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Question 1
Correct
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A 70-year old man is being evaluated by the respiratory team for progressive cough and shortness of breath over the last 10 months. He has no history of smoking and is typically healthy. The only notable change in his lifestyle is that he recently started breeding pigeons after retiring. Upon examination, the patient is diagnosed with interstitial pneumonia.
What is the most frequently linked organism with interstitial pneumonia?Your Answer: Mycoplasma
Explanation:Types of Bacterial Pneumonia and Their Patterns in the Lung
Bacterial pneumonia can be caused by various organisms, each with their own unique patterns in the lung. Mycoplasma, viruses like RSV and CMV, and fungal infections like histoplasmosis typically cause interstitial patterns in the lung. Haemophilus influenzae, Staphylococcus, Pneumococcus, Escherichia coli, and Klebsiella all typically have the same alveolar pattern, with Klebsiella often causing an aggressive, necrotizing lobar pneumonia. Streptococcus pneumoniae is the most common cause of typical bacterial pneumonia, while Staphylococcus aureus pneumonia is typically of the alveolar type and seen in intravenous drug users or patients with underlying debilitating conditions. Mycoplasma pneumonia may also have extra-pulmonary manifestations. These conditions are sometimes referred to as atypical pneumonia.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 50-year-old man visits the Respiratory Outpatients Department complaining of a dry cough and increasing breathlessness. During the examination, the doctor observes finger clubbing, central cyanosis, and fine end-inspiratory crackles upon auscultation. The chest X-ray shows reticular shadows and peripheral honeycombing, while respiratory function tests indicate a restrictive pattern with reduced lung volumes but a normal forced expiratory volume in 1 second (FEV1): forced vital capacity (FVC) ratio. The patient's pulmonary fibrosis is attributed to which of the following medications?
Your Answer: Bleomycin
Explanation:Drug-Induced Pulmonary Fibrosis: Causes and Investigations
Pulmonary fibrosis is a condition characterized by scarring of the lungs, which can be caused by various diseases and drugs. One drug that has been linked to pulmonary fibrosis is bleomycin, while other causes include pneumoconiosis, occupational lung diseases, and certain medications. To aid in diagnosis, chest X-rays, high-resolution computed tomography (CT), and lung function tests may be performed. Treatment involves addressing the underlying cause. However, drugs such as aspirin, ramipril, spironolactone, and simvastatin have not been associated with pulmonary fibrosis. It is important to be aware of the potential risks of certain medications and to monitor for any adverse effects.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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An 80-year-old man comes to the Emergency Department complaining of difficulty breathing. His vital signs show a pulse rate of 105 bpm, a respiratory rate of 30 breaths per minute, and SpO2 saturations of 80% on pulse oximetry. He has a history of COPD for the past 10 years. Upon examination, there is reduced air entry bilaterally and coarse crackles. What would be the most crucial investigation to conduct next?
Your Answer: Chest X-ray
Correct Answer: Arterial blood gas (ABG)
Explanation:Importance of Different Investigations in Assessing Acute Respiratory Failure
When a patient presents with acute respiratory failure, it is important to conduct various investigations to determine the underlying cause and severity of the condition. Among the different investigations, arterial blood gas (ABG) is the most important as it helps assess the partial pressures of oxygen and carbon dioxide, as well as the patient’s pH level. This information can help classify respiratory failure into type I or II and identify potential causes of respiratory deterioration. In patients with a history of COPD, ABG can also determine if they are retaining carbon dioxide, which affects their target oxygen saturations.
While a chest X-ray may be considered to assess for underlying pathology, it is not the most important investigation. A D-dimer may be used to rule out pulmonary embolism, and an electrocardiogram (ECG) may be done to assess for cardiac causes of respiratory failure. However, ABG should be prioritized before these investigations.
Pulmonary function tests may be required after initial assessment of oxygen saturations to predict potential respiratory failure based on the peak expiratory flow rate. Overall, a combination of these investigations can help diagnose and manage acute respiratory failure effectively.
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This question is part of the following fields:
- Respiratory
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Question 4
Correct
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A 63-year-old man who used to work as a stonemason presents to the clinic with complaints of shortness of breath on minimal exercise and a dry cough. He has been experiencing progressive shortness of breath over the past year. He is a smoker, consuming 20-30 cigarettes per day, and has occasional wheezing. On examination, he is clubbed and bilateral late-inspiratory crackles can be heard at both lung bases. A chest X-ray shows upper lobe nodular opacities. His test results show a haemoglobin level of 125 g/l (normal range: 135-175 g/l), a WCC of 4.6 × 109/l (normal range: 4-11 × 109/l), platelets of 189 × 109/l (normal range: 150-410 × 109/l), a sodium level of 139 mmol/l (normal range: 135-145 mmol/l), a potassium level of 4.9 mmol/l (normal range: 3.5-5.0 mmol/l), a creatinine level of 135 μmol/l (normal range: 50-120 μmol/l), an FVC of 2.1 litres (normal range: >4.05 litres), and an FEV1 of 1.82 litres (normal range: >3.15 litres). Based on these findings, what is the most likely diagnosis?
Your Answer: Occupational interstitial lung disease
Explanation:Possible Occupational Lung Diseases and Differential Diagnosis
This patient’s history of working as a stonemason suggests a potential occupational exposure to silica dust, which can lead to silicosis. The restrictive lung defect seen in pulmonary function tests supports this diagnosis, which can be confirmed by high-resolution computerised tomography. Smoking cessation is crucial in slowing the progression of lung function decline.
Idiopathic pulmonary fibrosis is another possible diagnosis, but the occupational exposure makes silicosis more likely. Occupational asthma, caused by specific workplace stimuli, is also a consideration, especially for those in certain occupations such as paint sprayers, food processors, welders, and animal handlers.
