin.

      Today, his blood tests show the following results:
      - Hemoglobin (Hb): 13.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 21.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 17.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Platelets: 567 x 109/l (normal range: 150-400 x 109/l)
      - C-reactive protein (CRP): 187 mg/l (normal range: < 5 mg/l)
      - Sodium (Na): 127 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 122 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 7.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      - Aspartate aminotransferase (AST): 121 IU/l (normal range: 8-40 IU/l)
      - Alkaline phosphatase (ALP): 296 IU/l (normal range: 30-200 IU/l)
      - Bilirubin: 14 micromol/l (normal range: 3-17 micromol/l)

      What is the SINGLE most likely causative organism?

      Your Answer: Pneumocystis jiroveci

      Correct Answer: Coxiella burnetii

      Explanation:

      Q fever is a highly contagious infection caused by Coxiella burnetii, which can be transmitted from animals to humans. It is commonly observed as an occupational disease among individuals working in farming, slaughterhouses, and animal research. Approximately 50% of cases do not show any symptoms, while those who are affected often experience flu-like symptoms such as headache, fever, muscle pain, diarrhea, nausea, and vomiting.

      In some cases, patients may develop an atypical pneumonia characterized by a dry cough and minimal chest signs. Q fever can also lead to hepatitis and enlargement of the liver (hepatomegaly), although jaundice is not commonly observed. Typical blood test results for Q fever include an elevated white cell count (30-40%), ALT/AST levels that are usually 2-3 times higher than normal, increased ALP levels (70%), reduced sodium levels (30%), and reactive thrombocytosis.

      It is important to check patients for heart murmurs and signs of valve disease, as these conditions increase the risk of developing infective endocarditis. Treatment for Q fever typically involves a two-week course of doxycycline.

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      • Respiratory
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  • Question 2 - A 45-year-old man comes in with a history of a high temperature, loss...

    Incorrect

    • A 45-year-old man comes in with a history of a high temperature, loss of smell, a persistent cough, and increasing difficulty breathing. He underwent a COVID-19 test two days ago, which has returned positive.
      Which established scoring system can be utilized to forecast the risk of severe respiratory illness within 24 hours for patients admitted from the emergency department with COVID-19?

      Your Answer: MASCC Risk Index Score

      Correct Answer: qCSI Score

      Explanation:

      The qCSI Score, also known as the Quick COVID-19 Severity Index, is a tool that can predict the risk of critical respiratory illness in patients who are admitted from the emergency department with COVID-19. This score takes into consideration three criteria: respiratory rate, pulse oximetry, and oxygen flow rate. By assessing these factors, the qCSI Score can provide an estimation of the 24-hour risk of severe respiratory complications in these patients.

      On the other hand, the qSOFA Score is a different tool that is used to identify high-risk patients for in-hospital mortality when there is a suspicion of infection, particularly in cases of sepsis. However, it is important to note that the qSOFA Score is not specifically designed for use in the setting of febrile neutropenia.

      Another scoring system, known as the CURB-65 Score, is utilized to estimate the mortality risk associated with community-acquired pneumonia. This score helps healthcare professionals determine whether a patient should receive inpatient or outpatient treatment based on their likelihood of experiencing adverse outcomes.

      Lastly, the SCAP Score is a scoring system that predicts the risk of adverse outcomes in patients with community-acquired pneumonia who present to the emergency department. By assessing various clinical factors, this score can provide valuable information to healthcare providers regarding the potential severity of the illness and the need for further intervention.

      In addition to these scores, there is also the MASCC Risk Index Score, which is specifically used in the context of cancer patients receiving supportive care. This score helps assess the risk of complications in this vulnerable population and aids in making informed decisions regarding their treatment and management.

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      • Respiratory
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  • Question 3 - You are managing a 72-year-old patient with type 2 respiratory failure. It has...

    Incorrect

    • You are managing a 72-year-old patient with type 2 respiratory failure. It has been decided to initiate BiPAP therapy. What initial EPAP and IPAP pressure settings would you recommend?

      Your Answer: EPAP 7-10 cmH2O IPAP 3-5 cmH2O

      Correct Answer:

      Explanation:

      When determining the initial EPAP and IPAP pressure settings for this patient, it is important to consider their specific needs and condition. In general, the EPAP pressure should be set between 3-5 cmH2O, which helps to maintain positive pressure in the airways during exhalation, preventing them from collapsing. This can improve oxygenation and reduce the work of breathing.

      The IPAP pressure, on the other hand, should be set between 10-15 cmH2O. This higher pressure during inhalation helps to overcome any resistance in the airways and ensures adequate ventilation. It also assists in improving the patient’s tidal volume and reducing carbon dioxide levels.

