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  • Question 1 - A 60-year-old woman presents with new onset difficulty breathing. During chest examination, you...

    Incorrect

    • A 60-year-old woman presents with new onset difficulty breathing. During chest examination, you observe whispering pectoriloquy over her left lower lobe.
      What is the PRIMARY probable cause of this chest sign?

      Your Answer: Pleural effusion

      Correct Answer: Lung consolidation

      Explanation:

      Whispering pectoriloquy is a phenomenon that occurs when there is lung consolidation. It is characterized by an amplified and clearer sound of whispering that can be heard when using a stethoscope to listen to the affected areas of the lungs. To conduct the test, patients are usually instructed to whisper the phrase ninety-nine.

    • This question is part of the following fields:

      • Respiratory
      14.8
      Seconds
  • Question 2 - A 45-year-old woman comes in with a one-week history of fatigue, fever, headache,...

    Incorrect

    • A 45-year-old woman comes in with a one-week history of fatigue, fever, headache, muscle aches, and a dry cough that has now started to produce a small amount of sputum. She has also been experiencing occasional episodes of diarrhea for the past two days. During the examination, audible crackles are heard at the base of her lungs. Her blood test results today show evidence of hemolytic anemia and the presence of cold agglutinins.

      What is the SINGLE most appropriate antibiotic to prescribe for this patient?

      Your Answer: Ciprofloxacin

      Correct Answer: Clarithromycin

      Explanation:

      This patient presents with symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection with Mycoplasma pneumoniae. The clinical features of Mycoplasma pneumoniae infection include a flu-like illness that precedes respiratory symptoms, along with fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness.

      Mycoplasma pneumoniae infection is commonly associated with the development of erythema multiforme, a rash characterized by multiple red lesions on the limbs that evolve into target lesions a few days after the rash appears. Additionally, this infection can also cause Steven-Johnson syndrome. It is worth noting that haemolytic anaemia with cold agglutinins can complicate Mycoplasma pneumoniae infections, providing further evidence for the diagnosis.

      The recommended first-line antibiotic for treating this case would be a macrolide, such as clarithromycin. Doxycycline can also be used but is generally considered a second-line option.

    • This question is part of the following fields:

      • Respiratory
      32.4
      Seconds
  • Question 3 - 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 appropriate antibiotic choice for this patient?

      Your Answer: Clarithromycin

      Correct Answer: Doxycycline

      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.

    • This question is part of the following fields:

      • Respiratory
      24.2
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  • Question 4 - A 10-year-old girl presents with a history of a persistent cough that has...

    Correct

    • A 10-year-old girl presents with a history of a persistent cough that has been present for the past three weeks. The cough occurs in short bursts with an inspiration followed by a series of hacking coughs. She occasionally vomits after coughing. She mentions that the cough is worse at night and that she has fainted once during a coughing fit. She is otherwise healthy, and her vaccinations are up-to-date.

      Upon examination, her chest is clear, but there are three small subconjunctival hemorrhages and some petechiae on her face. A complete blood count reveals a lymphocyte count of 22 x 109/l (1.3-3.5 x 109/l).

      What is the SINGLE most likely diagnosis?

      Your Answer: Pertussis

      Explanation:

      This presentation strongly indicates a diagnosis of whooping cough, also known as pertussis. Whooping cough 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. The 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 low-grade fever and symptoms similar to a cold. A cough may be present, but it is usually mild and not as severe as in the second stage. The catarrhal stage typically lasts for about a week.

      The second stage is known as the paroxysmal stage. During this stage, the characteristic paroxysmal cough develops as the symptoms from the catarrhal stage start to improve. 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 this period. The later stages of this stage 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. It is important to note that a history of vaccination does not guarantee immunity, as it only provides about 95% protection.

      The presence of marked lymphocytosis in this case also supports a diagnosis of pertussis, as it is a common finding. A lymphocyte count greater than 20 x 109/l is highly suggestive of the disease.

    • This question is part of the following fields:

      • Respiratory
      24.3
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  • Question 5 - A 32 year old is brought into the emergency department after being rescued...

    Incorrect

    • A 32 year old is brought into the emergency department after being rescued from the water by a lifeguard at a nearby beach following signs of distress and submersion. In terms of drowning, what is the primary determinant of prognosis?

      Your Answer: Length of resuscitation

      Correct Answer: Submersion time

      Explanation:

      The duration of submersion is the most crucial factor in predicting the outcome of drowning incidents. If the submersion time is less than 10 minutes, it is considered a positive indicator for prognosis, while if it exceeds 25 minutes, it is considered a negative indicator. There are other factors that are associated with higher rates of illness and death, such as a low Glasgow Coma Score, absence of pupillary response, pH imbalance (acidosis), and low blood pressure (hypotension). However, it is important to note that these prognostic factors have not been consistently validated in studies and cannot reliably predict the outcome of drowning incidents.

      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.

    • This question is part of the following fields:

      • Respiratory
      10.3
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  • Question 6 - A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell...

    Correct

    • A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell and has experienced recent weight loss. Additionally, she has developed a rash. Her medical history includes a diagnosis of asthma last year and allergic rhinitis. On examination, she has a normal body temperature, her blood pressure is 180/95, and she has a purpuric rash primarily on her legs. During chest examination, a few scattered wheezes are heard.

      Recently, she had a blood test, and the results are as follows:
      - Hemoglobin (Hb): 10.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 23.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 8.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Lymphocytes: 2.1 x 109/l (normal range: 1.3-3.5 x 109/l)
      - Eosinophils: 15.7 x 109/l (normal range: 0.04-0.44 x 109/l)
      - C-reactive protein (CRP): 107 mg/l (normal range: <5 mg/l)
      - Sodium (Na): 142 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.6 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 255 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 14.8 mmol/l (normal range: 2.5-7.5 mmol/l)

      What is the SINGLE most likely diagnosis?

      Your Answer: Churg-Strauss syndrome

      Explanation:

      This individual has presented with haemoptysis and a purpuric rash, alongside a history of asthma and allergic rhinitis. Blood tests have revealed elevated inflammatory markers, pronounced eosinophilia, and acute renal failure. The most likely diagnosis in this case is Churg-Strauss syndrome.

      Churg-Strauss syndrome is a rare autoimmune vasculitis that affects small and medium-sized blood vessels. The American College of Rheumatology has established six criteria for diagnosing Churg-Strauss syndrome. The presence of at least four of these criteria is highly indicative of the condition:

      1. Asthma (wheezing, expiratory rhonchi)
      2. Eosinophilia of more than 10% in peripheral blood
      3. Paranasal sinusitis
      4. Pulmonary infiltrates (which may be transient)
      5. Histological confirmation of vasculitis with extravascular eosinophils
      6. Mononeuritis multiplex or polyneuropathy

      Churg-Strauss syndrome can affect various organ systems, with the most common clinical features including:

      – Constitutional symptoms: fever, fatigue, weight loss, and arthralgia
      – Respiratory symptoms: asthma, haemoptysis, allergic rhinitis, and sinusitis
      – Cardiovascular symptoms: heart failure, myocarditis, and myocardial infarction
      – Gastrointestinal symptoms: gastrointestinal bleeding, bowel ischaemia, and appendicitis
      – Dermatological symptoms: purpura, livedo reticularis, and skin nodules
      – Renal symptoms: glomerulonephritis, renal failure, and hypertension
      – Neurological symptoms: mononeuritis multiplex

      Investigations often reveal eosinophilia, anaemia, elevated CRP and ESR, elevated creatinine, and elevated serum IgE levels. Approximately 70% of patients test positive for p-ANCA.

