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Question 1
Incorrect
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An older woman presents to the Emergency Department with probable community acquired pneumonia (CAP). The consultant asks you to refer to the CURB-65 score to determine the next management plan.
Which of the following statements is part of the CURB-65 score?Your Answer: Respiratory rate > 24 breaths per minute
Correct Answer: Urea > 7 mmol/l
Explanation:Understanding the CURB-65 Score for Assessing Severity of CAP
The CURB-65 score is a clinical prediction tool recommended by the British Thoracic Society for assessing the severity of community-acquired pneumonia (CAP). It is a 6-point score based on five criteria: confusion, urea level, respiratory rate, blood pressure, and age. Patients with a score of 0 are at low risk and may not require hospitalization, while those with a score of 3 or more are at higher risk of death and may require urgent admission. It is important to use the correct criteria for each parameter, such as an Abbreviated Mental Test Score of 8 or less for confusion and a respiratory rate of 30 or more for tachypnea. Understanding and documenting the CURB-65 score can aid in clinical decision-making for patients with CAP.
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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 58-year-old Afro-Caribbean man presents to you with increasing difficulty in breathing and shortness of breath. A chest examination reveals decreased expansion on the right side of the chest, along with decreased breath sounds and stony dullness to percussion. A chest X-ray reveals a pleural effusion which you proceed to tap for diagnostic serum biochemistry, cytology and culture. The cytology and culture results are still awaited, although the serum biochemistry returns back showing the following:
Pleural fluid protein 55 g/dl
Pleural fluid cholesterol 4.5 g/dl
Pleural fluid lactate dehydrogenase (LDH) : serum ratio 0.7
Which of the following might be considered as a diagnosis in this patient?Your Answer: Sarcoidosis
Explanation:Differentiating Causes of Pleural Effusion: Sarcoidosis, Myxoedema, Meigs Syndrome, Cardiac Failure, and Nephrotic Syndrome
When analyzing a pleural effusion, the protein levels can help differentiate between potential causes. An exudate pleural effusion, with protein levels greater than 30 g/l, can be caused by inflammatory or malignant conditions such as sarcoidosis, tuberculosis, or carcinoma. However, if the protein level falls between 25 and 35 g/l, Light’s criteria should be applied to accurately differentiate. On the other hand, a transudate pleural effusion, with protein levels less than 30 g/l, can be caused by conditions such as myxoedema or cardiac failure. Meigs syndrome, a pleural effusion caused by a benign ovarian tumor, and nephrotic syndrome, which causes a transudate pleural effusion, can also be ruled out based on the biochemistry results. It is important to consider all potential causes and conduct further investigations to properly diagnose and manage the underlying condition.
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This question is part of the following fields:
- Respiratory
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Question 3
Correct
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A 62-year-old man who is a smoker presents with gradual-onset shortness of breath, over the last month. Chest radiograph shows a right pleural effusion.
What would be the most appropriate next investigation?Your Answer: Pleural aspirate
Explanation:Investigations for Pleural Effusion: Choosing the Right Test
When a patient presents with dyspnoea and a suspected pleural effusion, choosing the right investigation is crucial for accurate diagnosis and management. Here are some of the most appropriate investigations for different types of pleural effusions:
1. Pleural aspirate: This is the most appropriate next investigation to measure the protein content and determine whether the fluid is an exudate or a transudate.
2. Computerised tomography (CT) of the chest: An exudative effusion would prompt investigation with CT of the chest or thoracoscopy to look for conditions such as malignancy or tuberculosis (TB).
3. Bronchoscopy: Bronchoscopy would be appropriate if there was need to obtain a biopsy for a suspected tumour, but so far no lesion has been identified.
4. Echocardiogram: A transudative effusion would prompt investigations such as an echocardiogram to look for heart failure, or liver imaging to look for cirrhosis.
5. Spirometry: Spirometry would have been useful if chronic obstructive pulmonary disease (COPD) was suspected, but at this stage the pleural effusion is likely the cause of dyspnoea and should be investigated.
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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 65-year-old man comes to the Emergency Department with confusion and difficulty breathing, with an AMTS score of 9. During the examination, his respiratory rate is 32 breaths/minute, and his blood pressure is 100/70 mmHg. His blood test shows a urea level of 6 mmol/l. What is a predictive factor for increased mortality in this pneumonia patient?
Your Answer: Respiratory rate >30 breaths/minute
Explanation:Prognostic Indicators in Pneumonia: Understanding the CURB 65 Score
The CURB 65 score is a widely used prognostic tool for patients with pneumonia. It consists of five indicators, including confusion, urea levels, respiratory rate, blood pressure, and age. A respiratory rate of >30 breaths/minute and new-onset confusion with an AMTS score of <8 are two of the indicators that make up the CURB 65 score. However, in the case of a patient with a respiratory rate of 32 breaths/minute and an AMTS score of 9, these indicators still suggest a poor prognosis. A urea level of >7 mmol/l and a blood pressure of <90 mmHg systolic and/or 60 mmHg diastolic are also indicators of a poor prognosis. Finally, age >65 is another indicator that contributes to the CURB 65 score. Understanding these indicators can help healthcare professionals assess the severity of pneumonia and determine appropriate treatment plans.