      Therefore, the recommended initial EPAP and IPAP pressure settings for this patient would be EPAP 3-5 cmH2O / IPAP 10-15 cmH2O. These settings provide a balance between maintaining airway patency during exhalation and ensuring sufficient ventilation during inhalation. However, it is important to regularly assess the patient’s response to therapy and adjust the settings as needed to optimize their respiratory function.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

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      • Respiratory
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  • Question 4 - A 4-year-old girl presents with stridor and a barking cough. Her mother reports...

    Incorrect

    • A 4-year-old girl presents with stridor and a barking cough. Her mother reports that she has had a slight cold for a few days and her voice had been hoarse. Her vital signs are as follows: temperature 38.1°C, heart rate 135, respiratory rate 30, oxygen saturation 97% on room air. Her chest examination is unremarkable, but you observe the presence of stridor at rest.

      What is the SINGLE most probable causative organism?

      Your Answer: Corynebacterium diphtheriae

      Correct Answer: Parainfluenza virus

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

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      • Respiratory
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  • Question 5 - A 40-year-old man presents with a sudden worsening of his asthma symptoms. His...

    Incorrect

    • A 40-year-old man presents with a sudden worsening of his asthma symptoms. His heart rate is 110 bpm, respiratory rate 30/min, and his oxygen saturations are 88% on room air. He is feeling fatigued, and his breathing sounds weak, with no audible sounds in his chest. He has already received two consecutive nebulizers of salbutamol, 40 mg, one nebulizer of ipratropium bromide, and 40 mg of prednisolone orally. The ICU outreach team has been notified and will arrive soon.
      Which of the following medications would be most appropriate to administer while waiting for the ICU outreach team to arrive?

      Your Answer: IV ketamine

      Correct Answer: IV magnesium sulphate

      Explanation:

      This patient exhibits signs of potentially life-threatening asthma. In adults, acute severe asthma is characterized by a peak expiratory flow (PEF) of 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, and an inability to complete sentences in one breath. On the other hand, life-threatening asthma is indicated by a PEF below 33% of the best or predicted value, a blood oxygen saturation (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kPA, a normal partial pressure of carbon dioxide (PaCO2) within the range of 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, and hypotension.

      To address acute asthma in adults, the recommended drug doses include administering 5 mg of salbutamol through an oxygen-driven nebulizer, delivering 500 mcg of ipratropium bromide via an oxygen-driven nebulizer, providing 40-50 mg of prednisolone orally, administering 100 mg of hydrocortisone intravenously, and infusing 1.2-2 g of magnesium sulfate intravenously over a period of 20 minutes.

      According to the current Advanced Life Support (ALS) guidelines, it is advisable to seek senior advice before considering the use of intravenous aminophylline in cases of severe or life-threatening asthma. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by a continuous infusion of 500-700 mcg/kg/hour. To prevent toxicity, it is important to maintain serum theophylline levels below 20 mcg/ml.

      In situations where inhaled therapy is not feasible, intravenous salbutamol can be considered, with a slow administration of 250 mcg. However, it should only be used when a patient is receiving bag-mask ventilation.

      It is worth noting that there is currently no evidence supporting the use of leukotriene receptor antagonists, such as montelukast, or Heliox in the management of acute severe or life-threatening asthma.

      For further information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

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      • Respiratory
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  • Question 6 - A 12-month-old child is brought in to the Emergency Department with a high...

    Incorrect

    • A 12-month-old child is brought in to the Emergency Department with a high temperature and difficulty breathing. You measure their respiratory rate and note that it is elevated.
      According to the NICE guidelines, what is considered to be the threshold for tachypnoea in an infant of this age?

      Your Answer: RR >50 breaths/minute

      Correct Answer: RR >40 breaths/minute

      Explanation:

      According to the current NICE guidelines on febrile illness in children under the age of 5, there are certain symptoms and signs that may indicate the presence of pneumonia. These include tachypnoea, which is a rapid breathing rate. For infants aged 0-5 months, a respiratory rate (RR) of over 60 breaths per minute is considered suggestive of pneumonia. For infants aged 6-12 months, an RR of over 50 breaths per minute is indicative, and for children older than 12 months, an RR of over 40 breaths per minute may suggest pneumonia.

      Other signs that may point towards pneumonia include crackles in the chest, nasal flaring, chest indrawing, and cyanosis. Crackles are abnormal sounds heard during breathing, while nasal flaring refers to the widening of the nostrils during breathing. Chest indrawing is the inward movement of the chest wall during inhalation, and cyanosis is the bluish discoloration of the skin or mucous membranes due to inadequate oxygen supply.

      Additionally, a low oxygen saturation level of less than 95% while breathing air is also considered suggestive of pneumonia. These guidelines can be found in more detail in the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

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  • Question 7 - A 45-year-old man comes in with a dry cough that has been going...

    Incorrect

    • A 45-year-old man comes in with a dry cough that has been going on for a week. He also complains of muscle aches, fatigue, and a sore throat. In the past day, he has developed diarrhea and a mild throbbing headache. During the examination, his temperature is measured at 37.8°C, and faint crackles are heard at the base of his lungs.