      The mainstay of treatment for Churg-Strauss syndrome is high-dose steroids. In cases with life-threatening complications, cyclophosphamide and azathioprine are often administered.

      Polyarteritis nodosa is another vasculitic disorder that affects small and medium-sized blood vessels. It can impact the gastrointestinal tract, kidneys, skin, and joints, but it is not typically associated with rhinitis or asthma.

    • This question is part of the following fields:

      • Respiratory
      22.5
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  • Question 7 - A 25-year-old woman presents to the emergency department with a complaint of progressive...

    Incorrect

    • A 25-year-old woman presents to the emergency department with a complaint of progressive lip swelling that began 1 hour ago. Upon reviewing her medical history, it is noted that she has a previous diagnosis of hereditary angioedema (HAE). The following findings have been documented:

      - Blood pressure: 120/80 mmHg
      - Pulse rate: 90 beats per minute
      - Respiratory rate: 16 breaths per minute
      - Temperature: 37.5 degrees Celsius

      What is the primary concern regarding this patient?

      Your Answer: Secondary sepsis

      Correct Answer: Airway obstruction

      Explanation:

      The primary concern regarding this patient is airway obstruction. The patient’s complaint of progressive lip swelling, along with her previous diagnosis of hereditary angioedema (HAE), suggests that she may be experiencing an allergic reaction. Angioedema can cause swelling in various parts of the body, including the lips, tongue, and throat. If the swelling progresses and affects the airway, it can lead to difficulty breathing and potentially block the airway completely. This can be a life-threatening emergency and requires immediate intervention to ensure the patient’s airway remains open and they can breathe properly.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

    • This question is part of the following fields:

      • Respiratory
      50.3
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  • Question 8 - You are evaluating a 68-year-old patient with a known history of COPD who...

    Incorrect

    • You are evaluating a 68-year-old patient with a known history of COPD who has come to the emergency department due to worsening shortness of breath and a cough producing green sputum. An arterial blood gas is obtained and the results are as follows:

      Parameter Result
      pH 7.31
      pO2 9.1 kPa
      pCO2 6.5 kPa
      Bicarbonate 32 mmol/l
      Base Excess +4

      The patient is given immediate doses of prednisone and amoxicillin, and nebulized salbutamol is administered. After one hour of treatment, a repeat blood gas is obtained with the patient receiving 40% inspired oxygen via venturi. The results are as follows:

      Parameter Result
      pH 7.27
      pO2 9.0 kPa
      pCO2 7.2 kPa
      Bicarbonate 33 mmol/l
      Base Excess +5

      Which of the following interventions would be the most appropriate to implement next?

      Your Answer: Atrovent nebuliser

      Correct Answer: Non-invasive ventilation

      Explanation:

      According to the brit-thoracic guidelines, if a patient with COPD continues to experience respiratory acidosis even after receiving standard medical therapy for one hour, it is recommended to consider using non-invasive ventilation (NIV). This is especially important if the patient’s hypoxia and hypercapnia are worsening despite the initial treatment.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      30.4
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  • Question 9 - A 23 year old male is brought to the emergency department (ED) by...

    Correct

    • A 23 year old male is brought to the emergency department (ED) by ambulance after being hit by a car while riding his bike. The patient appears restless. His vital signs are as follows:

      Blood Pressure: 86/54 mmHg
      Pulse Rate: 138 bpm
      Respiration Rate: 32 rpm
      SpO2: 94% on 15l oxygen

      During the examination, you observe tracheal deviation towards the left, absent breath sounds on the right side, and hyper-resonant percussion note on the right side.

      What is the probable diagnosis?

      Your Answer: Right sided tension pneumothorax

      Explanation:

      One of the clinical features of a tension pneumothorax is the deviation of the trachea away from the side where the pneumothorax is located. This particular feature is typically observed in cases of right-sided tension pneumothorax.

      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.

    • This question is part of the following fields:

      • Respiratory
      21.6
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  • Question 10 - You review a 30-year-old man who presents with an acute exacerbation of asthma...

    Incorrect

    • You review a 30-year-old man who presents with an acute exacerbation of asthma and consider ordering a chest X-ray.
      Which of the following is NOT a reason to perform a chest X-ray in the evaluation of acute asthma?

      Your Answer: Requirement of ventilation

      Correct Answer: Acute severe asthma

      Explanation:

      Chest X-rays are not typically recommended as a routine investigation for acute asthma. However, they may be necessary in specific situations. These situations include suspected pneumomediastinum or consolidation, as well as cases of life-threatening asthma. Additionally, if a patient fails to respond adequately to treatment or requires ventilation, a chest X-ray may be performed. It is important to note that these circumstances warrant the use of chest X-rays, but they are not routinely indicated for the investigation of acute asthma.

    • This question is part of the following fields:

      • Respiratory
      78.3
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  • Question 11 - A 4-year-old boy has been seen by one of your colleagues a few...

    Correct

    • A 4-year-old boy has been seen by one of your colleagues a few days earlier due to a persistent cough and fever that he has had for the past 10 days. The cough is a harsh, hacking cough and tends to occur in short bursts. Your colleague suspected a diagnosis of whooping cough and organized for a nasopharyngeal swab to be sent for culture.

      You review the child today with his parents having received notification from the lab that the child has a confirmed diagnosis of whooping cough. He lives with his parents and has a younger sister who is 2 years old. The mother is currently 36 weeks pregnant. The sister is up-to-date with all of her vaccinations as per the current US vaccination schedule.

      Which members of the household should receive chemoprophylaxis?

      Your Answer: The mother, father, and brother

      Explanation:

      Whooping cough is a respiratory infection caused by the bacteria Bordetella pertussis. It is highly contagious and spreads to about 90% of close household contacts. Public Health England (PHE) has identified two priority groups for managing whooping cough contacts. Group 1 includes infants under one year who have received less than three doses of the pertussis vaccine and are at risk of severe infection. Group 2 includes pregnant women at 32 weeks or more, healthcare workers dealing with infants and pregnant women, individuals working with unvaccinated infants under 4 months old, and individuals living with unvaccinated infants under 4 months old.

      According to current guidelines, antibiotic prophylaxis with a macrolide antibiotic like erythromycin should only be given to close contacts if the following criteria are met: the index case has had symptoms within the past 21 days and there is a close contact in one of the priority groups. If both criteria are met, all contacts, regardless of age and vaccination status, should be offered chemoprophylaxis. In this case, the mother falls into group 2, so the recommended action is to provide chemoprophylaxis to all household contacts, including the mother, father, and brother. Additionally, those who receive chemoprophylaxis should also consider immunization or a booster dose based on their current vaccination status.

