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Question 1
Correct
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A 48-year-old male presents for a preoperative evaluation for an inguinal hernia repair. During the assessment, you observe a loculated left pleural effusion on his chest x-ray. Upon further inquiry, the patient discloses that he worked as a builder three decades ago. What is the probable reason for the effusion?
Your Answer: Mesothelioma
Explanation:Due to his profession as a builder, this individual is at risk of being exposed to asbestos. Given the 30-year latent period and the presence of a complex effusion, it is highly probable that the underlying cause is mesothelioma.
Understanding Mesothelioma
Mesothelioma is a type of cancer that affects the mesothelial layer of the pleural cavity, which is commonly linked to asbestos exposure. Although it is rare, other mesothelial layers in the abdomen may also be affected. Symptoms of mesothelioma include dyspnoea, weight loss, chest wall pain, and clubbing. In some cases, patients may present with painless pleural effusion. It is important to note that only 20% of patients have pre-existing asbestosis, but 85-90% have a history of asbestos exposure, with a latent period of 30-40 years.
Diagnosis of mesothelioma is typically made through a chest x-ray, which may show pleural effusion or pleural thickening. A pleural CT is then performed to confirm the diagnosis. If a pleural effusion is present, fluid is sent for MC&S, biochemistry, and cytology. However, cytology is only helpful in 20-30% of cases. Local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield of around 95%. If an area of pleural nodularity is seen on CT, an image-guided pleural biopsy may be used.
Management of mesothelioma is mainly symptomatic, with industrial compensation available for those who have been exposed to asbestos. Chemotherapy and surgery may be options for those who are operable. Unfortunately, the prognosis for mesothelioma is poor, with a median survival of only 12 months.
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This question is part of the following fields:
- Respiratory System
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Question 2
Incorrect
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An 80-year-old woman presents to the emergency department with a 2-day history of severe abdominal pain, accompanied by nausea and vomiting. Upon examination, she has a distended abdomen that is tender to the touch, and bowel sounds are infrequent. Her medical history includes a hysterectomy and cholecystectomy. A CT scan is ordered, which reveals a bowel obstruction at the L1 level. What is the most likely affected area?
Your Answer: Ileum
Correct Answer: Duodenum
Explanation:The 2nd segment of the duodenum is situated at the transpyloric plane, which corresponds to the level of L1 and is a significant anatomical reference point.
The Transpyloric Plane and its Anatomical Landmarks
The transpyloric plane is an imaginary horizontal line that passes through the body of the first lumbar vertebrae (L1) and the pylorus of the stomach. It is an important anatomical landmark used in clinical practice to locate various organs and structures in the abdomen.
Some of the structures that lie on the transpyloric plane include the left and right kidney hilum (with the left one being at the same level as L1), the fundus of the gallbladder, the neck of the pancreas, the duodenojejunal flexure, the superior mesenteric artery, and the portal vein. The left and right colic flexure, the root of the transverse mesocolon, and the second part of the duodenum also lie on this plane.
In addition, the upper part of the conus medullaris (the tapered end of the spinal cord) and the spleen are also located on the transpyloric plane. Knowing the location of these structures is important for various medical procedures, such as abdominal surgeries and diagnostic imaging.
Overall, the transpyloric plane serves as a useful reference point for clinicians to locate important anatomical structures in the abdomen.
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This question is part of the following fields:
- Respiratory System
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Question 3
Correct
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A 29-year-old cyclist is brought to the emergency department by air ambulance following a car collision. She was intubated at the scene and currently has a Glasgow Coma Score of 8. Where is the control and regulation of the respiratory centers located?
Your Answer: Brainstem
Explanation:The brainstem houses the respiratory centres, which are responsible for regulating various aspects of breathing. These centres are located in the upper pons, lower pons and medulla oblongata.
The thalamus plays a role in sensory, motor and cognitive functions, and its axons connect with the cerebral cortex. The cerebellum coordinates voluntary movements and helps maintain balance and posture. The parietal lobe processes sensory information, including discrimination and body orientation. The primary visual cortex is located in the occipital lobe.
The Control of Ventilation in the Human Body
The control of ventilation in the human body is a complex process that involves various components working together to regulate the respiratory rate and depth of respiration. The respiratory centres, chemoreceptors, lung receptors, and muscles all play a role in this process. The automatic, involuntary control of respiration occurs from the medulla, which is responsible for controlling the respiratory rate and depth of respiration.
The respiratory centres consist of the medullary respiratory centre, apneustic centre, and pneumotaxic centre. The medullary respiratory centre has two groups of neurons, the ventral group, which controls forced voluntary expiration, and the dorsal group, which controls inspiration. The apneustic centre, located in the lower pons, stimulates inspiration and activates and prolongs inhalation. The pneumotaxic centre, located in the upper pons, inhibits inspiration at a certain point and fine-tunes the respiratory rate.
Ventilatory variables, such as the levels of pCO2, are the most important factors in ventilation control, while levels of O2 are less important. Peripheral chemoreceptors, located in the bifurcation of carotid arteries and arch of the aorta, respond to changes in reduced pO2, increased H+, and increased pCO2 in arterial blood. Central chemoreceptors, located in the medulla, respond to increased H+ in brain interstitial fluid to increase ventilation. It is important to note that the central receptors are not influenced by O2 levels.
Lung receptors also play a role in the control of ventilation. Stretch receptors respond to lung stretching, causing a reduced respiratory rate, while irritant receptors respond to smoke, causing bronchospasm. J (juxtacapillary) receptors are also involved in the control of ventilation. Overall, the control of ventilation is a complex process that involves various components working together to regulate the respiratory rate and depth of respiration.
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This question is part of the following fields:
- Respiratory System
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Question 4
Correct
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A 50-year-old woman with a recent diagnosis of COPD is admitted to the hospital for treatment of an exacerbation caused by infection. She reports smoking 10 cigarettes per day and has a family history of lung cancer. Her chest x-ray shows signs of emphysema, and she mentions that her parents and siblings also have the disease. She asks for advice on the best course of action to improve her prognosis.
Your Answer: Stop smoking
Explanation:The most crucial step to enhance the patient’s prognosis is to assist them in quitting smoking. While lung reduction surgery and long-term oxygen therapy may benefit certain patient groups, smoking cessation remains the top priority. Proper inhaler technique and adherence, as well as the use of home nebulizers, can provide symptomatic relief for the patient.
The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenzae vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.
Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.
If the patient does not have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.
Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE does not recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers
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This question is part of the following fields:
- Respiratory System
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Question 5
Correct
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A 27-year-old woman, who has had eczema and asthma since childhood, comes for her yearly asthma check-up. She has been using her salbutamol inhaler more frequently over the last 3 months and is concerned that it may be due to getting a new kitten. In allergic asthma, which cell is present in excessive amounts?
Your Answer: Eosinophils
Explanation:The patient’s medical background indicates that she may have atopic asthma. It is probable that her symptoms have worsened and she has had to use more salbutamol reliever due to an allergy to her new kitten’s animal dander.
Individuals with allergic asthma have been found to have increased levels of eosinophils in their airways. The severity of asthma is linked to the number of eosinophils present, as they contribute to long-term airway inflammation by causing damage, blockages, and hyperresponsiveness.
The immediate symptoms of asthma after exposure are caused by mast cell degranulation.
Asthma is a common respiratory disorder that affects both children and adults. It is characterized by chronic inflammation of the airways, resulting in reversible bronchospasm and airway obstruction. While asthma can develop at any age, it typically presents in childhood and may improve or resolve with age. However, it can also persist into adulthood and cause significant morbidity, with around 1,000 deaths per year in the UK.
Several risk factors can increase the likelihood of developing asthma, including a personal or family history of atopy, antenatal factors such as maternal smoking or viral infections, low birth weight, not being breastfed, exposure to allergens and air pollution, and the hygiene hypothesis. Patients with asthma may also suffer from other atopic conditions such as eczema and hay fever, and some may be sensitive to aspirin. Occupational asthma is also a concern for those exposed to allergens in the workplace.
Symptoms of asthma include coughing, dyspnea, wheezing, and chest tightness, with coughing often worse at night. Signs may include expiratory wheezing on auscultation and reduced peak expiratory flow rate. Diagnosis is typically made through spirometry, which measures the volume and speed of air during exhalation and inhalation.
Management of asthma typically involves the use of inhalers to deliver drug therapy directly to the airways. Short-acting beta-agonists such as salbutamol are the first-line treatment for relieving symptoms, while inhaled corticosteroids like beclometasone dipropionate and fluticasone propionate are used for daily maintenance therapy. Long-acting beta-agonists like salmeterol and leukotriene receptor antagonists like montelukast may also be used in combination with other medications. Maintenance and reliever therapy (MART) is a newer approach that combines ICS and a fast-acting LABA in a single inhaler for both daily maintenance and symptom relief. Recent guidelines recommend offering a leukotriene receptor antagonist instead of a LABA for patients on SABA + ICS whose asthma is not well controlled, and considering MART for those with poorly controlled asthma.
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This question is part of the following fields:
- Respiratory System
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Question 6
Incorrect
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A 20-year-old woman comes to your general practice complaining of hearing difficulties for the past month. She was previously diagnosed with tinnitus by one of your colleagues at the practice 11 months ago. The patient reports that she can hear better when outside but struggles in quiet environments. Upon otoscopy, no abnormalities are found. Otosclerosis is one of the differential diagnoses for this patient, which primarily affects the ossicle that connects to the cochlea. What is the name of the ossicle that attaches to the cochlea at the oval window?
Your Answer: Calcaneus
Correct Answer: Stapes
Explanation:The stapes bone is the correct answer.
The ossicles are three bones located in the middle ear. They are arranged from lateral to medial and include the malleus, incus, and stapes. The malleus is the most lateral bone and its handle and lateral process attach to the tympanic membrane, making it visible on otoscopy. The head of the malleus articulates with the incus. The stapes bone is the most medial of the ossicles and is also known as the stirrup.
Anatomy of the Ear
The ear is divided into three distinct regions: the external ear, middle ear, and internal ear. The external ear consists of the auricle and external auditory meatus, which are innervated by the greater auricular nerve and auriculotemporal branch of the trigeminal nerve. The middle ear is the space between the tympanic membrane and cochlea, and is connected to the nasopharynx by the eustachian tube. The tympanic membrane is composed of three layers and is approximately 1 cm in diameter. The middle ear is innervated by the glossopharyngeal nerve. The ossicles, consisting of the malleus, incus, and stapes, transmit sound vibrations from the tympanic membrane to the inner ear. The internal ear contains the cochlea, which houses the organ of corti, the sense organ of hearing. The vestibule accommodates the utricule and saccule, which contain endolymph and are surrounded by perilymph. The semicircular canals, which share a common opening into the vestibule, lie at various angles to the petrous temporal bone.
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This question is part of the following fields:
- Respiratory System
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Question 7
Correct
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Which of the structures listed below are not located within the mediastinum?
Your Answer: Vertebral bodies
Explanation:Both the lungs and vertebral bodies are located outside of the mediastinum.
The mediastinum is the area located between the two pulmonary cavities and is covered by the mediastinal pleura. It extends from the thoracic inlet at the top to the diaphragm at the bottom. The mediastinum is divided into four regions: the superior mediastinum, middle mediastinum, posterior mediastinum, and anterior mediastinum.
The superior mediastinum is the area between the manubriosternal angle and T4/5. It contains important structures such as the superior vena cava, brachiocephalic veins, arch of aorta, thoracic duct, trachea, oesophagus, thymus, vagus nerve, left recurrent laryngeal nerve, and phrenic nerve. The anterior mediastinum contains thymic remnants, lymph nodes, and fat. The middle mediastinum contains the pericardium, heart, aortic root, arch of azygos vein, and main bronchi. The posterior mediastinum contains the oesophagus, thoracic aorta, azygos vein, thoracic duct, vagus nerve, sympathetic nerve trunks, and splanchnic nerves.
In summary, the mediastinum is a crucial area in the thorax that contains many important structures and is divided into four regions. Each region contains different structures that are essential for the proper functioning of the body.
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This question is part of the following fields:
- Respiratory System
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Question 8
Incorrect
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What is the embryonic origin of the pulmonary artery?
Your Answer: Fifth pharyngeal arch
Correct Answer: Sixth pharyngeal arch
Explanation:The right pulmonary artery originates from the proximal portion of the sixth pharyngeal arch on the right side, while the distal portion of the same arch gives rise to the left pulmonary artery and the ductus arteriosus.
The Development and Contributions of Pharyngeal Arches
During the fourth week of embryonic growth, a series of mesodermal outpouchings develop from the pharynx, forming the pharyngeal arches. These arches fuse in the ventral midline, while pharyngeal pouches form on the endodermal side between the arches. There are six pharyngeal arches, with the fifth arch not contributing any useful structures and often fusing with the sixth arch.