      What is the SINGLE most probable organism responsible for these symptoms?

      Your Answer: Klebsiella pneumoniae

      Correct Answer: Mycoplasma pneumoniae

      Explanation:

      This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features commonly associated with Mycoplasma pneumoniae infection include a flu-like illness that occurs before respiratory symptoms, fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness. It is worth noting that Mycoplasma pneumoniae is frequently linked to the development of erythema multiforme and can also be a cause of Steven-Johnson syndrome. The rash associated with erythema multiforme is characterized by multiple red lesions on the limbs that develop into target lesions a few days after the rash first appears.

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  • Question 8 - A child presents with a severe acute asthma attack. After a poor response...

    Incorrect

    • A child presents with a severe acute asthma attack. After a poor response to their initial salbutamol nebulizer, you administer a second nebulizer that also contains ipratropium bromide. How long would it take for the ipratropium bromide to have its maximum effect?

      Your Answer: Less than 5 minutes

      Correct Answer: 30-60 minutes

      Explanation:

      Ipratropium bromide is a medication that falls under the category of antimuscarinic drugs. It is commonly used to manage acute asthma and chronic obstructive pulmonary disease (COPD). While it can provide short-term relief for chronic asthma, it is generally recommended to use short-acting β2 agonists as they act more quickly and are preferred.

      According to the guidelines set by the British Thoracic Society (BTS), nebulized ipratropium bromide (0.5 mg every 4-6 hours) can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      For mild cases of chronic obstructive pulmonary disease, aerosol inhalation of ipratropium can be used for short-term relief, as long as the patient is not already using a long-acting antimuscarinic drug like tiotropium. The maximum effect of ipratropium occurs within 30-60 minutes after use, and its bronchodilating effects can last for 3-6 hours. Typically, treatment with ipratropium is recommended three times a day to maintain bronchodilation.

      The most common side effect of ipratropium bromide is dry mouth. Other potential side effects include constipation, cough, paroxysmal bronchospasm, headache, nausea, and palpitations. It is important to note that ipratropium can cause urinary retention in patients with prostatic hyperplasia and bladder outflow obstruction. Additionally, it can trigger acute closed-angle glaucoma in susceptible patients.

      For more information on the management of asthma, it is recommended to refer to the BTS/SIGN Guideline on the Management of Asthma.

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  • Question 9 - A 45-year-old man presents with a sudden onset of severe asthma symptoms. You...

    Correct

    • A 45-year-old man presents with a sudden onset of severe asthma symptoms. You begin treatment for the patient, following the most recent BTS guidelines.

      According to the BTS guidelines, what is the appropriate course of action for management?

      Your Answer: Steroids should be given in all cases of acute asthma attack

      Explanation:

      The BTS guidelines for managing acute asthma in adults provide the following recommendations:

      Oxygen:
      – It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.

      β2 agonists therapy:
      – High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
      – Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
      – For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
      – In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.

      Ipratropium bromide:
      – Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      Steroid therapy:
      – Steroids should be given in adequate doses for all cases of acute asthma attacks.
      – Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.

      Other therapies:
      – Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
      – A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
      – Routine prescription of antibiotics is not necessary for patients with acute asthma.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

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      • Respiratory
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  • Question 10 - A 35-year-old woman with no significant medical history complains of chest pain on...

    Incorrect

    • A 35-year-old woman with no significant medical history complains of chest pain on the right side and difficulty breathing. She does not take any medications regularly and has no known allergies to drugs. She has been a heavy smoker for the past six years.

      What is the SINGLE most probable diagnosis?

      Your Answer: Asthma

      Correct Answer: Pneumothorax

      Explanation:

      The risk of primary spontaneous pneumothorax is associated with smoking tobacco and increases as the duration of exposure and daily consumption rise. The changes caused by smoking in the small airways may contribute to the development of local emphysema, leading to the formation of bullae. In this case, the patient does not have any clinical features or significant risk factors for the other conditions mentioned. Therefore, primary spontaneous pneumothorax is the most probable diagnosis.

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      • Respiratory
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  • Question 11 - A 72-year-old man comes in with increasing shortness of breath. During the examination,...

    Incorrect

    • A 72-year-old man comes in with increasing shortness of breath. During the examination, it is noted that he has reduced chest movement on the right side. Dullness to percussion and decreased breath sounds are also observed over the right lower lobe. A chest X-ray confirms the presence of a significant pleural effusion. You plan to perform a percutaneous needle aspiration.

      Which ONE statement about percutaneous needle aspiration is accurate?