    • This question is part of the following fields:

      • Respiratory
      174.1
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  • Question 12 - A 60-year-old retired factory worker presents with increasing shortness of breath and decreased...

    Incorrect

    • A 60-year-old retired factory worker presents with increasing shortness of breath and decreased ability to exercise. He smokes 15 cigarettes per day. During the examination, digital clubbing and fine bilateral basal crepitations are noted. A chest X-ray was recently performed and revealed pleural plaques and interstitial changes.
      What is the SINGLE most probable diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Correct Answer: Asbestosis

      Explanation:

      This patient’s medical history and physical examination findings are indicative of a diagnosis of asbestosis. Additionally, the patient exhibits characteristics consistent with interstitial lung disease that has developed as a result of the asbestosis.

      Exposure to asbestos was prevalent in various professions, particularly during the 1970s and earlier. Occupations commonly associated with asbestos exposure include shipyard workers, builders, miners, and pipefitters.

      It is important to consider the possibility of mesothelioma in individuals who have been exposed to asbestos. This should be suspected if the patient presents with constitutional symptoms such as weight loss, fatigue, and loss of appetite, along with the presence of thickening of the pleura and/or accumulation of fluid in the pleural space.

    • This question is part of the following fields:

      • Respiratory
      19.9
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  • Question 13 - You are managing a 65-year-old patient who has presented with confusion, shortness of...

    Correct

    • You are managing a 65-year-old patient who has presented with confusion, shortness of breath, and a productive cough. A diagnosis of pneumonia and sepsis is made. You ask the nurse to administer oxygen to the patient. What target parameter would you use to guide oxygen therapy in this patient who does not have a known history of respiratory disease?

      Your Answer: SpO2 >94%

      Explanation:

      In this case, the most appropriate target parameter to guide oxygen therapy would be an SpO2 (oxygen saturation) level of greater than 94%.

      Further Reading:

      There are multiple definitions of sepsis, leading to confusion among healthcare professionals. The Sepsis 3 definition describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sepsis 2 definition includes infection plus two or more SIRS criteria. The NICE definition states that sepsis is a clinical syndrome triggered by the presence of infection in the blood, activating the body’s immune and coagulation systems. The Sepsis Trust defines sepsis as a dysregulated host response to infection mediated by the immune system, resulting in organ dysfunction, shock, and potentially death.

      The confusion surrounding sepsis terminology is further compounded by the different versions of sepsis definitions, known as Sepsis 1, Sepsis 2, and Sepsis 3. The UK organizations RCEM and NICE have not fully adopted the changes introduced in Sepsis 3, causing additional confusion. While Sepsis 3 introduces the use of SOFA scores and abandons SIRS criteria, NICE and the Sepsis Trust have rejected the use of SOFA scores and continue to rely on SIRS criteria. This discrepancy creates challenges for emergency department doctors in both exams and daily clinical practice.

      To provide some clarity, RCEM now recommends referring to national standards organizations such as NICE, SIGN, BTS, or others relevant to the area. The Sepsis Trust, in collaboration with RCEM and NICE, has published a toolkit that serves as a definitive reference point for sepsis management based on the sepsis 3 update.

      There is a consensus internationally that the terms SIRS and severe sepsis are outdated and should be abandoned. Instead, the terms sepsis and septic shock should be used. NICE defines septic shock as a life-threatening condition characterized by low blood pressure despite adequate fluid replacement and organ dysfunction or failure. Sepsis 3 defines septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, along with a serum lactate level greater than 2 mmol/l despite adequate volume resuscitation.

      NICE encourages clinicians to adopt an approach of considering sepsis in all patients, rather than relying solely on strict definitions. Early warning or flag systems can help identify patients with possible sepsis.

    • This question is part of the following fields:

      • Respiratory
      19.9
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  • Question 14 - A 30 year old patient is brought to the emergency department by bystanders...

    Incorrect

    • A 30 year old patient is brought to the emergency department by bystanders after a hit and run incident. Upon examination, you observe that the patient is experiencing difficulty breathing and has tracheal deviation towards the left side. Based on these findings, you suspect the presence of a tension pneumothorax. What signs would you anticipate observing in this patient?

      Your Answer: Absent breath sounds on left side

      Correct Answer: Elevated jugular venous pressure

      Explanation:

      Tension pneumothorax is a condition characterized by certain clinical signs. These signs include pulsus paradoxus, which is an abnormal decrease in blood pressure during inspiration; elevated JVP or distended neck veins; diaphoresis or excessive sweating; and cyanosis, which is a bluish discoloration of the skin. Tracheal deviation to the left is often observed in patients with a right-sided pneumothorax. On the affected side, hyper-resonance and absent breath sounds can be expected. Patients with tension pneumothorax typically appear agitated and distressed, and they experience noticeable difficulty in breathing. Hypotension, a pulse rate exceeding 135 bpm, pulsus paradoxus, and elevated JVP are additional signs associated with tension pneumothorax. These signs occur because the expanding pneumothorax compresses the mediastinum, leading to impaired venous return and cardiac output.

      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
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  • Question 15 - A 6-month-old infant is brought to the Emergency Department with a high fever...

    Correct

    • A 6-month-old infant is brought to the Emergency Department with a high fever and difficulty breathing. You assess the infant's respiratory rate and observe that it is increased.
      As per the NICE guidelines, what is considered the cutoff for tachypnea in an infant of this age?

      Your Answer: RR >60 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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      • Respiratory
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  • Question 16 - A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting,...

    Incorrect

    • A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting, fatigue, and fainting. He has recently returned from a wellness retreat in France. The patient is referred to the medical team on duty and admitted to the hospital. They suspect a potential diagnosis of Legionnaires' disease.
      What is the definitive test used to confirm a case of Legionnaires' disease?

      Your Answer: Four-fold increase in titre of indirect immunofluorescent antibody test

      Correct Answer: Isolation and culture from a sputum sample

      Explanation:

      The guidelines from the British Thoracic Society (BTS) recommend conducting investigations for Legionella infection in the following cases: severe community-acquired pneumonia, patients with specific risk factors, and during outbreaks of community-acquired pneumonia. To confirm a case, the Public Health England (PHE) requires one of the following: isolation and culture of Legionella species from clinical specimens (typically sputum), seroconversion with a four-fold increase in titre of indirect immunofluorescent antibody test (IFAT) using a validated technique, or confirmation of Legionella pneumophila urinary antigen using validated reagents or kits. The gold standard for confirmation is the isolation and culture of Legionella species, while cases of Pontiac fever are usually culture-negative. The HPA considers a case presumptive if there is a clinical diagnosis of pneumonia with a single high titre of 128 using IFAT, or a single titre of 64 in an outbreak. A positive result by direct immunofluorescence on a clinical specimen using validated monoclonal antibodies is also considered a presumptive case.

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      • Respiratory
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  • Question 17 - A 30-year-old woman comes in with a persistent cough and wheezing.
    Which ONE...