Chronic obstructive pulmonary disease (COPD) is unlikely due to the restrictive spirometry results, as it is characterised by an obstructive pattern. Non-occupational asthma is also less likely given the patient’s age, chest X-ray findings, and restrictive lung defect.
In summary, the patient’s occupational history and pulmonary function tests suggest a potential diagnosis of silicosis, with other possible occupational lung diseases and differential diagnoses to consider.
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This question is part of the following fields:
- Respiratory
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Question 5
Correct
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A 75-year-old man with chronic obstructive pulmonary disease (COPD) comes in for a review of his home oxygen therapy. The results of his arterial blood gas (ABG) are as follows:
Investigation Result Normal range
pH 7.34 7.35–7.45
pa(O2) 8.0 kPa 10.5–13.5 kPa
pa(CO2) 7.6 kPa 4.6–6.0 kPa
HCO3- 36 mmol 24–30 mmol/l
Base excess +4 mmol −2 to +2 mmol
What is the best interpretation of this man's ABG results?Your Answer: Respiratory acidosis with partial metabolic compensation
Explanation:Understanding Arterial Blood Gas (ABG) Results: A Five-Step Approach
Arterial Blood Gas (ABG) results provide valuable information about a patient’s acid-base balance and oxygenation status. Understanding ABG results requires a systematic approach. The Resuscitation Council (UK) recommends a five-step approach to assessing ABGs.
Step 1: Assess the patient and their oxygenation status. A pa(O2) level of >10 kPa is considered normal.
Step 2: Determine if the patient is acidotic (pH <7.35) or alkalotic (pH >7.45).
Step 3: Evaluate the respiratory component of the acid-base balance. A high pa(CO2) level (>6.0) suggests respiratory acidosis or compensation for metabolic alkalosis, while a low pa(CO2) level (<4.5) suggests respiratory alkalosis or compensation for metabolic acidosis. Step 4: Evaluate the metabolic component of the acid-base balance. A high bicarbonate (HCO3) level (>26 mmol) suggests metabolic alkalosis or renal compensation for respiratory acidosis, while a low bicarbonate level (<22 mmol) suggests metabolic acidosis or renal compensation for respiratory alkalosis. Step 5: Interpret the results in the context of the patient’s clinical history and presentation. It is important to note that ABG results should not be interpreted in isolation. A thorough clinical assessment is necessary to fully understand a patient’s acid-base balance and oxygenation status.
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This question is part of the following fields:
- Respiratory
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Question 6
Correct
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A 45-year-old female patient complained of cough with heavy sputum production, shortness of breath, and a low-grade fever. She has been smoking 20 cigarettes per day for the past 25 years. Upon examination, her arterial blood gases showed a pH of 7.4 (normal range: 7.36-7.44), pCO2 of 6 kPa (normal range: 4.5-6), and pO2 of 7.9 kPa (normal range: 8-12). Based on these findings, what is the most likely diagnosis for this patient?
Your Answer: Chronic bronchitis
Explanation:Diagnosis of Acute Exacerbation of Chronic Obstructive Airways Disease
There is a high probability that the patient is experiencing an acute exacerbation of chronic obstructive airways disease (COAD), particularly towards the chronic bronchitic end of the spectrum. This conclusion is based on the patient’s symptoms and the relative hypoxia with high pCO2. The diagnosis suggests that the patient’s airways are obstructed, leading to difficulty in breathing and reduced oxygen supply to the body. The exacerbation may have been triggered by an infection or exposure to irritants such as cigarette smoke. Early intervention is crucial to manage the symptoms and prevent further complications.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 65-year-old lady is admitted with severe pneumonia and, while on the ward, develops a warm, erythematosus, tender and oedematous left leg. A few days later, her breathing, which was improving with antibiotic treatment, suddenly deteriorated.
Which one of the following is the best diagnostic test for this patient?Your Answer: Arterial blood gas measurement
Correct Answer: Computed tomography (CT) pulmonary angiogram
Explanation:The Best Imaging Method for Dual Pathology: Resolving Pneumonia and Pulmonary Embolus
Computed tomography (CT) pulmonary angiography is the best imaging method for a patient with dual pathology of resolving pneumonia and a pulmonary embolus secondary to a deep vein thrombosis. This method uses intravenous contrast to image the pulmonary vessels and can detect a filling defect within the bright pulmonary arteries, indicating a pulmonary embolism.
A V/Q scan, which looks for a perfusion mismatch, may indicate a pulmonary embolism, but would not be appropriate in this case due to the underlying pneumonia making interpretation difficult.
A D-dimer test should be performed, but it is non-specific and may be raised due to the pneumonia. It should be used together with the Wells criteria to consider imaging.
A chest X-ray should be performed to ensure there is no worsening pneumonia or pneumothorax, but in this case, a pulmonary embolism is the most likely diagnosis and therefore CTPA is required.
An arterial blood gas measurement can identify hypoxia and hypocapnia associated with an increased respiratory rate, but this is not specific to a pulmonary embolism and many pulmonary diseases can cause this arterial blood gas picture.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 68-year-old man with chronic obstructive pulmonary disease (COPD) visits his general practitioner (GP) complaining of increased wheezing, breathlessness, and a dry cough. He is able to speak in complete sentences.
During the examination, the following observations are made:
Temperature 37.2 °C
Respiratory rate 18 breaths per minute
Blood pressure 130/70 mmHg
Heart rate 90 bpm
Oxygen saturations 96% on room air
He has diffuse expiratory wheezing.