      Your Answer: The patient should be positioned in the left lateral position

      Correct Answer: The needle should be inserted just above the upper border of the chosen rib

      Explanation:

      A pleural effusion refers to the accumulation of excess fluid in the pleural cavity, which is the fluid-filled space between the parietal and visceral pleura. Normally, this cavity contains about 5-10 ml of lubricating fluid that allows the pleurae to slide over each other and helps the lungs fill with air as the thorax expands. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons: to investigate pleural effusion and to provide relief from breathlessness caused by pleural effusion. According to the guidelines from the British Thoracic Society (BTS), pleural aspiration should be reserved for the investigation of unilateral exudative pleural effusions. It should not be done if unilateral or bilateral transudative effusion is suspected, unless there are atypical features or a lack of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

      During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line at the back (approximately 10 cm to the side of the spine), one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.

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      • Respiratory
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  • Question 12 - A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain...

    Incorrect

    • A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain radiating down the inner side of his left upper arm into his forearm and hand. He has a history of heavy smoking and has been diagnosed with COPD. Upon examination, he exhibits weakness and noticeable muscle wasting in his forearm and hand on the same side. Additionally, he has a Horner's syndrome on the affected side. The Chest X-ray image is provided below:

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Right upper lobe pneumonia

      Correct Answer: Pancoast tumour

      Explanation:

      This patient presents with a noticeable mass at the top of the right lung, which is clearly visible on the chest X-ray. Based on the symptoms and clinical presentation, it is highly likely that this is a Pancoast tumor, and the overall diagnosis is Pancoast syndrome.

      A Pancoast tumor is a type of tumor that develops at the apex of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. The majority of Pancoast tumors are classified as non-small cell cancers.

      Pancoast syndrome occurs when the tumor invades various structures and tissues around the thoracic inlet. This includes the invasion of the cervical sympathetic plexus on the same side as the tumor, leading to the development of Horner’s syndrome. Additionally, there may be reflex sympathetic dystrophy in the arm on the affected side, resulting in increased sensitivity to touch and changes in the skin.

      Patients with Pancoast syndrome may also experience shoulder and arm pain due to the tumor invading the brachial plexus roots C8-T1. This can lead to muscle wasting in the hand and tingling sensations in the inner side of the arm. In some cases, there may be involvement of the unilateral recurrent laryngeal nerve, causing unilateral vocal cord paralysis and resulting in a hoarse voice and/or a bovine cough. Phrenic nerve involvement is less common but can also occur.

      Horner’s syndrome, which is a key feature of Pancoast syndrome, is caused by compression of the sympathetic chain from the hypothalamus to the orbit. The three main symptoms of Horner’s syndrome are drooping of the eyelid (ptosis), constriction of the pupil (pupillary miosis), and lack of sweating on the forehead (anhydrosis).

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  • Question 13 - A 3-year-old toddler arrives in a deteriorated state with acute and severe asthma....

    Incorrect

    • A 3-year-old toddler arrives in a deteriorated state with acute and severe asthma. The child's weight is 16 kg. In accordance with the BTS guidelines, what is the recommended dosage of prednisolone for this case?

      Your Answer: 10 mg

      Correct Answer: 20 mg

      Explanation:

      The BTS guidelines for acute asthma in children recommend administering oral steroids early in the treatment of asthma attacks. It is advised to give a dose of 20 mg prednisolone for children aged 2–5 years and a dose of 30–40 mg for children over 5 years old. If a child is already taking maintenance steroid tablets, they should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the medication, the dose of prednisolone should be repeated. In cases where a child is unable to keep down orally ingested medication, intravenous steroids should be considered. Typically, treatment for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering off the medication is not necessary unless the steroid course exceeds 14 days. For more information, refer to the BTS/SIGN Guideline on the Management of Asthma.

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      • Respiratory
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  • Question 14 - A 42 year old female is brought into the emergency department with multiple...

    Incorrect

    • A 42 year old female is brought into the emergency department with multiple injuries following a severe car accident. The patient was intubated at the scene due to low GCS and concerns about their ability to maintain their airway. You are checking the patient's ventilation and blood gases. The PaO2/FiO2 ratio is 140 mmHg with PEEP 7 cm H2O. What does this suggest?

      Your Answer: Normal lung function

      Correct Answer: Moderate acute respiratory distress syndrome

      Explanation:

      A PaO2/FiO2 ratio ranging from 100 mmHg to 200 mmHg indicates the presence of moderate Acute Respiratory Distress Syndrome (ARDS).

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

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  • Question 15 - A 6-year-old girl presents with a history of a persistent cough that has...

    Incorrect

    • A 6-year-old girl presents with a history of a persistent cough that has been present for the past four weeks. The cough occurs in quick bursts with a deep breath in followed by a series of forceful coughs. She occasionally vomits after coughing. Her mother reports that the cough is more severe at night.

      During the examination, her chest sounds clear, but you observe two small subconjunctival hemorrhages and some tiny red spots on her face.

      What is the MOST suitable test to perform in this case?