    Incorrect

    • A 30-year-old woman comes in with a persistent cough and wheezing.
      Which ONE clinical characteristic would indicate a possible diagnosis of severe acute asthma?

      Your Answer: Silent chest

      Correct Answer: Heart rate of 115 bpm

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

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      • Respiratory
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  • Question 18 - A 35-year-old woman presents with a two-week history of a persistent cough that...

    Incorrect

    • A 35-year-old woman presents with a two-week history of a persistent cough that has now started to produce a small amount of sputum. She is also experiencing muscle aches, fatigue, headaches, and has had diarrhea for the past three days. Her vital signs are as follows: temperature 37.8°C, heart rate 88, blood pressure 120/80, respiratory rate 20, oxygen saturation 99% on room air. Upon examination, she has crackling sounds heard on the left side of her chest. A chest X-ray reveals consolidation in the left lower lobe.

      What is the MOST appropriate course of action for management?

      Your Answer: No treatment is required in this case

      Correct Answer: Clarithromycin 500 mg PO BD for 14 days

      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 of Mycoplasma pneumoniae infection typically include a flu-like illness that precedes respiratory symptoms, along with fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs may develop later in the illness. Interestingly, the X-ray features of the pneumonia are often more noticeable than the severity of the chest symptoms.

      Treatment for Mycoplasma pneumoniae infection can involve the use of macrolides, such as clarithromycin, or tetracyclines, such as doxycycline. The recommended minimum treatment period is 10-14 days, making clarithromycin a preferable option over doxycycline in this particular case.

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      • Respiratory
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  • Question 19 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Correct

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After evaluating him, you determine that he has community-acquired pneumonia. He has no significant medical history but has a known allergy to penicillin.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer: Clarithromycin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

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      • Respiratory
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  • Question 20 - You evaluate a 9-year-old boy with a high temperature and a persistent, forceful...

    Correct

    • You evaluate a 9-year-old boy with a high temperature and a persistent, forceful cough for the past two weeks. A nasopharyngeal swab has been collected and has tested positive for Bordetella pertussis. You initiate a course of antibiotics. The parents of the child would like to know the duration for which he should stay home from school after starting antibiotic treatment for this infection.

      Your Answer: 48 hours

      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 highly contagious disease can be passed on to around 90% of close household contacts.

      To prevent the spread of whooping cough, Public Health England advises that children with the illness should stay away from school, nursery, or childminders for 48 hours after starting antibiotic treatment. If no antibiotic treatment is given, they should be kept away for 21 days from the onset of the illness. It’s important to note that even after treatment, non-infectious coughing may persist for several weeks.

      For more information on how to control infections in schools and other childcare settings, you can refer to the guidance provided by Public Health England.

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      • Respiratory
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  • Question 21 - A 72 year old male with a history of COPD is brought into...

    Correct

    • A 72 year old male with a history of COPD is brought into the emergency department due to worsening shortness of breath. You observe that the patient has been utilizing home oxygen, home salbutamol and ipratropium nebulizers, and began taking a rescue pack of antibiotics and steroids yesterday.

      Which of the following factors would indicate the initiation of BiPAP ventilation?

      Your Answer: pH less than 7.35 on arterial blood gas

      Explanation:

      Non-invasive ventilation is recommended for patients with hypercapnia and acidosis. Respiratory acidosis, indicated by a pH level below 7.35, is a strong indication for the use of BiPAP. However, patients with a pH level of 7.25 or lower may not respond well to non-invasive ventilation and should be considered for intensive care unit (ITU) treatment. Another criterion for the use of BiPAP is hypercapnia, which is characterized by an arterial pCO2 level greater than 6.0 KPa.

      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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  • Question 22 - You are caring for a hypoxic patient in the resuscitation bay. One of...

    Correct

    • You are caring for a hypoxic patient in the resuscitation bay. One of the potential diagnoses is methemoglobinemia. What test would you employ to confirm this diagnosis?

      Your Answer: MetHb

      Explanation:

      COHb is a measure used to evaluate the presence of carbon monoxide poisoning in individuals who are in good health. hHb refers to deoxygenated haemoglobin.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

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      • Respiratory
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  • Question 23 - A 30-year-old man comes in with a cough and wheezing.
    What ONE clinical...

    Incorrect

    • A 30-year-old man comes in with a cough and wheezing.
      What ONE clinical feature would indicate a potential diagnosis of severe asthma?

      Your Answer: Heart rate of 120 bpm

      Correct Answer: Normal PaCO2

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

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      • Respiratory
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  • Question 24 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Incorrect

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After conducting a clinical evaluation, you determine that he has community-acquired pneumonia. He has no significant medical history and no reported drug allergies.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer: Erythromycin

      Correct Answer: Amoxicillin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

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      • Respiratory
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  • Question 25 - A 32-year-old woman comes in with a history of worsening wheezing for the...

    Incorrect

    • A 32-year-old woman comes in with a history of worsening wheezing for the past two days. She has a history of seasonal allergies in the summer months, which have been more severe than usual in recent weeks. On auscultation of her chest, scattered polyphonic wheezes are heard. Her peak flow at presentation is 275 L/min, and her personal best peak flow is 500 L/min.
      How would you categorize this asthma episode?

      Your Answer: Acute severe asthma

      Correct Answer: Moderate asthma

      Explanation:

      This man is experiencing an acute asthma episode. His initial peak flow is 55% of his best, indicating a moderate exacerbation according to the BTS guidelines. Acute asthma can be classified as moderate, acute severe, life-threatening, or near-fatal.

      Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the individual’s best or predicted value. There are no signs of acute severe asthma in this case.

      Acute severe asthma is identified by any one of the following criteria: a PEFR between 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, or the inability to complete sentences in one breath.

      Life-threatening asthma is indicated by any one of the following: a PEFR below 33% of the best or predicted value, oxygen saturation (SpO2) below 92%, arterial oxygen pressure (PaO2) below 8 kPa, normal arterial carbon dioxide pressure (PaCO2) between 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension.

      Near-fatal asthma is characterized by elevated PaCO2 levels and/or the need for mechanical ventilation with increased inflation pressures.

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      • Respiratory
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  • Question 26 - A 72-year-old man presents with a severe exacerbation of his COPD. He has...

    Incorrect

    • A 72-year-old man presents with a severe exacerbation of his COPD. He has been given a loading dose of aminophylline and you now intend to establish a maintenance infusion. He weighs 70 kg.
      What is the appropriate maintenance infusion rate for him?

      Your Answer: 20 mg/hour

      Correct Answer: 25 mg/hour

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a 50 kg individual, the appropriate infusion rate would be 25 mg/hour. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

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  • Question 27 - A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has...

    Incorrect

    • A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has been feeling extremely tired and has been experiencing worsening nausea over the past few days. She also complains of intermittent chest pain. The patient mentions that her urine has been dark in color. She has no significant medical history and smokes 10 cigarettes per day. On examination, she appears pale and has inspiratory crackles at both bases. Her blood pressure is elevated at 175/94 mmHg. Urinalysis reveals proteinuria and microscopic haematuria.