Each pharyngeal arch has its own set of muscular and skeletal contributions, as well as an associated endocrine gland, artery, and nerve. The first arch contributes muscles of mastication, the maxilla, Meckel’s cartilage, and the incus and malleus bones. The second arch contributes muscles of facial expression, the stapes bone, and the styloid process and hyoid bone. The third arch contributes the stylopharyngeus muscle, the greater horn and lower part of the hyoid bone, and the thymus gland. The fourth arch contributes the cricothyroid muscle, all intrinsic muscles of the soft palate, the thyroid and epiglottic cartilages, and the superior parathyroids. The sixth arch contributes all intrinsic muscles of the larynx (except the cricothyroid muscle), the cricoid, arytenoid, and corniculate cartilages, and is associated with the pulmonary artery and recurrent laryngeal nerve.
Overall, the development and contributions of pharyngeal arches play a crucial role in the formation of various structures in the head and neck region.
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This question is part of the following fields:
- Respiratory System
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Question 9
Incorrect
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A 24-year-old man is admitted to the emergency department after a car accident. During the initial evaluation, he complains of difficulty breathing. A portable chest X-ray shows a 3 cm gap between the right lung margin and the chest wall, indicating a significant traumatic pneumothorax. The medical team administers high-flow oxygen and performs a right-sided chest drain insertion to drain the pneumothorax.
What is a potential negative outcome that could arise from the insertion of a chest drain?Your Answer: Hospital-acquired pneumonia
Correct Answer: Winging of the scapula
Explanation:Insertion of a chest drain poses a risk of damaging the long thoracic nerve, which runs from the neck to the serratus anterior muscle. This can result in weakness or paralysis of the muscle, causing a winged scapula that is noticeable along the medial border of the scapula. It is important to use aseptic technique during the procedure to prevent hospital-acquired pleural infection. Chylothorax, pneumothorax, and pyothorax are all conditions that may require chest drain insertion, but they are not known complications of the procedure. Therefore, these options are not applicable.
Anatomy of Chest Drain Insertion
Chest drain insertion is necessary for various medical conditions such as trauma, haemothorax, pneumothorax, and pleural effusion. The size of the chest drain used depends on the specific condition being treated. While ultrasound guidance is an option, the anatomical method is typically tested in exams.
It is recommended that chest drains are placed in the safe triangle, which is located in the mid axillary line of the 5th intercostal space. This triangle is bordered by the anterior edge of the latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla. Another triangle, known as the triangle of auscultation, is situated behind the scapula and is bounded by the trapezius, latissimus dorsi, and vertebral border of the scapula. By folding the arms across the chest and bending forward, parts of the sixth and seventh ribs and the interspace between them become subcutaneous and available for auscultation.
References:
– Prof Harold Ellis. The applied anatomy of chest drains insertions. British Journal of hospital medicine 2007; (68): 44-45.
– Laws D, Neville E, Duffy J. BTS guidelines for insertion of chest drains. Thorax, 2003; (58): 53-59. -
This question is part of the following fields:
- Respiratory System
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Question 10
Incorrect
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A 54-year-old man complains of facial pain and discomfort during meals. He has been experiencing halitosis and a dry mouth. Additionally, he has a lump under his left mandible. What is the probable underlying diagnosis?
Your Answer: Adenocarcinoma of the submandibular gland
Correct Answer: Stone impacted in Whartons duct
Explanation:The signs are indicative of sialolithiasis, which usually involves the formation of stones in the submandibular gland and can block Wharton’s duct. Stensen’s duct, on the other hand, is responsible for draining the parotid gland.
Diseases of the Submandibular Glands
The submandibular glands are responsible for producing mixed seromucinous secretions, which can range from more serous to more mucinous depending on parasympathetic activity. These glands secrete approximately 800-1000ml of saliva per day, with parasympathetic fibers derived from the chorda tympani nerves and the submandibular ganglion. However, several conditions can affect the submandibular glands.
One such condition is sialolithiasis, which occurs when salivary gland calculi form in the submandibular gland. These stones are usually composed of calcium phosphate or calcium carbonate and can cause colicky pain and postprandial swelling of the gland. Sialography is used to investigate the site of obstruction and associated stones, with impacted stones in the distal aspect of Wharton’s duct potentially removed orally. However, other stones and chronic inflammation may require gland excision.
Sialadenitis is another condition that can affect the submandibular glands, usually as a result of Staphylococcus aureus infection. This can cause pus to leak from the duct and erythema to be noted. A submandibular abscess may develop, which is a serious complication as it can spread through other deep fascial spaces and occlude the airway.
Finally, submandibular tumors can also affect these glands, with only 8% of salivary gland tumors affecting the submandibular gland. Of these, 50% are malignant, usually adenoid cystic carcinoma. Diagnosis usually involves fine needle aspiration cytology, with imaging using CT and MRI. Due to the high prevalence of malignancy, all masses of the submandibular glands should generally be excised.
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This question is part of the following fields:
- Respiratory System
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Question 11
Correct
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A 65-year-old male with a history of chronic obstructive pulmonary disease (COPD) has been admitted and treated for infective exacerbations of COPD three times in the past year. Despite his respiratory issues, he continues to smoke. He is currently receiving only short-acting beta2-agonist therapy. During his COPD patient review with the nurse practitioner at his local general practice, spirometry results reveal a drop in his FEV1 from 65% to 58%.
What is the most effective approach to manage his condition and prevent further decline in his FEV1?Your Answer: Smoking cessation
Explanation:The most effective intervention to slow the decrease in FEV1 experienced by patients with COPD is to stop smoking. If the patient has no asthmatic/steroid-responsive features, the next step in management would be to add a long-acting beta2-agonist (LABA) and a long-acting muscarinic antagonist. If the patient has asthmatic/steroid-responsive features, the next step would be to add a LABA and an inhaled corticosteroid. Oral theophylline is only considered if inhaled therapy is not possible, and oral prednisolone is only used during acute infective exacerbations of COPD to help with inflammation and is not a long-term solution to slow the reduction of FEV1.
The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenzae vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.
Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.
If the patient does not have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.
Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE does not recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers
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This question is part of the following fields:
- Respiratory System
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Question 12
Incorrect
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A 67-year-old man has been diagnosed with stage III lung cancer and is concerned about potential complications. What are the risks he may face?