      Your Answer: Serial peak flow measurements

      Correct Answer: Serology for anti-pertussis toxin IgG antibody levels

      Explanation:

      This presentation strongly suggests a diagnosis of whooping cough, which is an infection of the upper respiratory tract caused by the bacteria Bordetella pertussis. The disease is highly contagious and is transmitted through respiratory droplets. The incubation period is typically 7-21 days, and it is estimated that about 90% of close household contacts will become infected.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, is similar to a mild respiratory infection with symptoms such as low-grade fever and a runny nose. A cough may be present, but it is usually not as severe as in the second stage. This phase typically lasts about a week.

      The second stage, called the paroxysmal stage, is characterized by the development of a distinctive cough. The coughing occurs in spasms, often preceded by an inspiratory whoop sound. These spasms are followed by a series of rapid, hacking coughs. Patients may also experience vomiting and develop subconjunctival hemorrhages and petechiae. Between spasms, patients generally feel well and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) has specific recommendations for testing for whooping cough based on the age of the patient, the time since onset of illness, and the severity of the presentation.

      For infants under 12 months of age, hospitalized patients should be tested using PCR testing. Non-hospitalized patients within two weeks of onset should be investigated with culture of a nasopharyngeal swab or aspirate. Non-hospitalized patients presenting over two weeks after onset should be tested using serology for anti-pertussis toxin IgG antibody levels.

      For children over 12 months of age and adults, patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Patients aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after onset should have oral fluid testing for anti-pertussis toxin IgG antibody levels.

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  • Question 16 - A 45-year-old man comes in with a high temperature, shivering, aching head, cough,...

    Incorrect

    • A 45-year-old man comes in with a high temperature, shivering, aching head, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the birdhouse. During the examination, a red rash is noticed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.
      What is the BEST antibiotic to prescribe for this patient?

      Your Answer: Co-amoxiclav

      Correct Answer: Doxycycline

      Explanation:

      Psittacosis is a type of infection that can be transmitted from animals to humans, known as a zoonotic infection. It is caused by a bacterium called Chlamydia psittaci. This infection is most commonly seen in people who own domestic birds, but it can also affect those who work in pet shops or zoos.

      The typical presentation of psittacosis includes symptoms similar to those of pneumonia that is acquired within the community. People may experience flu-like symptoms along with severe headaches and sensitivity to light. In about two-thirds of patients, an enlargement of the spleen, known as splenomegaly, can be observed.

      Infected individuals often develop a reddish rash with flat spots on their face, known as Horder’s spots. Additionally, they may experience skin conditions such as erythema nodosum or erythema multiforme.

      The recommended treatment for psittacosis is a course of tetracycline or doxycycline, which should be taken for a period of 2-3 weeks.

    • This question is part of the following fields:

      • Respiratory
      20.5
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  • Question 17 - A 70-year-old nursing home resident is brought to the Emergency Department because she...

    Correct

    • A 70-year-old nursing home resident is brought to the Emergency Department because she has rapidly declined in the past 24 hours. She appears extremely ill and has a temperature of 39.3°C. She has a history of stroke, is typically confined to bed, and struggles with communication. During the examination, she exhibits rapid heart rate, rapid breathing, and coarse crackles in the right middle and lower areas.

      What is the SINGLE most probable diagnosis?

      Your Answer: Aspiration pneumonia

      Explanation:

      This patient presents with clinical features that are indicative of a right middle/lower lobe pneumonia. Considering her past medical history of a stroke and the specific location of the chest signs, it is highly probable that she is suffering from aspiration pneumonia.

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      • Respiratory
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  • Question 18 - Following the passing of a young patient treated for an extended cardiac arrest...

    Incorrect

    • Following the passing of a young patient treated for an extended cardiac arrest after a near-drowning incident, your supervisor requests that you arrange a training session for the junior physicians. Which of the following statements accurately reflects the management of near-drowning patients?

      Your Answer: Nebulised bronchodilators are ineffective in treating bronchospasm associated with drowning and should be avoided

      Correct Answer: Patients should be extricated from the water in the horizontal position

      Explanation:

      When rescuing drowning patients, it is important to extricate them from the water in a horizontal position whenever possible. This is because the pressure of the water on the body when submerged increases the flow of blood back to the heart, which in turn increases cardiac output. However, when the patient is removed from the water, this pressure effect is lost, which can lead to a sudden drop in blood pressure and circulatory collapse due to the loss of peripheral resistance and pooling of blood in the veins. By extricating the patient in a horizontal position, we can help counteract this effect.

      It is worth noting that the amount of water in the lungs after drowning is typically small, usually less than 4 milliliters per kilogram of body weight. Therefore, attempting to drain the water from the lungs is ineffective and not recommended.

      In cases of fresh water drowning, pneumonia may occur due to unusual pathogens such as aeromonas spp, burkholderia pseudomallei, chromobacterium spp, pseudomonas species, and leptospirosis.