      Her blood results today are as follows:
      Hb 8.4 g/dl (13-17 g/dl)
      MCV 69 fl (76-96 fl)
      WCC 21.5 x 109/l (4-11 x 109/l)
      Neutrophils 17.2 x 109/l (2.5-7.5 x 109/l)
      Na 134 mmol/l (133-147 mmol/l)
      K 4.2 mmol/l (3.5-5.0 mmol/l)
      Creat 232 micromol/l (60-120 micromol/l)
      Urea 12.8 mmol/l (2.5-7.5 mmol/l)

      Which SINGLE investigation will confirm the diagnosis in this case?

      Your Answer: Renal ultrasound scan

      Correct Answer: Renal biopsy

      Explanation:

      The most probable diagnosis in this situation is Goodpasture’s syndrome, a rare autoimmune vasculitic disorder characterized by three main symptoms: pulmonary hemorrhage, glomerulonephritis, and the presence of anti-glomerular basement membrane (Anti-GBM) antibodies. Goodpasture’s syndrome is more prevalent in men, particularly in smokers. It is also associated with HLA-B7 and HLA-DRw2.

      The clinical manifestations of Goodpasture’s syndrome include constitutional symptoms like fever, fatigue, nausea, and weight loss. Patients may also experience hemoptysis or pulmonary hemorrhage, chest pain, breathlessness, and inspiratory crackles at the lung bases. Anemia due to bleeding within the lungs, arthralgia, rapidly progressive glomerulonephritis, hematuria, hypertension, and rarely hepatosplenomegaly may also be present.

      Blood tests will reveal iron deficiency anemia, an elevated white cell count, and renal impairment. Elisa for Anti-GBM antibodies is highly sensitive and specific, but it is not widely available. Approximately 30% of patients may also have circulating antineutrophilic cytoplasmic antibodies (ANCAs), although these are not specific for Goodpasture’s syndrome and can be found in other conditions such as Wegener’s granulomatosis, which also cause renal impairment and pulmonary hemorrhage.

      Diagnosis is typically confirmed through a renal biopsy, which can detect the presence of anti-GBM antibodies. This would be the most appropriate investigation to confirm the diagnosis in this case.

      The management of Goodpasture’s syndrome involves a combination of plasmapheresis to remove circulating antibodies and the use of corticosteroids or cyclophosphamide.

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  • Question 28 - You evaluate a 47-year-old man with a history of increasing shortness of breath...

    Incorrect

    • You evaluate a 47-year-old man with a history of increasing shortness of breath and a persistent dry cough. He has a smoking history of 25 pack-years.
      The recent lung function test findings are as follows:
      FEV1/FVC ratio = 85% predicted
      FVC = 60% predicted
      What is the MOST LIKELY diagnosis in this case?

      Your Answer: Chronic obstructive pulmonary disease (COPD)

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      This patient has a history of worsening breathlessness and lung function tests that show a pattern of restrictive lung disease. In restrictive lung disease, the ratio of FEV1 to FVC is usually normal, around 70% predicted, but the FVC is reduced to less than 80% predicted. Both the FVC and FEV1 can be reduced in this condition. The ratio can also be higher if the FVC is reduced to a greater extent. Out of the options provided, only idiopathic pulmonary fibrosis can cause a restrictive lung disease pattern. Smoking is a risk factor for developing idiopathic pulmonary fibrosis, especially if the person has smoked more than 20 packs of cigarettes per year.

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      • Respiratory
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  • Question 29 - A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty...

    Incorrect

    • A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the bird exhibit. During the examination, a reddish macular rash is observed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.

      What is the specific name of the rash on his face that is associated with this condition?

      Your Answer: Malar flush

      Correct Answer: Horder’s spots

      Explanation:

      Psittacosis is a type of infection that can be transmitted from animals to humans, caused by a bacterium called Chlamydia psittaci. It is most commonly seen in people who own domestic birds, as well as those who work in pet shops or zoos. The typical symptoms of psittacosis include pneumonia that is acquired within the community, along with flu-like symptoms. Many patients also experience severe headaches and sensitivity to light. Enlargement of the spleen is a common finding in about two-thirds of individuals with this infection.

      Infected individuals often develop a rash on their face, known as Horder’s spots, which appear as reddish macules. In some cases, erythema nodosum and erythema multiforme may also occur. The recommended treatment for psittacosis is a course of tetracycline or doxycycline for a period of 2-3 weeks.

      On the other hand, rose spots are typically observed in cases of typhoid fever. These spots have a similar appearance to Horder’s spots but are usually found on the trunk rather than the face. Erythema marginatum is a pale red rash seen in rheumatic fever, while malar flush, also known as ‘mitral facies’, refers to the reddish discoloration of the cheeks commonly seen in individuals with mitral stenosis. Lastly, erythema chronicum migrans is the distinctive rash seen in Lyme disease, characterized by a circular rash with a central ‘bulls-eye’ appearance that spreads outward from the site of a tick bite.

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  • Question 30 - A 35-year-old man who resides in a Traveller community comes in with a...

    Incorrect

    • A 35-year-old man who resides in a Traveller community comes in with a severe paroxysmal cough and a fever that has persisted for the last 10 days. He reports not having received any vaccinations. A nasopharyngeal swab for pertussis comes back positive. He is currently 18 weeks into his wife's pregnancy.
      What is the most suitable initial antibiotic to prescribe?

      Your Answer: Amoxicillin

      Correct Answer: Erythromycin

      Explanation:

      Pertussis, also known as whooping cough, is a respiratory infection caused by the bacteria Bordetella pertussis. Despite being a bacterial disease, antibiotics do not change the course of the illness once it has taken hold. However, macrolide antibiotics have been proven to shorten the period of contagiousness. Therefore, it is important to administer antibiotics as soon as possible after the onset of symptoms to eliminate the bacteria and reduce further transmission. It is crucial to start antibiotics within three weeks of symptom onset, as they do not affect the progression of the illness or the contagious period.

      First-line treatment for pertussis includes macrolide antibiotics. For babies under one month old, clarithromycin is recommended. For children one month and older, as well as non-pregnant adults, azithromycin or clarithromycin are the preferred options. Pregnant women should be treated with erythromycin. In cases where macrolides are not suitable or well-tolerated, co-trimoxazole can be used off-label.

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  • Question 31 - A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Correct

    • A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Brazil. 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.
      Which of the following tests should be ordered?

      Your Answer: Doppler ultrasound scan of leg

      Explanation:

      Based on the clinical history and examination, it strongly indicates that the patient may have a pulmonary embolism caused by a deep vein thrombosis in his right leg. To confirm this, it is recommended that he undergoes a CT pulmonary angiogram and doppler ultrasound scan of his right leg.

      The typical symptoms of a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. Additionally, there may be symptoms suggesting the presence of a deep vein thrombosis. Other signs to look out for 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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  • Question 32 - A 62-year-old woman presents with a persistent cough that has been ongoing for...