What is the most appropriate course of action for this patient?Your Answer: Oral amoxicillin
Correct Answer: Prednisolone
Explanation:Treatment Options for Acute Exacerbation of COPD
When a patient presents with evidence of an acute non-infective exacerbation of COPD, treatment with oral corticosteroids is appropriate. Short-acting bronchodilators may also be necessary. If the patient’s observations are not grossly deranged, they can be managed in the community with instructions to seek further medical input if their symptoms worsen.
Antibiotics are not indicated for non-infective exacerbations of COPD. However, if the patient has symptoms of an infective exacerbation, antibiotics may be prescribed based on the Anthonisen criteria.
Referral to a hospital medical team for admission is not necessary unless the patient is haemodynamically unstable, hypoxic, or experiencing respiratory distress.
A chest X-ray is not required unless there is suspicion of underlying pneumonia or pneumothorax. If the patient fails to respond to therapy or develops new symptoms, a chest X-ray may be considered at a later stage.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 21-year old patient is brought to the Emergency Department by paramedics following an assault. On examination, there are two puncture wounds on the posterior chest wall. The ambulance crew believe the patient was attacked with a screwdriver. He is currently extremely short of breath, haemodynamically unstable, and his oxygen saturations are falling despite high-flow oxygen. There are reduced breath sounds in the right hemithorax.
What is the most appropriate first step in managing this patient?Your Answer: Urgent chest radiograph
Correct Answer: Needle decompression of right hemithorax
Explanation:Management of Tension Pneumothorax in Penetrating Chest Trauma
Tension pneumothorax is a life-threatening condition that requires immediate intervention in patients with penetrating chest trauma. The following steps should be taken:
1. Clinical Diagnosis: Falling oxygen saturations, cardiovascular compromise, and reduced breath sounds in the affected hemithorax are suggestive of tension pneumothorax. This is a clinical diagnosis.
2. Needle Decompression: Immediate needle decompression with a large bore cannula placed into the second intercostal space, mid-clavicular line is required. This is a temporizing measure to provide time for placement of a chest drain.
3. Urgent Chest Radiograph: A chest radiograph may be readily available, but it should not delay decompression of the tension pneumothorax. It should be delayed until placement of the chest drain.
4. Placement of Chest Drain: This is the definitive treatment of a tension pneumothorax, but immediate needle decompression should take place first.
5. Contact On-Call Anaesthetist: Invasive ventilation by an anaesthetist will not improve the patient’s condition.
6. Avoid Non-Invasive Ventilation: Non-invasive ventilation would worsen the tension pneumothorax and should be avoided.
In summary, prompt recognition and management of tension pneumothorax are crucial in patients with penetrating chest trauma. Needle decompression followed by chest drain placement is the definitive treatment.
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This question is part of the following fields:
- Respiratory
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Question 10
Correct
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A 45-year-old man presents to his GP with persistent wheezing and difficulty breathing. Despite being prescribed a salbutamol inhaler, his symptoms continue and he is forced to take time off work. His GP increases his treatment by adding oral prednisolone, which initially helps but his symptoms return upon returning to work. However, during a two-week vacation, his wheezing significantly improves. Upon returning to work, he suffers an acute asthma attack and is taken to the hospital by ambulance. Which diagnostic test is most likely to confirm the diagnosis?
Your Answer: Peak flow rates measured at home and in work
Explanation:Occupational Asthma and its Causes
Occupational asthma (OA) is a type of asthma that develops in adulthood and is caused by exposure to allergens in the workplace. Symptoms improve significantly when the affected person is away from their work environment. OA can be triggered by immunologic or non-immunologic stimuli. Immunologic stimuli have a latency period between exposure and symptom onset, while non-immunologic stimuli do not. Non-immunologic stimuli that trigger OA are referred to as reactive airways dysfunction syndrome (RADS) or irritant-induced asthma.
Immunologic OA can be caused by high-molecular-weight or low-molecular-weight allergens. High-molecular-weight allergens include domestic and laboratory animals, fish and seafood, flour and cereals, and rubber. Low-molecular-weight allergens include metals, drugs, dyes and bleaches, isocyanates (naphthalene), and wood dust. It is important to identify the specific allergen causing OA in order to prevent further exposure and manage symptoms effectively.
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This question is part of the following fields:
- Respiratory
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Question 11
Incorrect
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A 68-year-old woman presents to the Emergency Department with a 48-hour history of shortness of breath and an increased volume and purulence of sputum. She has a background history of chronic obstructive pulmonary disease (COPD), hypertension and ischaemic heart disease. Her observations show: heart rate (HR) 116 bpm, blood pressure (BP) 124/68 mmHg, respiratory rate (RR) 18 breaths per minute and oxygen saturation (SaO2) 94% on 2l/min via nasal cannulae. She is commenced on treatment for an infective exacerbation of COPD with nebulised bronchodilators, intravenous antibiotics, oral steroids and controlled oxygen therapy with a Venturi mask. After an hour of therapy, the patient is reassessed. Her observations after an hour are: BP 128/74 mmHg, HR 124 bpm, RR 20 breaths per minute and SaO2 93% on 24% O2 via a Venturi mask. Arterial blood gas sampling is performed:
Investigation Result Normal value
pH 7.28 7.35–7.45
PO2 8.6 kPa 10.5–13.5 kPa
pCO2 8.4 kPa 4.6–6.0 kPa
cHCO3- (P)C 32 mmol/l 24–30 mmol/l
Lactate 1.4 mmol/l 0.5–2.2 mmol/l
Sodium (Na+) 134 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Chloride (Cl-) 116 mmol/l 98-106 mmol/l
Glucose 5.4 mmol/l 3.5–5.5 mmol/l
Following this review and the arterial blood gas results, what is the most appropriate next step in this patient’s management?Your Answer: The patient’s oxygen should be increased, as they remain relatively hypoxic despite oxygen therapy
Correct Answer: The patient should be considered for non-invasive ventilation (NIV)
Explanation:Management of Respiratory Acidosis in COPD Patients
The management of respiratory acidosis in COPD patients requires careful consideration of the individual’s condition. In this scenario, the patient should be considered for non-invasive ventilation (NIV) as recommended by the British Thoracic Society. NIV is particularly indicated in patients with a pH of 7.25–7.35. Patients with a pH of <7.25 may benefit from NIV but have a higher risk for treatment failure and therefore should be considered for management in a high-dependency or intensive care setting. However, NIV is not indicated in patients with impaired consciousness, severe hypoxaemia or copious respiratory secretions. It is important to note that a ‘Do Not Resuscitate Order’ should not be automatically made for patients with COPD. Each decision regarding resuscitation should be made on an individual basis. Intubation and ventilation should not be the first line of treatment in this scenario. A trial of NIV would be the most appropriate next step, as it has been demonstrated to reduce the need for intensive care management in this group of patients. Increasing the patient’s oxygen may be appropriate in type 1 respiratory failure, but in this case, NIV is the recommended approach. Intravenous magnesium therapy is not routinely recommended in COPD and is only indicated in the context of acute asthma. In conclusion, the management of respiratory acidosis in COPD patients requires a tailored approach based on the individual’s condition. NIV should be considered as the first line of treatment in this scenario.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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A 35-year-old woman with a history of asthma and eczema visits her General Practitioner and inquires about the reason for her continued wheezing hours after being exposed to pollen. She has a known allergy to tree pollen.