Your Answer: Goodpasture's disease
Correct Answer: Pneumothorax
Explanation:Pneumothorax is more likely to occur in individuals with lung cancer.
Pneumothorax: Characteristics and Risk Factors
Pneumothorax is a medical condition characterized by the presence of air in the pleural cavity, which is the space between the lungs and the chest wall. This condition can occur spontaneously or as a result of trauma or medical procedures. There are several risk factors associated with pneumothorax, including pre-existing lung diseases such as COPD, asthma, cystic fibrosis, lung cancer, and Pneumocystis pneumonia. Connective tissue diseases like Marfan’s syndrome and rheumatoid arthritis can also increase the risk of pneumothorax. Ventilation, including non-invasive ventilation, can also be a risk factor.
Symptoms of pneumothorax tend to come on suddenly and can include dyspnoea, chest pain (often pleuritic), sweating, tachypnoea, and tachycardia. In some cases, catamenial pneumothorax can be the cause of spontaneous pneumothoraces occurring in menstruating women. This type of pneumothorax is thought to be caused by endometriosis within the thorax. Early diagnosis and treatment of pneumothorax are crucial to prevent complications and improve outcomes.
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This question is part of the following fields:
- Respiratory System
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Question 13
Incorrect
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A 26-year-old male is brought to the emergency department by his mother. He is agitated, restless, and anxious.
Upon examination, dilated pupils are observed, and an ECG reveals sinus tachycardia.
The patient has a medical history of chronic asthma and is currently taking modified-release theophylline tablets.
According to his mother, he returned from a trip to Pakistan last night and has been taking antibiotics for bacterial gastroenteritis for the past four days. He has three days left on his antibiotic course.
What could be the cause of his current presentation?Your Answer: Loperamide
Correct Answer: Ciprofloxacin
Explanation:Terbinafine is frequently prescribed for the treatment of fungal nail infections as an antifungal medication.
Theophylline and its Poisoning
Theophylline is a naturally occurring methylxanthine that is commonly used as a bronchodilator in the management of asthma and COPD. Its exact mechanism of action is still unknown, but it is believed to be a non-specific inhibitor of phosphodiesterase, resulting in an increase in cAMP. Other proposed mechanisms include antagonism of adenosine and prostaglandin inhibition.
However, theophylline poisoning can occur and is characterized by symptoms such as acidosis, hypokalemia, vomiting, tachycardia, arrhythmias, and seizures. In such cases, gastric lavage may be considered if the ingestion occurred less than an hour prior. Activated charcoal is also recommended, while whole-bowel irrigation can be performed if theophylline is in sustained-release form. Charcoal hemoperfusion is preferable to hemodialysis in managing theophylline poisoning.
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This question is part of the following fields:
- Respiratory System
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Question 14
Correct
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A 27-year-old woman is expecting her first baby. During routine midwife appointments, it was discovered that she has hypertension and proteinuria, which are signs of pre-eclampsia. To prevent respiratory distress syndrome, a complication of prematurity caused by inadequate pulmonary surfactant production, she will require steroid doses before induction of preterm labor. Which cell type is being targeted by corticosteroids in this patient?
Your Answer: Type 2 pneumocytes
Explanation:Types of Pneumocytes and Their Functions
Pneumocytes are specialized cells found in the lungs that play a crucial role in gas exchange. There are two main types of pneumocytes: type 1 and type 2. Type 1 pneumocytes are very thin squamous cells that cover around 97% of the alveolar surface. On the other hand, type 2 pneumocytes are cuboidal cells that secrete surfactant, a substance that reduces surface tension in the alveoli and prevents their collapse during expiration.
Type 2 pneumocytes start to develop around 24 weeks gestation, but adequate surfactant production does not take place until around 35 weeks. This is why premature babies are prone to respiratory distress syndrome. In addition, type 2 pneumocytes can differentiate into type 1 pneumocytes during lung damage, helping to repair and regenerate damaged lung tissue.
Apart from pneumocytes, there are also club cells (previously termed Clara cells) found in the bronchioles. These non-ciliated dome-shaped cells have a varied role, including protecting against the harmful effects of inhaled toxins and secreting glycosaminoglycans and lysozymes. Understanding the different types of pneumocytes and their functions is essential in comprehending the complex mechanisms involved in respiration.
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This question is part of the following fields:
- Respiratory System
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Question 15
Incorrect
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During a consultant-led ward round in the early morning, a patient recovering from endovascular thrombectomy for acute mesenteric ischemia is examined. The reports indicate an embolus in the superior mesenteric artery.
What is the correct description of the plane at which the superior mesenteric artery branches off the abdominal aorta and its corresponding vertebral body?Your Answer: Trans-tubercular plane - L5
Correct Answer: Transpyloric plane - L1
Explanation:The superior mesenteric artery originates from the abdominal aorta at the transpyloric plane, which is an imaginary axial plane located at the level of the L1 vertebral body and midway between the jugular notch and superior border of the pubic symphysis. Another transverse plane commonly used in anatomy is the subcostal plane, which passes through the 10th costal margin and the vertebral body L3. Additionally, the trans-tubercular plane, which is a horizontal plane passing through the iliac tubercles and in line with the 5th lumbar vertebrae, is often used to delineate abdominal regions in surface anatomy.
The Transpyloric Plane and its Anatomical Landmarks
The transpyloric plane is an imaginary horizontal line that passes through the body of the first lumbar vertebrae (L1) and the pylorus of the stomach. It is an important anatomical landmark used in clinical practice to locate various organs and structures in the abdomen.
Some of the structures that lie on the transpyloric plane include the left and right kidney hilum (with the left one being at the same level as L1), the fundus of the gallbladder, the neck of the pancreas, the duodenojejunal flexure, the superior mesenteric artery, and the portal vein. The left and right colic flexure, the root of the transverse mesocolon, and the second part of the duodenum also lie on this plane.
In addition, the upper part of the conus medullaris (the tapered end of the spinal cord) and the spleen are also located on the transpyloric plane. Knowing the location of these structures is important for various medical procedures, such as abdominal surgeries and diagnostic imaging.
Overall, the transpyloric plane serves as a useful reference point for clinicians to locate important anatomical structures in the abdomen.
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This question is part of the following fields:
- Respiratory System
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Question 16
Correct
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A 27-year-old man is undergoing respiratory spirometry. He performs a maximal inhalation followed by a maximal exhalation. Which of the following measurements will most accurately depict this process?