    Incorrect

    • A 62-year-old woman presents with a persistent cough that has been ongoing for several months. She reports that the cough occasionally produces a small amount of phlegm, especially in the morning. She has experienced a significant weight loss of 28 pounds over the past six months and constantly feels fatigued. Even with minimal physical activity, she becomes short of breath. She has no significant medical history and is a non-smoker. She enjoys keeping and racing pigeons as a hobby. Upon examination, bilateral fine end-inspiratory crackles are heard.

      What is the SINGLE most likely diagnosis?

      Your Answer: Bronchiectasis

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

      This patient is likely to have pigeon fancier’s lung, which is a type of extrinsic allergic alveolitis (EAA) caused by chronic exposure to avian antigens found in bird droppings. This condition leads to hypersensitivity pneumonitis and the formation of granulomas in the lungs.

      While his presentation could also be consistent with idiopathic pulmonary fibrosis, the fact that he keeps and races pigeons makes EAA more likely in this case.

      EAA can manifest as either an acute or chronic condition. The acute form typically presents with flu-like symptoms such as fever, cough, chest tightness, and breathlessness occurring 4 to 6 hours after exposure.

      The clinical features of chronic pigeon fancier’s lung include a productive cough, progressive breathlessness, weight loss, anorexia, fatigue, and malaise.

      Other forms of EAA include farmer’s lung (caused by exposure to Saccharopolyspora rectivirgula from wet hay), malt-worker’s lung (caused by exposure to Aspergillus clavatus from moldy malt), cheese-worker’s lung (caused by exposure to Penicillium casei from moldy cheese), chemical worker’s lung (caused by exposure to trimetallic anhydride, diisocyanate, and methylene diisocyanate), mushroom worker’s lung (caused by exposure to thermophilic actinomycetes in mushroom compost), and hot tub lung (caused by exposure to Mycobacterium avium from poorly maintained hot tubs).

    • This question is part of the following fields:

      • Respiratory
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  • Question 33 - A 60-year-old woman comes in with a cough producing green sputum that has...

    Incorrect

    • A 60-year-old woman comes in with a cough producing green sputum that has been ongoing for the past two days. During the examination, she has a fever, with a temperature of 38.0°C, and exhibits coarse crackles in the lower right lung on chest examination.

      What is the MOST LIKELY single causative organism?

      Your Answer: Klebsiella pneumoniae

      Correct Answer: Streptococcus pneumoniae

      Explanation:

      This patient is displaying symptoms and signs that are in line with community-acquired pneumonia (CAP). The most frequent cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

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      • Respiratory
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  • Question 34 - You are managing a 72-year-old male patient who has been intubated as a...

    Incorrect

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What is one of the four diagnostic criteria for ARDS?

      Your Answer: pCO2 > 9.0 KPa

      Correct Answer: Presence of hypoxaemia

      Explanation:

      One of the diagnostic criteria for ARDS is the presence of hypoxemia. Other criteria include the onset of symptoms within 7 days of a clinical insult or new/worsening respiratory symptoms, bilateral opacities on chest X-ray that cannot be fully explained by other conditions, and respiratory failure that cannot be fully attributed to cardiac failure or fluid overload.

      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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      • Respiratory
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  • Question 35 - A 72 year old male presents to the emergency department complaining of shortness...

    Correct

    • A 72 year old male presents to the emergency department complaining of shortness of breath. The patient has had a tracheostomy for several years after being on a ventilator for an extended period of time due to a severe head injury. You provide high flow oxygen and remove the inner tube of the tracheostomy. However, there is no improvement in the patient's condition. What would be the most suitable course of action for managing this patient?

      Your Answer: Pass suction catheter

      Explanation:

      If a patient with breathing difficulty does not show improvement after removing the inner tracheostomy tube, it is recommended to use a suction catheter to remove any secretions. This can help clear any blockage caused by secretions or debris in or near the tube. If this does not improve the situation, the next step would be to deflate the cuff. If deflating the cuff stabilizes or improves the patient’s condition, it suggests that air can flow around the tube within the airway, indicating that the tracheostomy tube may be obstructed or displaced.

      Further Reading:

      Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

      When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

      Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

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      • Respiratory
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  • Question 36 - A toddler is brought to the hospital with bronchiolitis because of low oxygen...

    Incorrect

    • A toddler is brought to the hospital with bronchiolitis because of low oxygen levels and difficulty with eating.
      What is the MOST suitable treatment option?

      Your Answer: Hypertonic saline nebuliser

      Correct Answer: Nasogastric feeding

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute 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 certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      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 in the management of bronchiolitis.

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      • Respiratory
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  • Question 37 - A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling...

    Incorrect

    • A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling in her arms and hands. Upon examination, you observe that her face is also swollen and she has multiple enlarged veins and telangiectasia on her chest. She has a history of long-term smoking.

      What is the SINGLE most probable diagnosis?

      Your Answer: Cushing syndrome

      Correct Answer: Superior vena cava syndrome

      Explanation:

      This patient has come in with worsening shortness of breath and coughing up blood. They have a long history of smoking, and the likely diagnosis is superior vena cava obstruction caused by a primary bronchial tumor.

      The typical symptoms of superior vena cava obstruction include breathlessness, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

      Given the severity of the symptoms, this man needs to be urgently referred and admitted to the hospital. To provide immediate relief, his head should be elevated and he should be given supplemental oxygen. Corticosteroids and diuretics may also be administered. Further investigation through CT scanning is necessary, and radiotherapy may be recommended as a treatment option.

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      • Respiratory
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  • Question 38 - A 6-year-old girl is brought in by her parents with wheezing and difficulty...

    Incorrect

    • A 6-year-old girl is brought in by her parents with wheezing and difficulty breathing. Over the past few days, she has been feeling sick and has had a decreased appetite. Her parents have noticed that she seems to struggle with breathing, especially when she is playing or exerting herself. Her oxygen levels are at 90% on room air, but all her other vital signs are normal. A chest X-ray is taken, which is shows left lung appears overinflated and hyperlucent, with concomitant rib flaring and a depressed ipsilateral hemidiaphragm. What is the MOST likely diagnosis for this patient?

      Your Answer: Lower respiratory tract infection

      Correct Answer: Inhaled foreign body

      Explanation:

      This child’s medical history and chest X-ray findings are indicative of an inhaled foreign object. Upon careful examination, it is evident that the left lung appears more transparent than the right lung, and the foreign body is lodged in the left tracheobronchial tree.

      Airway foreign bodies in children can be life-threatening, and it is important to consider this diagnosis when young children experience unexplained difficulty breathing and wheezing. Unfortunately, there is often a delay in diagnosing this condition.

      Foreign objects typically get stuck in the right tracheobronchial tree because the right main bronchus is wider, shorter, and more vertically positioned compared to the left main bronchus. However, they can become lodged anywhere in the tracheobronchial tree.

      While there is often a history of choking prior to the symptoms, this is not always the case. Any history of running with objects in the mouth or being in close proximity to small objects that can be placed in the mouth can provide important clues. In the absence of a choking history, clinical features may include paroxysmal coughing, unexplained difficulty breathing, changes in voice, poor appetite, irritability, decreased breath sounds on one side, and localized wheezing.