What is the most suitable explanation for this?Your Answer: Persistent bronchospasm causing smooth muscle hypertrophy
Correct Answer: Inflammation followed by mucosal oedema
Explanation:Understanding the Mechanisms of Allergic Asthma
Allergic asthma is a condition that is mediated by immunoglobulin E (IgE). When IgE binds to an antigen, it triggers mast cells to release histamine, leukotrienes, and prostaglandins, which cause bronchospasm and vasodilation. This leads to inflammation and edema of the mucosal lining of the airways, resulting in persistent symptoms or late symptoms after an acute asthma attack.
While exposure to another allergen could trigger an asthma attack, it is not the most appropriate answer if you are only aware of a known allergy to tree pollen. Smooth muscle hypertrophy may occur in the long-term, but the exact mechanism and functional effects of airway remodeling in asthma are not fully understood. Pollen stuck on Ciliary would act as a cough stimulant, clearing the pollen from the respiratory tract. Additionally, the Ciliary would clear the pollen up the respiratory tract as part of the mucociliary escalator.
It is important to note that pollen inhaled into the respiratory system is not systemically absorbed. Instead, it binds to immune cells and exhibits immune effects through cytokines produced by Th1 and Th2 cells. Understanding the mechanisms of allergic asthma can help individuals manage their symptoms and prevent future attacks.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 32-year-old female with a 10 year history of asthma presents with increasing dyspnoea after returning from a trip to Australia. She has not had a period in three months. On examination, she has a fever of 37.5°C, a pulse rate of 110/min, a blood pressure of 106/74 mmHg, and saturations of 93% on room air. Her respiratory rate is 24/min and auscultation of the chest reveals vesicular breath sounds. Peak flow is 500 L/min and her ECG shows no abnormalities except for a heart rate of 110 bpm. A chest x-ray is normal. What is the most likely diagnosis?
Your Answer: Anxiety attack
Correct Answer: Pulmonary embolism
Explanation:Risk Factors and Symptoms of Pulmonary Embolism
This patient presents with multiple risk factors for pulmonary embolism, including air travel and likely pregnancy. She is experiencing tachycardia and hypoxia, which require further explanation. However, there are no indications of a respiratory tract infection or acute asthma. It is important to note that an ECG and CXR may appear normal in cases of pulmonary embolism or may only show baseline tachycardia on the ECG. Therefore, it is crucial to consider the patient’s risk factors and symptoms when evaluating for pulmonary embolism. Proper diagnosis and treatment are essential to prevent potentially life-threatening complications.
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This question is part of the following fields:
- Respiratory
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Question 14
Incorrect
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A 56-year-old woman presents to the Emergency Department with a 2-week history of productive cough with green sputum and a one day history of palpitations. She also had some rigors and fever. On examination:
Result Normal
Respiratory rate (RR) 26 breaths/min 12–18 breaths/min
Sats 96% on air 94–98%
Blood pressure (BP) 92/48 mmHg <120/80 mmHg
Heart rate (HR) 130 bpm 60–100 beats/min
Some bronchial breathing at left lung base, heart sounds normal however with an irregularly irregular pulse. electrocardiogram (ECG) showed fast atrial fibrillation (AF). She was previously fit and well.
Which of the following is the most appropriate initial management?Your Answer: Digoxin
Correct Answer: Intravenous fluids
Explanation:Treatment for AF in a Patient with Sepsis
In a patient with sepsis secondary to pneumonia, the new onset of AF is likely due to the sepsis. Therefore, the priority is to urgently treat the sepsis with intravenous fluids and broad-spectrum antibiotics. If the AF persists after the sepsis is treated, other options for AF treatment can be considered. Bisoprolol and digoxin are not the first-line treatments for AF in this case. Oral antibiotics are not recommended for septic patients. Flecainide may be considered if the AF persists after the sepsis is treated.
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?
Your Answer: Occupational asthma
Correct Answer: Suboptimal therapy
Explanation:Differentiating Between Respiratory Conditions: A Guide
When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.
Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.
Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.
Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.
Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.
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This question is part of the following fields:
- Respiratory
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Question 16
Correct
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A 35-year-old man visits his doctor seeking assistance in quitting smoking. He has been smoking 20 cigarettes daily for the past six years and has a history of epilepsy. Which smoking cessation aid is most likely to result in adverse effects for this individual?