      If the patient experiences bronchospasm, nebulized bronchodilators can be used as a treatment.

      To prevent secondary brain injury, it is important to prevent hyperthermia. This can be achieved by maintaining the patient’s core body temperature below 36 degrees Celsius during the rewarming process.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

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      • Respiratory
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  • Question 19 - A 14 year old patient is brought into the emergency department struggling to...

    Correct

    • A 14 year old patient is brought into the emergency department struggling to breathe. Upon initial assessment, you observe tracheal deviation to the right, absence of breath sounds in the left hemithorax, and hyper-resonant percussion in the left hemithorax.

      What is the most crucial immediate intervention for this patient?

      Your Answer: Needle thoracocentesis

      Explanation:

      The key initial management for tension pneumothorax is needle thoracocentesis. This procedure is crucial as it rapidly decompresses the tension and allows for more definitive management to be implemented. It is important to note that according to ATLS guidelines, needle thoracocentesis should no longer be performed at the second intercostal space midclavicular line. Studies have shown that the fourth or fifth intercostal space midaxillary line is more successful in reaching the thoracic cavity in adult patients. Therefore, ATLS now recommends this location for needle decompression in adult patients.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

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      • Respiratory
      10.2
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  • Question 20 - A 10-month-old child is brought in to the Emergency Department with a high...

    Incorrect

    • A 10-month-old child is brought in to the Emergency Department with a high temperature and difficulty breathing. You measure his respiratory rate and note that it is elevated.
      According to the NICE guidelines, what is considered to be the threshold for tachypnoea in an infant of this age?

      Your Answer: RR >60 breaths/minute

      Correct Answer: RR >50 breaths/minute

      Explanation:

      According to the current NICE guidelines on febrile illness in children under the age of 5, there are certain symptoms and signs that may indicate the presence of pneumonia. These include tachypnoea, which is a rapid breathing rate. For infants aged 0-5 months, a respiratory rate (RR) of over 60 breaths per minute is considered suggestive of pneumonia. For infants aged 6-12 months, an RR of over 50 breaths per minute is indicative, and for children older than 12 months, an RR of over 40 breaths per minute may suggest pneumonia.

      Other signs that may point towards pneumonia include crackles in the chest, nasal flaring, chest indrawing, and cyanosis. Crackles are abnormal sounds heard during breathing, while nasal flaring refers to the widening of the nostrils during breathing. Chest indrawing is the inward movement of the chest wall during inhalation, and cyanosis is the bluish discoloration of the skin or mucous membranes due to inadequate oxygen supply.

      Additionally, a low oxygen saturation level of less than 95% while breathing air is also considered suggestive of pneumonia. These guidelines can be found in more detail in the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Respiratory
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  • Question 21 - A 6-month-old girl is brought by her parents to see her pediatrician due...

    Incorrect

    • A 6-month-old girl is brought by her parents to see her pediatrician due to a history of fever, cough, and difficulty breathing. The pediatrician diagnoses her with acute bronchiolitis and calls the Emergency Department to discuss whether the child will require admission.
      What would be a reason for referring the child to the hospital?

      Your Answer: Oxygen saturations of 95%

      Correct Answer:

      Explanation:

      Bronchiolitis is a respiratory infection that primarily affects infants aged 2 to 6 months. It is typically caused by a viral infection, with respiratory syncytial virus (RSV) being the most common culprit. RSV infections are most prevalent during the winter months, from November to March. In fact, bronchiolitis is the leading cause of hospitalization among infants in the UK.

      The symptoms of bronchiolitis include poor feeding (consuming less than 50% of their usual intake in the past 24 hours), lethargy, a history of apnea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis (bluish discoloration of the skin), and low oxygen saturation levels. For children aged 6 weeks and older, oxygen saturation levels below 90% indicate a need for medical attention. For babies under 6 weeks or those with underlying health conditions, oxygen saturation levels below 92% require medical attention.

      To confirm the diagnosis of bronchiolitis, a nasopharyngeal aspirate can be taken for rapid testing of RSV. This test is useful in preventing unnecessary further testing and allows for the isolation of the infected infant.

      Most infants with bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in cases of poor feeding, lethargy, a history of apnea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, and oxygen saturation levels below 94%. If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers for the treatment of bronchiolitis.

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      • Respiratory
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  • Question 22 - You are overseeing the care of a 68-year-old individual with COPD. The patient...

    Correct

    • You are overseeing the care of a 68-year-old individual with COPD. The patient has recently started using BiPAP. What is the desired range for oxygen saturation in a patient with COPD and type 2 respiratory failure who is receiving BiPAP?

      Your Answer: 88-92%

      Explanation:

      In patients with COPD and type 2 respiratory failure, the desired range for oxygen saturation while receiving BiPAP is typically 88-92%.