Your Answer: Vital capacity
Explanation:The maximum amount of air that can be breathed in and out within one minute is known as maximum voluntary ventilation.
Understanding Lung Volumes in Respiratory Physiology
In respiratory physiology, lung volumes can be measured to determine the amount of air that moves in and out of the lungs during breathing. The diagram above shows the different lung volumes that can be measured.
Tidal volume (TV) refers to the amount of air that is inspired or expired with each breath at rest. In males, the TV is 500ml while in females, it is 350ml.
Inspiratory reserve volume (IRV) is the maximum volume of air that can be inspired at the end of a normal tidal inspiration. The inspiratory capacity is the sum of TV and IRV. On the other hand, expiratory reserve volume (ERV) is the maximum volume of air that can be expired at the end of a normal tidal expiration.
Residual volume (RV) is the volume of air that remains in the lungs after maximal expiration. It increases with age and can be calculated by subtracting ERV from FRC. Speaking of FRC, it is the volume in the lungs at the end-expiratory position and is equal to the sum of ERV and RV.
Vital capacity (VC) is the maximum volume of air that can be expired after a maximal inspiration. It decreases with age and can be calculated by adding inspiratory capacity and ERV. Lastly, total lung capacity (TLC) is the sum of vital capacity and residual volume.
Physiological dead space (VD) is calculated by multiplying tidal volume by the difference between arterial carbon dioxide pressure (PaCO2) and end-tidal carbon dioxide pressure (PeCO2) and then dividing the result by PaCO2.
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This question is part of the following fields:
- Respiratory System
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Question 17
Correct
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A 75-year-old man visits his doctor complaining of weight loss and feeling full quickly. During the abdominal examination, the doctor notices a swollen lymph node in the left supraclavicular region. The doctor suspects that this could be a sign of gastric cancer with the spread of tumor emboli through the thoracic duct as it ascends from the abdomen into the mediastinum. Can you name the two other structures that pass through the diaphragm along with the thoracic duct?
Your Answer: Aorta and azygous vein
Explanation:The point at which the aorta, thoracic duct, and azygous vein cross the diaphragm is at T12, specifically at the aortic opening. This is also where the oesophageal branches of the left gastric veins, the vagal trunk, and the oesophagus pass through the diaphragm, at the oesophageal opening located at T10. The left phrenic nerve and sympathetic trunk have their own separate openings in the diaphragm. A lymph node in the left supraclavicular fossa, known as Virchow’s node, is a characteristic sign of early gastric carcinoma.
Structures Perforating the Diaphragm
The diaphragm is a dome-shaped muscle that separates the thoracic and abdominal cavities. It plays a crucial role in breathing by contracting and relaxing to create negative pressure in the lungs. However, there are certain structures that perforate the diaphragm, allowing them to pass through from the thoracic to the abdominal cavity. These structures include the inferior vena cava at the level of T8, the esophagus and vagal trunk at T10, and the aorta, thoracic duct, and azygous vein at T12.
To remember these structures and their corresponding levels, a helpful mnemonic is I 8(ate) 10 EGGS AT 12. This means that the inferior vena cava is at T8, the esophagus and vagal trunk are at T10, and the aorta, thoracic duct, and azygous vein are at T12. Knowing these structures and their locations is important for medical professionals, as they may need to access or treat them during surgical procedures or diagnose issues related to them.
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This question is part of the following fields:
- Respiratory System
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Question 18
Correct
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A 70-year-old man presents with haemoptysis and undergoes a bronchoscopy. The carina is noted to be widened. Where does the trachea bifurcate?
Your Answer: T5
Explanation:The trachea divides into two branches at the fifth thoracic vertebrae, or sometimes the sixth in individuals who are tall.
Anatomy of the Trachea
The trachea, also known as the windpipe, is a tube-like structure that extends from the C6 vertebrae to the upper border of the T5 vertebrae where it bifurcates into the left and right bronchi. It is supplied by the inferior thyroid arteries and the thyroid venous plexus, and innervated by branches of the vagus, sympathetic, and recurrent nerves.
In the neck, the trachea is anterior to the isthmus of the thyroid gland, inferior thyroid veins, and anastomosing branches between the anterior jugular veins. It is also surrounded by the sternothyroid, sternohyoid, and cervical fascia. Posteriorly, it is related to the esophagus, while laterally, it is in close proximity to the common carotid arteries, right and left lobes of the thyroid gland, inferior thyroid arteries, and recurrent laryngeal nerves.
In the thorax, the trachea is anterior to the manubrium, the remains of the thymus, the aortic arch, left common carotid arteries, and the deep cardiac plexus. Laterally, it is related to the pleura and right vagus on the right side, and the left recurrent nerve, aortic arch, and left common carotid and subclavian arteries on the left side.
Overall, understanding the anatomy of the trachea is important for various medical procedures and interventions, such as intubation and tracheostomy.
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This question is part of the following fields:
- Respiratory System
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Question 19
Correct
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A 75-year-old man presents to the Emergency Department with acute shortness of breath following a 4-day febrile illness. On initial assessment, his oxygen saturation is 70% on room air with a PaO2 of 4.2kpa on an arterial blood gas.
What would be the anticipated physiological response in this patient?Your Answer: Pulmonary artery vasoconstriction
Explanation:When faced with hypoxia, the pulmonary arteries undergo vasoconstriction, which redirects blood flow away from poorly oxygenated areas of the lungs and towards well-oxygenated regions. In cases where patients remain hypoxic despite optimal mechanical ventilation, inhaled nitric oxide can be used to induce pulmonary vasodilation and reverse this response.
The statement that increased tidal volume with decreased respiratory rate is a response to hypoxia is incorrect. While an increase in tidal volume may occur, it is typically accompanied by an increase in respiratory rate.
Pulmonary artery vasodilation is also incorrect. Hypoxia actually induces vasoconstriction in the pulmonary vasculature, as explained above.
Similarly, reduced tidal volume with increased respiratory rate is not a direct response to hypoxia. While respiratory rate may increase, tidal volumes typically increase in response to hypoxia.
In contrast to the pulmonary vessels, the systemic vasculature vasodilates in response to hypoxia.
The Effects of Hypoxia on Pulmonary Arteries
When the partial pressure of oxygen in the blood decreases, the pulmonary arteries undergo vasoconstriction. This means that the blood vessels narrow, allowing blood to be redirected to areas of the lung that are better aerated. This response is a natural mechanism that helps to improve the efficiency of gaseous exchange in the lungs. By diverting blood to areas with more oxygen, the body can ensure that the tissues receive the oxygen they need to function properly. Overall, hypoxia triggers a physiological response that helps to maintain homeostasis in the body.