Your Answer: Bupropion
Explanation:Options for Smoking Cessation in Patients with Seizure History
Patients with a predisposition or past history of seizures should avoid bupropion due to an increased risk of seizures. The Medicines and Health products Regulatory Authority (MHRA) warns against prescribing bupropion to patients who experience seizures. However, behavioural therapy is encouraged for all patients who wish to quit smoking. E-cigarettes can be a safer alternative and may eventually help patients quit entirely, but they are not currently funded by the NHS. Nicotine replacement therapy in the form of patches or gum can also be used. Varenicline is cautioned but not contraindicated for use in patients with seizures, so it should only be used if the benefits outweigh the risk.
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This question is part of the following fields:
- Respiratory
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Question 17
Incorrect
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A 41-year-old man presents with wheezing and shortness of breath. He reports no history of smoking or drug use. An ultrasound reveals cirrhosis of the liver, and he is diagnosed with alpha-1-antitrypsin deficiency. He undergoes a liver transplant. What type of emphysema is he now at higher risk of developing?
Your Answer:
Correct Answer: Panacinar
Explanation:Different Types of Emphysema and Their Characteristics
Emphysema is a lung condition that has various forms, each with its own distinct characteristics. The four main types of emphysema are panacinar, compensatory, interstitial, centriacinar, and paraseptal.
Panacinar emphysema affects the entire acinus, from the respiratory bronchiole to the distal alveoli. It is often associated with α-1-antitrypsin deficiency.
Compensatory emphysema occurs when the lung parenchyma is scarred, but it is usually asymptomatic.
Interstitial emphysema is not a true form of emphysema, but rather occurs when air penetrates the pulmonary interstitium. It can be caused by chest wounds or alveolar tears resulting from coughing and airway obstruction.
Centriacinar emphysema is characterized by enlargement of the central portions of the acinus, specifically the respiratory bronchiole. It is often caused by exposure to coal dust and tobacco products.
Paraseptal emphysema is associated with scarring and can lead to spontaneous pneumothorax in young patients. It is more severe when it occurs in areas adjacent to the pleura, where it can cause the development of large, cyst-like structures that can rupture into the pleural cavity.
In summary, understanding the different types of emphysema and their characteristics is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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A 28-year-old woman presents to her Occupational Health Service. She works in the sterile supplies group at her local hospital. Over the past few months, she has noticed increasing shortness of breath with cough and wheeze during the course of a working week, but improves when she takes a week off on holiday. On examination at the general practitioner’s surgery, after a few weeks off, her chest is clear.
Peak flow diary:
Monday p.m 460 l/min (85% predicted)
Tuesday p.m 440 l/min
Wednesday p.m 400 l/min
Thursday p.m 370 l/min
Friday p.m 350 l/min
Saturday a.m 420 l/min
Which of the following is the most appropriate treatment choice?Your Answer:
Correct Answer: Redeployment to another role if possible
Explanation:Managing Occupational Asthma: Redeployment and Avoiding Suboptimal Treatment Options
Based on the evidence from the patient’s peak flow diary, it is likely that they are suffering from occupational asthma. This could be due to a number of agents, such as glutaraldehyde used in hospital sterilisation units. The best course of action would be to redeploy the patient to another role, if possible, and monitor their peak flows at work. Starting medical management for asthma would not be the optimal choice in this case. Other causes of occupational asthma include isocyanates, metals, animal antigens, plant products, acid anhydrides, biological enzymes, and wood dusts. While salbutamol inhaler may provide temporary relief, it is not a long-term solution. Inhaled steroids like beclomethasone or fluticasone/salmeterol may help manage symptoms, but since the cause has been identified, they would not be the most appropriate course of action. A 7-day course of oral prednisolone would only provide temporary relief and is not a realistic long-term treatment option.
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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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A 42-year-old man presents to the Emergency Department with complaints of severe breathlessness after being exposed to smoke during a house fire. He reports vomiting twice and experiencing a headache and dizziness.
Upon examination, the patient is found to be tachypnoeic with good air entry, and his oxygen saturations are at 100% on air. He appears drowsy, but his Glasgow Coma Scale (GCS) score is 15, and there are no signs of head injury on his neurological examination.
What is the initial step in managing this patient's condition?Your Answer:
Correct Answer: High-flow oxygen
Explanation:Treatment Options for Smoke Inhalation Injury
Smoke inhalation injury can lead to carbon monoxide (CO) poisoning, which is characterized by symptoms such as headache, dizziness, and vomiting. It is important to note that normal oxygen saturation may be present despite respiratory distress due to the inability of a pulse oximeter to differentiate between carboxyhaemoglobin and oxyhaemoglobin. Therefore, any conscious patient with suspected CO poisoning should be immediately treated with high-flow oxygen, which can reduce the half-life of carboxyhaemoglobin from up to four hours to 90 minutes.
Cyanide poisoning, which is comparatively rare, can also be caused by smoke inhalation. The treatment of choice for cyanide poisoning is a combination of hydroxocobalamin and sodium thiosulphate.
Hyperbaric oxygen may be beneficial for managing patients with CO poisoning, but high-flow oxygen should be provided immediately while waiting for initiation. Indications for hyperbaric oxygen include an unconscious patient, COHb > 25%, pH < 7.1, and evidence of end-organ damage due to CO poisoning. Bronchodilators such as nebulised salbutamol and ipratropium may be useful as supportive care in cases of inhalation injury where signs of bronchospasm occur. However, in this case, compatible signs such as wheeze and reduced air entry are not present. Metoclopramide may provide symptomatic relief of nausea, but it does not replace the need for immediate high-flow oxygen. Therefore, it is crucial to prioritize the administration of high-flow oxygen in patients with suspected smoke inhalation injury. Managing Smoke Inhalation Injury: Treatment Options and Priorities
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This question is part of the following fields:
- Respiratory
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Question 20
Incorrect
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A middle-aged man is brought into the Emergency Department after a road traffic collision (RTC). During examination, he is found to be tachycardic at 120 bpm, sweating profusely, and pale. His right side has decreased breath sounds and chest movement, and his trachea is deviated to the left. You are requested to insert a large-bore cannula.