      Maintaining oxygen saturation within this range is crucial for individuals with COPD as it helps strike a balance between providing enough oxygen to meet the body’s needs and avoiding the risk of oxygen toxicity. Oxygen saturation levels below 88% may indicate inadequate oxygenation, while levels above 92% may lead to oxygen toxicity and other complications.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

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      • Respiratory
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  • Question 23 - A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Incorrect

    • A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Australia. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
      What is the PRIMARY diagnosis in this case?

      Your Answer: Myocardial infarction

      Correct Answer: Pulmonary embolism

      Explanation:

      Based on the clinical history and examination, it strongly indicates that the patient has developed a pulmonary embolism due to a deep vein thrombosis in his right leg.

      The symptoms commonly associated with a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. These symptoms may also suggest the presence of a deep vein thrombosis. Other clinical features that may be observed are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.

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      • Respiratory
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  • Question 24 - A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing,...

    Incorrect

    • A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing, and wheezing. Blood tests reveal an elevated packed cell volume (PCV). A chest X-ray shows more than 6 ribs visible above the diaphragm in the midclavicular line. An arterial blood gas indicates slightly low pO2 levels.

      What is the SINGLE most probable diagnosis?

      Your Answer: Bronchial carcinoma

      Correct Answer: COPD

      Explanation:

      Based on the provided information, it is highly probable that this patient is suffering from chronic obstructive pulmonary disease (COPD). This conclusion is supported by several factors. Firstly, the patient has a history of chronic productive cough and wheezing, which are common symptoms of COPD. Additionally, the patient has a long-term smoking history, which is a major risk factor for developing this condition.

      Furthermore, the patient’s raised packed cell volume (PCV) is likely a result of chronic hypoxemia, a common complication of COPD. This indicates that the patient’s body is trying to compensate for the low oxygen levels in their blood.

      Moreover, the chest X-ray reveals evidence of hyperinflation, which is a characteristic finding in patients with COPD. This suggests that the patient’s lungs are overinflated and not functioning optimally.

      Lastly, the arterial blood gas analysis shows hypoxemia, indicating that the patient has low levels of oxygen in their blood. This is another significant finding that aligns with a diagnosis of COPD.

      In summary, based on the patient’s history, smoking habits, raised PCV, chest X-ray findings, and arterial blood gas results, it is highly likely that they have COPD.

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      • Respiratory
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  • Question 25 - A 3-year-old girl presents with stridor and a barking cough. Her mother reports...

    Incorrect

    • A 3-year-old girl presents with stridor and a barking cough. Her mother reports that she has had a slight cold for a few days and her voice had been hoarse. Her vital signs are as follows: temperature 38.1°C, heart rate 135, respiratory rate 30, oxygen saturation 97% on room air. Her chest examination is unremarkable, but you observe the presence of stridor at rest.

      What is the SINGLE most probable diagnosis?

      Your Answer: Bronchiolitis

      Correct Answer: Croup

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

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      • Respiratory
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  • Question 26 - A 6-month-old boy has been brought to the hospital for evaluation of a...

    Incorrect

    • A 6-month-old boy has been brought to the hospital for evaluation of a severe respiratory infection. The medical team suspects a diagnosis of pertussis (whooping cough).
      What is the MOST SUITABLE investigation for this case?

      Your Answer: Culture of nasopharyngeal aspirate

      Correct Answer: PCR testing

      Explanation:

      Whooping cough, also known as pertussis, is a respiratory infection caused by the bacteria Bordetella pertussis. It is transmitted through respiratory droplets and has an incubation period of about 7-21 days. This disease is highly contagious and can be transmitted to around 90% of close household contacts.

      The clinical course of whooping cough can be divided into two stages. The first stage is called the catarrhal stage, which resembles a mild respiratory infection with symptoms like low-grade fever and a runny nose. A cough may be present, but it is usually mild compared to the second stage. The catarrhal stage typically lasts for about a week.

      The second stage is known as the paroxysmal stage. During this phase, the cough becomes more severe as the catarrhal symptoms start to subside. The coughing occurs in spasms, often preceded by an inspiratory whoop sound, followed by a series of rapid coughs. Vomiting may occur, and patients may develop subconjunctival hemorrhages and petechiae. Patients generally feel well between coughing spasms, and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over time. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) provides recommendations for testing whooping cough based on the patient’s age, time since onset of illness, and severity of symptoms. For infants under 12 months of age who are hospitalized, PCR testing is recommended. Non-hospitalized infants within two weeks of symptom onset should undergo culture testing of a nasopharyngeal swab or aspirate. Non-hospitalized infants presenting over two weeks after symptom onset should be tested for anti-pertussis toxin IgG antibody levels using serology.