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This question is part of the following fields:
- Respiratory System
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Question 20
Correct
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A 35-year-old female smoker presents with acute severe asthma.
The patient's SaO2 levels are at 91% even with 15 L of oxygen, and her pO2 is at 8.2 kPa (10.5-13). There is widespread expiratory wheezing throughout her chest.
The medical team administers IV hydrocortisone, 100% oxygen, and 5 mg of nebulised salbutamol and 500 micrograms of nebulised ipratropium, but there is little response. Nebulisers are repeated 'back-to-back,' but the patient remains tachypnoeic with wheezing, although there is good air entry.
What should be the next step in the patient's management?Your Answer: IV Magnesium
Explanation:Acute Treatment of Asthma
When dealing with acute asthma, the initial approach should be SOS, which stands for Salbutamol, Oxygen, and Steroids (IV). It is also important to organize a CXR to rule out pneumothorax. If the patient is experiencing bronchoconstriction, further efforts to treat it should be considered. If the patient is tiring or has a silent chest, ITU review may be necessary. Magnesium is recommended at a dose of 2 g over 30 minutes to promote bronchodilation, as low magnesium levels in bronchial smooth muscle can favor bronchoconstriction. IV theophylline may also be considered, but magnesium is typically preferred. While IV antibiotics may be necessary, promoting bronchodilation should be the initial focus. IV potassium may also be required as beta agonists can push down potassium levels. Oral prednisolone can wait, as IV hydrocortisone is already part of the SOS approach. Non-invasive ventilation is not recommended for the acute management of asthma.
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This question is part of the following fields:
- Respiratory System
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Question 21
Incorrect
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A 65-year-old male with a diagnosis of lung cancer presents with fatigue and lightheadedness. Upon examination, the following results are obtained:
Plasma sodium concentration 115 mmol/L (137-144)
Potassium 3.5 mmol/L (3.5-4.9)
Urea 3.2 mmol/L (2.5-7.5)
Creatinine 67 µmol/L (60-110)
What is the probable reason for his symptoms based on these findings?Your Answer: Hypoadrenalism due to adrenal metastases
Correct Answer: Syndrome of inappropriate ADH secretion
Explanation:Syndrome of Inappropriate ADH Secretion
Syndrome of inappropriate ADH secretion (SIADH) is a condition characterized by low levels of sodium in the blood. This is caused by the overproduction of antidiuretic hormone (ADH) by the posterior pituitary gland. Tumors such as bronchial carcinoma can cause the ectopic elaboration of ADH, leading to dilutional hyponatremia. The diagnosis of SIADH is one of exclusion, but it can be supported by a high urine sodium concentration with high urine osmolality.
Hypoadrenalism is less likely to cause hyponatremia, as it is usually associated with hyperkalemia and mild hyperuricemia. On the other hand, diabetes insipidus is a condition where the kidneys are unable to reabsorb water, leading to excessive thirst and urination.
It is important to diagnose and treat SIADH promptly to prevent complications such as seizures, coma, and even death. Treatment options include fluid restriction, medications to block the effects of ADH, and addressing the underlying cause of the condition.
In conclusion, SIADH is a condition that can cause low levels of sodium in the blood due to the overproduction of ADH. It is important to differentiate it from other conditions that can cause hyponatremia and to treat it promptly to prevent complications.
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This question is part of the following fields:
- Respiratory System
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Question 22
Correct
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A 25-year-old woman visits the outpatient department with concerns of eyelid drooping, double vision, shortness of breath, and rapid breathing. These symptoms typically occur in the evening or after physical activity.
What respiratory condition could be causing her symptoms?Your Answer: Restrictive lung disease
Explanation:The presence of myasthenia gravis can result in a restrictive pattern of lung disease due to weakened chest wall muscles, leading to incomplete expansion during inhalation.
Occupational lung disease, also known as pneumoconioses, is caused by inhaling specific types of dust particles in the workplace, resulting in a restrictive pattern of lung disease. However, symptoms such as drooping eyelids and double vision are typically not associated with this condition.
Pneumonia is an infection of the lung tissue that typically presents with symptoms such as coughing, chest pain, fever, and difficulty breathing.
Pulmonary embolism is an acute condition that presents with symptoms such as chest pain, shortness of breath, and coughing up blood.
Understanding the Differences between Obstructive and Restrictive Lung Diseases
Obstructive and restrictive lung diseases are two distinct categories of respiratory conditions that affect the lungs in different ways. Obstructive lung diseases are characterized by a reduction in the flow of air through the airways due to narrowing or blockage, while restrictive lung diseases are characterized by a decrease in lung volume or capacity, making it difficult to breathe in enough air.
Spirometry is a common diagnostic tool used to differentiate between obstructive and restrictive lung diseases. In obstructive lung diseases, the ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is less than 80%, indicating a reduced ability to exhale air. In contrast, restrictive lung diseases are characterized by an FEV1/FVC ratio greater than 80%, indicating a reduced ability to inhale air.
Examples of obstructive lung diseases include chronic obstructive pulmonary disease (COPD), chronic bronchitis, and emphysema, while asthma and bronchiectasis are also considered obstructive. Restrictive lung diseases include intrapulmonary conditions such as idiopathic pulmonary fibrosis, extrinsic allergic alveolitis, and drug-induced fibrosis, as well as extrapulmonary conditions such as neuromuscular diseases, obesity, and scoliosis.
Understanding the differences between obstructive and restrictive lung diseases is important for accurate diagnosis and appropriate treatment. While both types of conditions can cause difficulty breathing, the underlying causes and treatment approaches can vary significantly.
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This question is part of the following fields:
- Respiratory System
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Question 23
Incorrect
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A 29-year-old male is injured by a gunshot to his right chest resulting in a right haemothorax that requires a thoracotomy. During the procedure, the surgeons opt to use a vascular clamp to secure the hilum of the right lung. What structure will be positioned most anteriorly at this location?
Your Answer: Pulmonary vein
Correct Answer: Phrenic nerve
Explanation:At the base of the right lung, the phrenic nerve is located in the anterior position.