      To aid in diagnosis, a chest X-ray should be taken during expiration as it can accentuate any differences between the two lungs. The following findings may be observed: the normal lung may appear smaller and denser than the affected lung, the affected lung may appear excessively transparent and overinflated, and a radio-opaque foreign object may be visible. However, it is important to note that approximately 35% of patients may have a normal chest X-ray.

      Bronchoscopy is considered the gold-standard test for diagnosing tracheobronchial foreign bodies. This procedure not only confirms the presence of a foreign object but also allows for potential retrieval.

      Possible complications of this condition include pneumonia, atelectasis (collapsed lung), bronchospasm (constriction of the airways), pneumothorax (collapsed lung due to air leakage), broncho-oesophageal fistula (abnormal connection between the bronchial tubes and the esophagus), and bronchiectasis (permanent dilation of the bronchial tubes).

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      • Respiratory
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  • Question 39 - A 32-year-old woman presents with a history of increased wheezing over the past...

    Incorrect

    • A 32-year-old woman presents with a history of increased wheezing over the past two days. She suffers from seasonal allergies in the spring months, which has been worse than usual over recent weeks. When auscultating her chest, you can hear scattered polyphonic wheezes. Her peak flow at presentation was 275 L/min, and her best ever peak flow is 500 L/min. After a single salbutamol nebulizer, her peak flow improves to 455 L/min, and she feels much better.
      Which of the following drug treatments should be administered next?

      Your Answer: IV aminophylline

      Correct Answer: Oral prednisolone

      Explanation:

      This individual has presented with an episode of acute asthma. Upon assessment, his initial peak flow is measured at 55% of his personal best, indicating a moderate exacerbation. In such cases, it is recommended to administer steroids, with a suggested dose of prednisolone 40-50 mg taken orally as the initial management step.

      Currently, the use of nebulized magnesium sulfate is not recommended for the treatment of acute asthma in adults. However, according to the current ALS guidelines, in severe or life-threatening asthma cases, IV aminophylline can be considered after seeking 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.

      In situations where inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation, IV salbutamol can be considered at a slow dose of 250 mcg. However, it should be noted that there is currently no evidence supporting the use of leukotriene receptor antagonists, like montelukast, in the management of acute asthma.

      The BTS guidelines classify acute asthma into four categories: moderate, acute severe, life-threatening, and near-fatal. Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the individual’s best or predicted value, with no features of acute severe asthma. Acute severe asthma is identified by a PEFR of 33-50% of the best or predicted value, along with respiratory rate >25/min, heart rate >110/min, or the inability to complete sentences in one breath.

      Life-threatening asthma is indicated by a PEFR <33% of the best or predicted value, SpO2 <92%, PaO2 <8 kPa, normal PaCO2 (4.6-6.0 kPa), and additional symptoms such as silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension. Near-fatal asthma is characterized by raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures.

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      • Respiratory
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  • Question 40 - A 45-year-old woman returns from a recent vacation on a cruise ship with...

    Incorrect

    • A 45-year-old woman returns from a recent vacation on a cruise ship with a persistent cough and a high temperature. Today she has also experienced frequent episodes of diarrhea and has developed sharp chest pain on both sides. She reports feeling short of breath, especially when she exerts herself. The cruise ship doctor had prescribed her amoxicillin a few days ago, but she has not seen any improvement.
      Her blood test results today are as follows:
      Hemoglobin (Hb): 14.4 g/dl (normal range: 13-17 g/dl)
      White blood cell count (WCC): 13.5 x 109/l (normal range: 4-11 x 109/l)
      Neutrophils: 10.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      Lymphocytes: 0.6 x 109/l (normal range: 1.3-3.5 x 109/l)
      Eosinophils: 0.35 x 109/l (normal range: 0.04-0.44 x 109/l)
      C-reactive protein (CRP): 87 mg/l (normal range: <5 mg/l)
      Sodium (Na): 122 mmol/l (normal range: 133-147 mmol/l)
      Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      Creatinine (Creat): 112 micromol/l (normal range: 60-120 micromol/l)
      Urea: 6.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      What is the SINGLE most likely causative organism?

      Your Answer: Mycoplasma pneumoniae

      Correct Answer: Legionella pneumophila

      Explanation:

      Legionella pneumophila is a type of Gram-negative bacterium that can be found in natural water supplies and soil. It is responsible for causing Legionnaires’ disease, a serious illness. Outbreaks of this disease have been associated with poorly maintained air conditioning systems, whirlpool spas, and hot tubs. In the past, there have been instances of Legionnaires’ disease outbreaks on cruise ships due to inadequate maintenance of air conditioning and shower units.

      The pneumonic form of Legionnaires’ disease presents with certain clinical features. Initially, there may be a mild flu-like prodrome lasting for 1-3 days. A persistent cough, which is usually non-productive and occurs in approximately 90% of cases, is also common. Other symptoms include pleuritic chest pain, haemoptysis, headache, nausea, vomiting, diarrhoea, and anorexia. Additionally, some individuals may experience a condition called syndrome of inappropriate antidiuretic hormone secretion (SIADH), which can lead to hyponatraemia.

      It is important to note that infections caused by Legionella pneumophila are resistant to amoxicillin. However, they can be effectively treated with macrolide antibiotics like erythromycin or quinolones such as ciprofloxacin. Tetracyclines, including doxycycline, can also be used for treatment.

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  • Question 41 - A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
    Which...

    Incorrect

    • A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
      Which of the following drug doses used in the treatment of acute adult asthma is incorrect?

      Your Answer: Hydrocortisone 100 mg IV

      Correct Answer: Terbutaline 5mg via oxygen-driven nebuliser

      Explanation:

      The recommended drug doses for adult acute asthma are as follows:

      – Salbutamol: Administer 5 mg using an oxygen-driven nebulizer.
      – Ipratropium bromide: Deliver 500 mcg via an oxygen-driven nebulizer.
      – Prednisolone: Take orally at a dose of 40-50 mg.
      – Hydrocortisone: Administer 100 mg intravenously.
      – Magnesium sulphate: Infuse 1.2-2 g intravenously over a period of 20 minutes.

      Terbutaline can be used as an alternative to salbutamol, with a dose of 10 mg via an oxygen-driven nebulizer. Intravenous salbutamol may be considered (250 mcg IV 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 may be considered in 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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  • Question 42 - A 3-year-old boy is brought in by his parents with a history of...

    Incorrect

    • A 3-year-old boy is brought in by his parents with a history of breathing difficulties, fever, and a cough. He is irritable and having difficulty eating. On examination, his temperature is 38.6°C, and you hear fine inspiratory crackles throughout his chest.

      What is the SINGLE most appropriate investigation?

      Your Answer: Arterial blood gas

      Correct Answer: Nasopharyngeal aspirate

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute 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 certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      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 in the management of bronchiolitis.

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      • Respiratory
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  • Question 43 - You assess a patient who complained of chest discomfort and difficulty breathing. Upon...