      For children over 12 months of age and adults, culture testing of a nasopharyngeal swab or aspirate is recommended within two weeks of symptom onset. Children aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after symptom onset should undergo oral fluid testing for anti-pertussis toxin IgG antibody levels. Children under 5 or adults over

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      • Respiratory
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  • Question 27 - A 3-year-old girl comes in with stridor and a barking cough. Her mother...

    Incorrect

    • A 3-year-old girl comes in with stridor and a barking cough. Her mother mentions that she has had a slight cold for a few days and her voice has been hoarse. Here are her observations: temperature 38.1°C, HR 135, RR 30, SaO2 97% on air. Her chest examination appears normal, but you notice the presence of stridor at rest.

      Which of the following medications is most likely to alleviate her symptoms?

      Your Answer: Nebulised hypertonic saline

      Correct Answer: Nebulised budesonide

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

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      • Respiratory
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  • Question 28 - A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing...

    Incorrect

    • A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing and chest pain that worsens with deep breaths. The results of his arterial blood gas (ABG) on room air are as follows:

      pH: 7.48
      pO2: 7.4 kPa
      PCO2: 3.1 kPa
      HCO3-: 24.5 mmol/l

      Which ONE statement about his ABG is correct?

      Your Answer: He has a respiratory acidosis

      Correct Answer: He has a respiratory alkalosis

      Explanation:

      Arterial blood gas (ABG) interpretation is crucial in evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analysers, they generally fall within the following ranges: pH of 7.35 – 7.45, pO2 of 10 – 14 kPa, PCO2 of 4.5 – 6 kPa, HCO3- of 22 – 26 mmol/l, and base excess of -2 – 2 mmol/l.

      In this particular case, the patient’s medical history raises concerns about a potential diagnosis of pulmonary embolism. The relevant ABG findings are as follows: significant hypoxia (indicating type 1 respiratory failure), elevated pH (alkalaemia), low PCO2, and normal bicarbonate levels. These findings suggest that the patient is experiencing primary respiratory alkalosis.

      By analyzing the ABG results, healthcare professionals can gain valuable insights into a patient’s respiratory function and acid-base status, aiding in the diagnosis and management of various conditions.

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  • Question 29 - A 40-year-old man presents very sick with an acute worsening of his asthma.
    Which...

    Correct

    • A 40-year-old man presents very sick with an acute worsening of his asthma.
      Which of the following is not advised in the management of acute asthma in adults?

      Your Answer: Nebulised magnesium

      Explanation:

      Currently, there is no evidence to support the use of nebulised magnesium sulphate in the treatment of adults with asthma. For adults experiencing acute asthma, the recommended drug doses are as follows:

      – Salbutamol: 5 mg administered through an oxygen-driven nebuliser.
      – Ipratropium bromide: 500 mcg delivered via an oxygen-driven nebuliser.
      – Prednisolone: 40-50 mg taken orally.
      – Hydrocortisone: 100 mg administered intravenously.
      – Magnesium sulphate: 1.2-2 g given intravenously over a period of 20 minutes.

      Intravenous salbutamol may be considered (250 mcg administered slowly) only when inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation.

      According to the current ALS guidelines, IV aminophylline can be considered in cases of severe or life-threatening asthma, following senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

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      • Respiratory
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  • Question 30 - A child presents with a severe acute asthma attack. After a poor response...

    Incorrect

    • A child presents with a severe acute asthma attack. After a poor response to their initial salbutamol nebulizer, you administer a second nebulizer that also contains ipratropium bromide.
      What is the estimated duration of action for ipratropium bromide?

      Your Answer:

      Correct Answer: 3-6 hours

      Explanation:

      Ipratropium bromide is a medication that falls under the category of antimuscarinic drugs. It is commonly used to manage acute asthma and chronic obstructive pulmonary disease (COPD). While it can provide short-term relief for chronic asthma, it is generally recommended to use short-acting β2 agonists as they act more quickly and are preferred.

      According to the guidelines set by the British Thoracic Society (BTS), nebulized ipratropium bromide (0.5 mg every 4-6 hours) can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      For mild cases of chronic obstructive pulmonary disease, aerosol inhalation of ipratropium can be used for short-term relief, as long as the patient is not already using a long-acting antimuscarinic drug like tiotropium. The maximum effect of ipratropium occurs within 30-60 minutes after use, and its bronchodilating effects can last for 3-6 hours. Typically, treatment with ipratropium is recommended three times a day to maintain bronchodilation.

      The most common side effect of ipratropium bromide is dry mouth. Other potential side effects include constipation, cough, paroxysmal bronchospasm, headache, nausea, and palpitations. It is important to note that ipratropium can cause urinary retention in patients with prostatic hyperplasia and bladder outflow obstruction. Additionally, it can trigger acute closed-angle glaucoma in susceptible patients.

      For more information on the management of asthma, it is recommended to refer to the BTS/SIGN Guideline on the Management of Asthma.

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      • Respiratory
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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (3/29) 10%
Passmed