Anatomy of the Lungs
The lungs are a pair of organs located in the chest cavity that play a vital role in respiration. The right lung is composed of three lobes, while the left lung has two lobes. The apex of both lungs is approximately 4 cm superior to the sternocostal joint of the first rib. The base of the lungs is in contact with the diaphragm, while the costal surface corresponds to the cavity of the chest. The mediastinal surface contacts the mediastinal pleura and has the cardiac impression. The hilum is a triangular depression above and behind the concavity, where the structures that form the root of the lung enter and leave the viscus. The right main bronchus is shorter, wider, and more vertical than the left main bronchus. The inferior borders of both lungs are at the 6th rib in the mid clavicular line, 8th rib in the mid axillary line, and 10th rib posteriorly. The pleura runs two ribs lower than the corresponding lung level. The bronchopulmonary segments of the lungs are divided into ten segments, each with a specific function.
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This question is part of the following fields:
- Respiratory System
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Question 24
Correct
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The pressure within the pleural space is positive with respect to atmospheric pressure, in which of the following scenarios?
Your Answer: During a Valsalva manoeuvre
Explanation:Extrinsic compression causes an increase in intrapleural pressure during a Valsalva manoeuvre.
Understanding Pleural Pressure
Pleural pressure refers to the pressure surrounding the lungs within the pleural space. The pleura is a thin membrane that invests the lungs and lines the walls of the thoracic cavity. The visceral pleura covers the lung, while the parietal pleura covers the chest wall. The two sides are continuous and meet at the hilum of the lung. The size of the lung is determined by the difference between the alveolar pressure and the pleural pressure, or the transpulmonary pressure.
During quiet breathing, the pleural pressure is negative, meaning it is below atmospheric pressure. However, during active expiration, the abdominal muscles contract to force up the diaphragm, resulting in positive pleural pressure. This may temporarily collapse the bronchi and cause limitation of air flow.
Gravity affects pleural pressure, with the pleural pressure at the base of the lung being greater (less negative) than at its apex in an upright individual. When lying on the back, the pleural pressure becomes greatest along the back. Alveolar pressure is uniform throughout the lung, so the top of the lung generally experiences a greater transpulmonary pressure and is therefore more expanded and less compliant than the bottom of the lung.
In summary, understanding pleural pressure is important in understanding lung function and how it is affected by various factors such as gravity and muscle contraction.
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This question is part of the following fields:
- Respiratory System
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Question 25
Incorrect
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Which of the following physiological changes does not take place after a tracheostomy?
Your Answer: Proportion of ciliated epithelial cells in the trachea may decrease.
Correct Answer: Work of breathing is increased.
Explanation:HFNC is a popular option for weaning ventilated patients as it reduces work of breathing and humidified air helps to reduce mucous viscosity.
Anatomy of the Trachea
The trachea, also known as the windpipe, is a tube-like structure that extends from the C6 vertebrae to the upper border of the T5 vertebrae where it bifurcates into the left and right bronchi. It is supplied by the inferior thyroid arteries and the thyroid venous plexus, and innervated by branches of the vagus, sympathetic, and recurrent nerves.
In the neck, the trachea is anterior to the isthmus of the thyroid gland, inferior thyroid veins, and anastomosing branches between the anterior jugular veins. It is also surrounded by the sternothyroid, sternohyoid, and cervical fascia. Posteriorly, it is related to the esophagus, while laterally, it is in close proximity to the common carotid arteries, right and left lobes of the thyroid gland, inferior thyroid arteries, and recurrent laryngeal nerves.
In the thorax, the trachea is anterior to the manubrium, the remains of the thymus, the aortic arch, left common carotid arteries, and the deep cardiac plexus. Laterally, it is related to the pleura and right vagus on the right side, and the left recurrent nerve, aortic arch, and left common carotid and subclavian arteries on the left side.
Overall, understanding the anatomy of the trachea is important for various medical procedures and interventions, such as intubation and tracheostomy.
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This question is part of the following fields:
- Respiratory System
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Question 26
Incorrect
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A 10-year-old boy comes to your clinic with a complaint of ear pain that started last night and kept him awake. He missed school today because of the pain and reports muffled sounds on the affected side. During otoscopy, you observe a bulging tympanic membrane with visible fluid behind it, indicating a middle ear infection. Can you identify which nerves pass through the middle ear?
Your Answer: Vestibulocochlear nerve
Correct Answer: Chorda tympani
Explanation:The chorda tympani is the correct answer. It is a branch of the seventh cranial nerve, the facial nerve, and carries parasympathetic and taste fibers. It passes through the middle ear before exiting and joining with the lingual nerve to reach the tongue and salivary glands.
The vestibulocochlear nerve is the eighth cranial nerve and carries balance and hearing information.
The maxillary nerve is the second division of the fifth cranial nerve and carries sensation from the upper teeth, nasal cavity, and skin.
The mandibular nerve is the third division of the fifth cranial nerve and carries sensation from the lower teeth, tongue, mandible, and skin. It also carries motor fibers to certain muscles.
The glossopharyngeal nerve is the ninth cranial nerve and carries taste and sensation from the posterior one-third of the tongue, as well as sensation from various areas. It also carries motor and parasympathetic fibers.
The patient in the question has ear pain, likely due to otitis media, as evidenced by a bulging tympanic membrane and fluid level on otoscopy.
Anatomy of the Ear
The ear is divided into three distinct regions: the external ear, middle ear, and internal ear. The external ear consists of the auricle and external auditory meatus, which are innervated by the greater auricular nerve and auriculotemporal branch of the trigeminal nerve. The middle ear is the space between the tympanic membrane and cochlea, and is connected to the nasopharynx by the eustachian tube. The tympanic membrane is composed of three layers and is approximately 1 cm in diameter. The middle ear is innervated by the glossopharyngeal nerve. The ossicles, consisting of the malleus, incus, and stapes, transmit sound vibrations from the tympanic membrane to the inner ear. The internal ear contains the cochlea, which houses the organ of corti, the sense organ of hearing. The vestibule accommodates the utricule and saccule, which contain endolymph and are surrounded by perilymph. The semicircular canals, which share a common opening into the vestibule, lie at various angles to the petrous temporal bone.
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This question is part of the following fields:
- Respiratory System
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Question 27
Incorrect
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A 56-year-old woman comes to the clinic complaining of a persistent cough and increased production of sputum over the past year. She also reports feeling fatigued and experiencing shortness of breath. The patient mentions having had four chest infections in the last 12 months, all of which were treated with antibiotics. She has no personal or family history of lung issues and has never smoked.