Where would you position it in this patient?Your Answer:
Correct Answer: In the second intercostal space, mid-clavicular line, on the side of the decreased breath sounds
Explanation:To treat a tension pneumothorax, emergency intervention is required. A large-bore cannula should be inserted into the second intercostal space, mid-clavicular line, on the side where breath sounds are decreased to relieve pressure in the pleural space. This is the correct location for needle decompression. However, it is important to note that definitive management involves inserting an intercostal chest drain. Inserting a needle into the fifth intercostal space, mid-axillary line of the chest, on the side of the decreased breath sounds is incorrect for needle decompression, but it is where the chest drain will be inserted afterwards. Inserting a needle into the second intercostal space, mid-axillary line of the chest, on the side with normal breath sounds is the correct space, but the wrong location and wrong side of the body. It would be challenging to insert a needle into this location in reality. Inserting a needle into the third intercostal space, mid-clavicular line, on the side of the decreased breath sounds is the correct anatomical line, but the incorrect intercostal space. Similarly, inserting a needle into the sixth intercostal space, mid-clavicular line, on the side of the chest with decreased breath sounds is the correct anatomical line, but the wrong intercostal space.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A 68-year-old retired caretaker with a well-documented history of chronic obstructive pulmonary disease (COPD) is admitted, for his fourth time this year, with shortness of breath and a cough productive of green sputum. Examination findings are: respiratory rate (RR) 32 breaths/min, temperature 37.4 °C, SpO2 86% on room air, asterixis and coarse crepitations at the left base. A chest X-ray (CXR) confirms left basal consolidation.
Which arterial blood gas (ABG) picture is likely to belong to the above patient?Your Answer:
Correct Answer: pH: 7.27, pa (O2): 7.1, pa (CO2): 8.9, HCO3–: 33.20, base excess (BE) 4.9 mmol
Explanation:Interpreting Blood Gas Results in COPD Patients
COPD is a common respiratory disease that can lead to exacerbations requiring hospitalization. In these patients, lower respiratory tract infections can quickly lead to respiratory failure and the need for respiratory support. Blood gas results can provide important information about the patient’s respiratory and metabolic status. In COPD patients, a type II respiratory failure with hypercapnia and acidosis is common, resulting in a low pH and elevated bicarbonate levels. However, blood gas results that show low carbon dioxide or metabolic acidosis are less likely to be in keeping with COPD. Understanding and interpreting blood gas results is crucial in managing COPD exacerbations and providing appropriate respiratory support.
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This question is part of the following fields:
- Respiratory
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Question 22
Incorrect
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An 85-year-old man with chronic COPD presents for a review of his home oxygen therapy. The following results are from his arterial blood gas (ABG):
pH 7.37 (normal range 7.35–7.45)
pa(O2) 7.6 (normal range 10–14 kPa)
pa(CO2) 8 (normal range 4.0–6.0 kPa)
HCO3 37 (normal range 22–26 mmol)
base excess +6 (normal range −2 to +2 mmol).
Which of the following best describe this man’s blood gas result?Your Answer:
Correct Answer: Compensation for respiratory acidosis secondary to chronic respiratory disease
Explanation:Understanding ABGs: A Five-Step Approach and Mnemonic
Arterial blood gas (ABG) analysis is a crucial tool in assessing a patient’s respiratory and metabolic status. The Resuscitation Council (UK) recommends a five-step approach to interpreting ABGs:
1. Assess the patient.
2. Assess their oxygenation (pa(O2) should be >10 kPa).
3. Determine if the patient is acidotic (pH < 7.35) or alkalotic (pH > 7.45).
4. Assess respiratory status by determining if their pa(CO2) is high or low.
5. Assess metabolic status by determining if their bicarbonate (HCO3) is high or low.To aid in understanding ABGs, the mnemonic ROME can be used:
– Respiratory = Opposite: A low pH and high pa(CO2) indicate respiratory acidosis, while a high pH and low pa(CO2) indicate respiratory alkalosis.
– Metabolic = Equivalent: A high pH and high HCO3 indicate metabolic alkalosis, while a low pH and low HCO3 indicate metabolic acidosis.Compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a normal pH, high pa(CO2), and high HCO3, indicating renal compensation. In contrast, compensation for respiratory alkalosis secondary to chronic respiratory disease would show a low pa(CO2) and a high pH.
Partial compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a high pa(CO2) and a high HCO3, with a normal pH indicating full compensation and a mildly altered pH indicating partial compensation. Compensation for metabolic acidosis secondary to chronic respiratory disease is not applicable, as this condition would present with low HCO3 levels.