    Incorrect

    • You assess a patient who complained of chest discomfort and difficulty breathing. Upon examination, it is determined that the patient has developed a spontaneous pneumothorax on the right side, and an unsuccessful pleural aspiration was attempted. The pneumothorax remains significant in size, and the patient continues to experience breathlessness. A Seldinger chest tube is inserted, but shortly after, it begins to drain bright red blood.

      Which complication is the most probable cause of this occurrence?

      Your Answer: Liver laceration

      Correct Answer: Intercostal artery laceration

      Explanation:

      Intercostal artery laceration during the insertion of a chest drain is a potentially life-threatening complication. Although rare, it occurs more frequently than other complications mentioned. To minimize the risk of damage to underlying structures and unsightly scarring, the British Thoracic Society (BTS) recommends inserting chest drains within the safe triangle. This triangle is defined by the base of the axilla, the lateral border of the latissimus dorsi, the lateral border of the pectoralis major, and the 5th intercostal space.

      Possible complications associated with the insertion of small-bore chest drains include puncture of the intercostal artery, organ perforation due to over-introduction of the dilator into the chest cavity, hospital-acquired pleural infection from non-aseptic techniques, inadequate stay suture leading to the chest tube falling out, and tube blockage, which may be more common with smaller bore Argyle drains.

      When using an intercostal approach, it is important to place the chest drain closer to the superior border of the rib below in the intercostal space. This positioning helps avoid injury to the intercostal neurovascular bundle located under the costal groove of the rib above.

      For more information, refer to the British Thoracic Society pleural disease guidelines.

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  • Question 44 - A 30 year old female is brought into the emergency department in a...

    Correct

    • A 30 year old female is brought into the emergency department in a comatose state. After initial investigations, it is determined that mechanical ventilation should be initiated. What is a characteristic of a lung protective ventilation approach?

      Your Answer: Permissible hypercapnia

      Explanation:

      Lung protective ventilation is a strategy that involves using smaller amounts of air during each breath (low tidal volumes) and restricting the maximum pressure applied during inhalation (plateau pressure). This approach also allows for a certain level of increased carbon dioxide levels in the body (hypercapnia).

      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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  • Question 45 - A 57-year-old man comes in with a fever, difficulty breathing, and a cough...

    Incorrect

    • A 57-year-old man comes in with a fever, difficulty breathing, and a cough with phlegm. During the examination, you notice crackling sounds in his lower left lung. You diagnose him with community-acquired pneumonia.
      Which of the following statements is accurate about the CURB-65 scoring system?

      Your Answer: A heart rate of 114 bpm scores 1 point

      Correct Answer: A serum urea of 7.5 mmol/l scores 1 point

      Explanation:

      The CURB criteria, also referred to as the CURB-65 criteria, is a clinical prediction rule that has been scientifically proven to predict mortality in cases of community-acquired pneumonia. These criteria consist of five factors: confusion of new onset (AMTS <8), urea level greater than 7 mmol/l, respiratory rate exceeding 30 per minute, blood pressure below 90 mmHg systolic or 60 mmHg diastolic, and age over 65 years. Based on the score obtained from these criteria, the risk level can be determined. A score of 0-1 indicates a low-risk situation, where outpatient treatment is recommended. A score of 2-3 suggests a moderate risk, and either inpatient treatment or an ambulatory care pathway is recommended. A score of 4-5 indicates a high risk, requiring hospitalization and potentially critical care involvement.

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  • Question 46 - A 14-month-old boy presents with a history of occasional wheezing and cough, which...

    Correct

    • A 14-month-old boy presents with a history of occasional wheezing and cough, which worsens at night. He recently had a cold and appears congested today. His mother reports that he often wheezes after a cold, and this can persist for several weeks after the infection has resolved. Both parents smoke, but his mother is trying to reduce her smoking, and neither parent smokes inside the house. There is no family history of asthma or allergies. Another doctor recently prescribed inhalers, but they have had little effect. On examination, he has a slight fever of 37.8°C, and there are scattered audible wheezes heard during chest examination.

      What is the SINGLE most likely diagnosis?

      Your Answer: Viral induced wheeze

      Explanation:

      Viral induced wheeze is a common condition in childhood that is triggered by a viral infection, typically a cold. The wheezing occurs during the infection and can persist for several weeks after the infection has cleared. This condition is most commonly seen in children under the age of three, as their airways are smaller. It is also more prevalent in babies who were small for their gestational age and in children whose parents smoke. It is important to note that viral induced wheeze does not necessarily mean that the child has asthma, although a small percentage of children with this condition may go on to develop asthma. Asthma is more commonly seen in children with a family history of asthma or allergies. Inhalers are often prescribed for the management of viral induced wheeze, but they may not always be effective.

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  • Question 47 - You are treating a 45-year-old patient with known COPD who has been brought...

    Incorrect

    • You are treating a 45-year-old patient with known COPD who has been brought to the ED due to worsening shortness of breath and suspected sepsis. You plan to obtain an arterial blood gas from the radial artery to assess for acidosis and evaluate lactate and base excess levels. What is the typical range for lactate?

      Your Answer: 2.1-4.4 mmol/L

      Correct Answer: 0.5-2.2 mmol/L

      Explanation:

      The typical range for lactate levels in the body is 0.5-2.2 mmol/L, according to most UK trusts. However, it is important to mention that the RCEM sepsis guides consider a lactate level above 2 mmol/L to be abnormal.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      18.3
      Seconds
  • Question 48 - A 28 year old male is brought into the ED after being discovered...

    Correct

    • A 28 year old male is brought into the ED after being discovered in a collapsed state. The patient is making minimal effort to breathe. The patient is a known IV drug user. The attending physician requests that you obtain an arterial blood gas sample from the radial artery. The blood gas is collected and the results are as follows:

      pH 7.30
      pO2 8.8 kPa
      pCO2 7.4 kPa
      Bicarbonate 26 mmol/L
      Chloride 98 mmol/L
      Potassium 5.6 mmol/L
      Sodium 135 mmol/L

      What type of acid-base abnormality is indicated?

      Your Answer: Respiratory acidosis

      Explanation:

      Respiratory acidosis occurs when the respiratory system is unable to effectively remove carbon dioxide from the body, leading to an increase in acidity. This is often seen in cases of opioid overdose, where respiratory depression can occur. In respiratory acidosis, the bicarbonate levels may rise as the body’s metabolic system tries to compensate for the increased acidity.

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      14
      Seconds
  • Question 49 - A 45-year-old man comes in with a history of a high temperature, loss...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Respiratory
      9.8
      Seconds
  • Question 50 - A 72-year-old man presents with a severe exacerbation of his COPD. You have...

    Incorrect

    • A 72-year-old man presents with a severe exacerbation of his COPD. You have been asked to administer a loading dose of aminophylline. He weighs 70 kg.
      What is the appropriate loading dose for him?

      Your Answer:

      Correct Answer: 300 mg over 15 minutes

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a patient weighing 60 kg, the appropriate loading dose would be 300 mg. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (15/49) 31%
Passmed