The healthcare provider suspects that bronchiectasis may be the underlying cause of her symptoms and orders appropriate tests.
Which test is most likely to provide a definitive diagnosis?Your Answer: Chest radiography
Correct Answer: High-resolution computerised tomography
Explanation:Bronchiectasis can be diagnosed through various methods, including chest radiography, histopathology, and pulmonary function tests.
Chest radiography can reveal thickened bronchial walls, cystic lesions with fluid levels, collapsed areas with crowded pulmonary vasculature, and scarring, which are characteristic features of bronchiectasis.
Histopathology, which is a more invasive investigation often done through autopsy or surgery, can show irreversible dilation of bronchial airways and bronchial wall thickening.
However, high-resolution computerised tomography is a more favorable imaging technique as it is less invasive than histopathology.
Pulmonary function tests are commonly used to diagnose bronchiectasis, but they should be used in conjunction with other investigations as they are not sensitive or specific enough to provide sufficient diagnostic evidence on their own. An obstructive pattern is the most common pattern encountered, but a restrictive pattern is also possible.
Understanding the Causes of Bronchiectasis
Bronchiectasis is a condition characterized by the permanent dilation of the airways due to chronic inflammation or infection. There are various factors that can lead to this condition, including post-infective causes such as tuberculosis, measles, pertussis, and pneumonia. Cystic fibrosis, bronchial obstruction caused by lung cancer or foreign bodies, and immune deficiencies like selective IgA and hypogammaglobulinaemia can also contribute to bronchiectasis. Additionally, allergic bronchopulmonary aspergillosis (ABPA), ciliary dyskinetic syndromes like Kartagener’s syndrome and Young’s syndrome, and yellow nail syndrome are other potential causes. Understanding the underlying causes of bronchiectasis is crucial in developing effective treatment plans for patients.
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This question is part of the following fields:
- Respiratory System
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Question 28
Incorrect
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A 35-year-old female presents with recurrent episodes of severe vertigo that have been disabling. She experiences these episodes multiple times a day, with each one lasting for about 10-20 minutes. Along with the vertigo, she also experiences ringing in both ears, nausea, and vomiting. She has noticed a change in her hearing in both ears, with difficulty hearing at times and normal hearing at other times. Additionally, she reports increased pressure in her ears. During the examination, you notice a painless rash behind her ear that has been present for many years.
What is the most likely diagnosis?Your Answer:
Correct Answer: Meniere’s disease
Explanation:Suspect Meniere’s disease in a patient presenting with vertigo, tinnitus, and fluctuating sensorineural hearing loss. Acoustic neuroma would present with additional symptoms such as facial numbness and loss of corneal reflex. Herpes Zoster Oticus (Ramsey Hunt syndrome) would present with facial palsy and a painless rash. Vestibular neuronitis would have longer episodes of vertigo, nausea, and vomiting, but no hearing loss. Benign paroxysmal positional vertigo would have brief episodes of vertigo after sudden head movements.
Meniere’s disease is a condition that affects the inner ear and its cause is unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.
The natural history of Meniere’s disease is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.
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This question is part of the following fields:
- Respiratory System
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Question 29
Incorrect
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A 63-year-old man arrives at the ER with a recent onset of left-sided facial paralysis. He reports experiencing a painful rash around his ear on the affected side for the past five days. Your suspicion is Ramsay Hunt syndrome. What virus is responsible for this condition?
Your Answer:
Correct Answer: Varicella zoster virus
Explanation:The geniculate ganglion of the facial nerve (CN VII) reactivates the varicella-zoster virus, causing Ramsay Hunt syndrome.
Infectious mononucleosis (glandular fever) is primarily linked to the Epstein-Barr virus.
Viral warts are commonly caused by human papillomavirus (HPV), with certain types being associated with gynaecological malignancy. Vaccines are now available to protect against the carcinogenic strains of HPV.
Oral or genital herpes infections are caused by the herpes simplex virus.
Understanding Ramsay Hunt Syndrome
Ramsay Hunt syndrome, also known as herpes zoster oticus, is a condition that occurs when the varicella zoster virus reactivates in the geniculate ganglion of the seventh cranial nerve. The first symptom of this syndrome is often auricular pain, followed by facial nerve palsy and a vesicular rash around the ear. Other symptoms may include vertigo and tinnitus.
To manage Ramsay Hunt syndrome, doctors typically prescribe oral acyclovir and corticosteroids. These medications can help reduce the severity of symptoms and prevent complications.
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This question is part of the following fields:
- Respiratory System
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Question 30
Incorrect
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A 53-year-old man arrives at the Emergency Department with jaundice and a distended abdomen. He has a history of alcoholism and has been hospitalized before for acute alcohol withdrawal. During the examination, you observe spider naevi on his upper chest wall and detect a shifting dullness on abdominal percussion, indicating ascites. Further imaging and investigation reveal portal vein hypertension and cirrhosis.
Where does this vessel start?Your Answer:
Correct Answer: L1
Explanation:Portal hypertension is commonly caused by liver cirrhosis, often due to alcohol abuse. The causes of this condition can be categorized as pre-hepatic, hepatic, or post-hepatic, depending on the location of the underlying pathology. The primary factors contributing to portal hypertension are increased vascular resistance in the portal venous system and elevated blood flow in the portal veins. The portal vein originates at the transpyloric plane, which is situated at the level of the body of L1. Other significant structures found at this location include the neck of the pancreas, the spleen, the duodenojejunal flexure, and the superior mesenteric artery.
The Transpyloric Plane and its Anatomical Landmarks
The transpyloric plane is an imaginary horizontal line that passes through the body of the first lumbar vertebrae (L1) and the pylorus of the stomach. It is an important anatomical landmark used in clinical practice to locate various organs and structures in the abdomen.
Some of the structures that lie on the transpyloric plane include the left and right kidney hilum (with the left one being at the same level as L1), the fundus of the gallbladder, the neck of the pancreas, the duodenojejunal flexure, the superior mesenteric artery, and the portal vein. The left and right colic flexure, the root of the transverse mesocolon, and the second part of the duodenum also lie on this plane.
In addition, the upper part of the conus medullaris (the tapered end of the spinal cord) and the spleen are also located on the transpyloric plane. Knowing the location of these structures is important for various medical procedures, such as abdominal surgeries and diagnostic imaging.
Overall, the transpyloric plane serves as a useful reference point for clinicians to locate important anatomical structures in the abdomen.
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This question is part of the following fields:
- Respiratory System
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