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This question is part of the following fields:
- Respiratory
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Question 23
Incorrect
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A 65 year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. There was an associated dry cough, but no fever. Examination revealed scattered wheezes and some expiratory high-pitched sounds. C-reactive protein (CRP) level was normal. Mantoux test was negative. Spirometry revealed the following report:
FEV1 51%
FVC 88%
FEV1/FVC 58%
What is the most likely diagnosis?Your Answer:
Correct Answer: Bronchiolitis obliterans (BO)
Explanation:Respiratory Disorders: Bronchiolitis Obliterans, ARDS, Pneumocystis Pneumonia, COPD Exacerbation, and Idiopathic Pulmonary Hypertension
Bronchiolitis obliterans (BO) is a respiratory disorder that may occur after bone marrow, heart, or lung transplant. It presents with an obstructive pattern on spirometry, low DLCO, and hypoxia. CT scan shows air trapping, and chest X-ray may show interstitial infiltrates with hyperinflation. BO may also occur in connective tissue diseases, such as rheumatoid arthritis, and idiopathic variety called cryptogenic organising pneumonia (COP). In contrast, acute respiratory distress syndrome (ARDS) patients deteriorate quickly, and pneumocystis pneumonia usually presents with normal clinical findings. Infective exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a productive cough and raised CRP, while idiopathic pulmonary hypertension has a restrictive pattern and inspiratory fine crepitations.
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This question is part of the following fields:
- Respiratory
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Question 24
Incorrect
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A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25 lb weight loss over the last 4 months. He reports a medical history significant for mild asthma controlled with an albuterol inhaler as needed. He takes no other medications and has no allergies. He has a 55 pack-year smoking history and has worked as a naval shipyard worker for 40 years. Examination reveals diffuse crackles in the posterior lung fields bilaterally and there is dullness to percussion one-third of the way up the right lung field. Ultrasound reveals free fluid in the pleural space.
Which one of the following set of test values is most consistent with this patient’s presentation?
(LDH: lactate dehydrogenase)
Option LDH plasma LDH pleural Protein plasma Protein pleural
A 180 100 7 3
B 270 150 8 3
C 180 150 7 4
D 270 110 8 3
E 180 100 7 2Your Answer:
Correct Answer: Option C
Explanation:Interpreting Light’s Criteria for Pleural Effusions
When evaluating a patient with a history of occupational exposure and respiratory symptoms, it is important to consider the possibility of pneumoconiosis, specifically asbestosis. Chronic exposure to asbestos can lead to primary bronchogenic carcinoma and mesothelioma. Chest radiography may reveal radio-opaque pleural and diaphragmatic plaques. In this case, the patient’s dyspnea, hemoptysis, and weight loss suggest primary lung cancer, with a likely malignant pleural effusion observed under ultrasound.
To confirm the exudative nature of the pleural effusion, Light’s criteria can be used. These criteria include a pleural:serum protein ratio >0.5, a pleural:serum LDH ratio >0.6, and pleural LDH more than two-thirds the upper limit of normal serum LDH. Meeting any one of these criteria indicates an exudative effusion.
Option C is the correct answer as it satisfies Light’s criteria for an exudative pleural effusion. Options A, B, D, and E do not meet the criteria. Understanding Light’s criteria can aid in the diagnosis and management of pleural effusions, particularly in cases where malignancy is suspected.
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This question is part of the following fields:
- Respiratory
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Question 25
Incorrect
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A 35-year-old man has just returned from a trip to Kenya. He has been experiencing a productive cough with blood-stained sputum, fever, and general malaise for the past week. Upon testing his sputum, he is diagnosed with tuberculosis and is prescribed isoniazid, rifampicin, pyrazinamide, and ethambutol for the initial phase of treatment. What drugs will he take during the continuation phase, which will last for four months after the initial two-month phase?
Your Answer:
Correct Answer: Rifampicin + Isoniazid
Explanation:Treatment Options for Tuberculosis: Medications and Considerations
Tuberculosis (TB) is a serious infectious disease that requires prompt and effective treatment. The following are some of the medications used in the treatment of TB, along with important considerations to keep in mind:
Rifampicin + Isoniazid
This combination is used in the initial treatment of TB, which lasts for two months. Before starting treatment, it is important to check liver and kidney function, as these medications can be associated with liver toxicity. Ethambutol should be avoided in patients with renal impairment. If TB meningitis is diagnosed, the continuation phase of treatment should be extended to 10 months and a glucocorticoid should be used in the first two weeks of treatment. Side effects to watch for include visual disturbances with ethambutol and peripheral neuropathy with isoniazid.Rifampicin + Pyrazinamide
Pyrazinamide is used only in the initial two-month treatment, while rifampicin is used in both the initial and continuation phases.Pyrazinamide + Ethambutol
These medications are used only in the initial stage of TB treatment.Rifampicin alone
Rifampicin is used in combination with isoniazid for the continuation phase of TB treatment.Rifampicin + Ethambutol
Rifampicin is used in the continuation phase, while ethambutol is used only in the initial two-month treatment.It is important to work closely with a healthcare provider to determine the best treatment plan for TB, taking into account individual patient factors and potential medication side effects.
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This question is part of the following fields:
- Respiratory
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Question 26
Incorrect
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A 40-year-old Afro-Caribbean man comes to the clinic complaining of fever, dry cough and joint pains. Upon examination, his chest is clear. He has several tender, warm, erythematous nodules on both shins. A chest X-ray reveals prominent hila bilaterally. What is the most probable diagnosis?
Your Answer:
Correct Answer: Sarcoidosis
Explanation:The patient is displaying symptoms that are typical of acute sarcoidosis, including erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia. The patient’s ethnic background, being Afro-Caribbean, is also a factor as sarcoidosis is more prevalent in this population. It is important to take a thorough medical history as sarcoidosis can mimic other diseases. Mycoplasma pneumonia presents with flu-like symptoms followed by a dry cough and reticulonodular shadowing on chest X-ray. Pneumocystis jirovecii pneumonia causes breathlessness, fever, and perihilar shadowing on chest X-ray and is associated with severe immunodeficiency. Pulmonary TB causes cough, fever, weight loss, and erythema nodosum, with typical chest X-ray findings including apical shadowing or cavity, or multiple nodules. Pulmonary fibrosis presents with shortness of breath, a non-productive cough, and bilateral inspiratory crepitations on auscultation. However, the X-ray findings in this patient are not consistent with pulmonary fibrosis as reticulonodular shadowing would be expected.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A 38-year-old male presents with complaints of difficulty breathing. During the physical examination, clubbing of the fingers is observed. What medical condition is commonly associated with clubbing?
Your Answer:
Correct Answer: Pulmonary fibrosis
Explanation:Respiratory and Other Causes of Clubbing of the Fingers
Clubbing of the fingers is a condition where the tips of the fingers become enlarged and the nails curve around the fingertips. This condition is often associated with respiratory diseases such as carcinoma of the lung, bronchiectasis, mesothelioma, empyema, and pulmonary fibrosis. However, it is not typically associated with chronic obstructive airway disease (COAD). Other causes of clubbing of the fingers include cyanotic congenital heart disease, inflammatory bowel disease, and infective endocarditis.
In summary, clubbing of the fingers is a physical manifestation of various underlying medical conditions. It is important to identify the underlying cause of clubbing of the fingers in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Respiratory
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Question 28
Incorrect
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A 35-year-old call centre operator with a 6-year history of sarcoidosis presents with worsening shortness of breath during his visit to Respiratory Outpatients. This is his fifth episode of this nature since his diagnosis. In the past, he has responded well to tapered doses of oral steroids. What initial test would be most useful in evaluating his current pulmonary condition before prescribing steroids?
Your Answer:
Correct Answer: Pulmonary function tests with transfer factor
Explanation:Pulmonary Function Tests with Transfer Factor in Sarcoidosis: An Overview
Sarcoidosis is a complex inflammatory disease that can affect multiple organs, with respiratory manifestations being the most common. Pulmonary function tests with transfer factor are a useful tool in assessing the severity of sarcoidosis and monitoring response to treatment. The underlying pathological process in sarcoidosis is interstitial fibrosis, leading to a restrictive pattern on pulmonary function tests with reduced transfer factor. While steroids are often effective in treating sarcoidosis, monitoring transfer factor levels can help detect exacerbations and assess response to treatment. Other diagnostic tests, such as arterial blood gas, chest X-ray, serum ACE levels, and HRCT of the chest, may also be useful in certain situations but are not always necessary as an initial test. Overall, pulmonary function tests with transfer factor play a crucial role in the management of sarcoidosis.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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A 67-year-old woman has had bowel surgery two days ago. She is currently on postoperative day one, and you are called to see her as she has developed sudden-onset shortness of breath. She denies any coughing but complains of chest discomfort. The surgical scar appears clean. Upon examination, the patient is afebrile; vital signs are stable other than rapid and irregular heartbeat and upon auscultation, the chest sounds are clear. The patient does not have any other significant past medical history, aside from her breast cancer for which she had a mastectomy five years ago. She has no family history of any heart disease.
What is the patient’s most likely diagnosis?Your Answer:
Correct Answer: Pulmonary embolism
Explanation:Differential Diagnosis for Sudden Onset Shortness of Breath postoperatively
When a patient experiences sudden onset shortness of breath postoperatively, it is important to consider various differential diagnoses. One possible diagnosis is pulmonary embolism, which is supported by the patient’s chest discomfort. Anaphylaxis is another potential diagnosis, but there is no mention of an allergen exposure or other signs of a severe allergic reaction. Pneumonia is unlikely given the absence of fever and clear chest sounds. Lung fibrosis is also an unlikely diagnosis as it typically presents gradually and is associated with restrictive respiratory diseases. Finally, cellulitis is not a probable diagnosis as there are no signs of infection and the surgical wound is clean. Overall, a thorough evaluation is necessary to determine the underlying cause of the patient’s sudden onset shortness of breath.
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This question is part of the following fields:
- Respiratory
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Question 30
Incorrect
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A 68-year-old retired plumber presents with progressive shortness of breath, haemoptysis and weight loss. He has a smoking history of 25 pack years.
A focal mass is seen peripherally in the left lower lobe on chest X-ray (CXR).
Serum biochemistry reveals:
Sodium (Na+): 136 mmol/l (normal range: 135–145 mmol/l)
Potassium (K+): 3.8 mmol/l (normal range: 3.5–5.0 mmol/l)
Corrected Ca2+: 3.32 mmol/l (normal range: 2.20–2.60 mmol/l)
Urea: 6.8 mmol/l (normal range: 2.5–6.5 mmol/l)
Creatinine: 76 μmol/l (normal range: 50–120 µmol/l)
Albumin: 38 g/l (normal range: 35–55 g/l)
What is the most likely diagnosis?Your Answer:
Correct Answer: Squamous cell bronchial carcinoma
Explanation:Understanding Squamous Cell Bronchial Carcinoma and Hypercalcemia
Squamous cell bronchial carcinoma is a type of non-small cell lung cancer that can cause hypercalcemia, a condition characterized by elevated levels of calcium in the blood. This occurs because the cancer produces a hormone that mimics the action of parathyroid hormone, leading to the release of calcium from bones, kidneys, and the gut. Focal lung masses on a chest X-ray can be caused by various conditions, including bronchial carcinoma, abscess, tuberculosis, and metastasis. Differentiating between subtypes of bronchial carcinoma requires tissue sampling, but certain features of a patient’s history may suggest a particular subtype. Small cell bronchial carcinoma, for example, is associated with paraneoplastic phenomena such as Cushing’s syndrome and SIADH. Mesothelioma, on the other hand, is linked to asbestos exposure and presents with pleural thickening or malignant pleural effusion on a chest X-ray. Overall, a focal lung mass in a smoker should be viewed with suspicion and thoroughly evaluated to determine the underlying cause.
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This question is part of the following fields:
- Respiratory
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