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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 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 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 6
Incorrect
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A 50-year-old woman presents to the hospital with shortness of breath and lethargy for the past two weeks.
On clinical examination, there are reduced breath sounds, dullness to percussion and decreased vocal fremitus at the left base.
Chest X-ray reveals a moderate left-sided pleural effusions. A pleural aspirate is performed on the ward. Analysis is shown:
Aspirate Serum
Total protein 18.5 g/l 38 g/l
Lactate dehydrogenase (LDH) 1170 u/l 252 u/l
pH 7.37 7.38
What is the most likely cause of the pleural effusion?Your Answer: Pulmonary embolus
Correct Answer: Hypothyroidism
Explanation:Understanding Pleural Effusions: Causes and Criteria for Exudates
Pleural effusions, the accumulation of fluid in the pleural space surrounding the lungs, can be classified as exudates or transudates using Light’s criteria. While the traditional cut-off value of >30 g/l of protein to indicate an exudate and <30 g/l for a transudate is no longer recommended, Light's criteria still provide a useful framework for diagnosis. An exudate is indicated when the ratio of pleural fluid protein to serum protein is >0.5, the ratio of pleural fluid LDH to serum LDH is >0.6, or pleural fluid LDH is greater than 2/3 times the upper limit for serum.
Exudate effusions are typically caused by inflammation and disruption to cell architecture, while transudates are often associated with systematic illnesses that affect oncotic or hydrostatic pressure. In the case of hypothyroidism, an endocrine disorder, an exudative pleural effusion is consistent with overstimulation of the ovaries.
Other conditions that can cause exudative pleural effusions include pneumonia and pulmonary embolism. Mesothelioma, a type of cancer associated with asbestos exposure, can also cause an exudative pleural effusion, but is less likely in the absence of chest pain, persistent cough, and unexplained weight loss.
Understanding the causes and criteria for exudative pleural effusions can aid in the diagnosis and treatment of various medical conditions.
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This question is part of the following fields:
- Respiratory
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Question 7
Correct
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Emily is a 6-year-old overweight girl brought in by concerned parents who are worried about her loud snoring and frequent interruptions in breathing which have been getting progressively worse. Her parents have been receiving complaints from the school teachers about her disruptive and inattentive behaviour in class. On examination, Emily has a short, thick neck and mildly enlarged tonsils but no other abnormalities.
What is the next best step in management?Your Answer: Order an overnight polysomnographic study
Explanation:Childhood Obstructive Sleep Apnoea: Diagnosis and Treatment Options
Childhood obstructive sleep apnoea (OSA) is a pathological condition that requires prompt diagnosis and treatment. A polysomnographic study should be performed before booking for an operation, as adenotonsillectomy is the treatment of choice for childhood OSA.
The clinical presentation of childhood OSA is non-specific but typically includes symptoms such as mouth breathing, abnormal breathing during sleep, poor sleep with frequent awakening or restlessness, nocturnal enuresis, nightmares, difficulty awakening, excessive daytime sleepiness or hyperactivity, and behavioural problems. However, parents should be reassured that snoring loudly is very normal in children his age and that his behaviour pattern will improve as he matures.
Before any intervention is undertaken, the patient should be first worked up for OSA with a polysomnographic study. While dental splints may have a small role to play in OSA, they are not the ideal treatment option. Intranasal budesonide is an option for mild to moderate OSA, but it is only a temporising measure and not a proven effective long-term treatment.
In conclusion, childhood OSA requires prompt diagnosis and treatment. Adenotonsillectomy is the treatment of choice, but a polysomnographic study should be performed before any intervention is undertaken. Parents should be reassured that snoring loudly is normal in children his age, and other treatment options such as dental splints and intranasal budesonide should be considered only after a thorough evaluation.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 49-year-old Caucasian woman presents with a severe acute attack of bronchial asthma. For 1 week, she has had fever, malaise, anorexia and weight loss. She has tingling and numbness in her feet and hands. On examination, palpable purpura is present and nodular lesions are present on the skin. Investigations revealed eosinophilia, elevated erythrocyte sedimentation rate (ESR), fibrinogen, and α-2-globulin, positive p-ANCA, and a chest X-ray reveals pulmonary infiltrates.
Which one of the following is the most likely diagnosis?Your Answer: Hypereosinophilic syndrome
Correct Answer: Allergic granulomatosis (Churg-Strauss syndrome)
Explanation:Comparison of Vasculitis Conditions with Eosinophilia
Eosinophilia is a common feature in several vasculitis conditions, but the clinical presentation and histopathologic features can help differentiate between them. Allergic granulomatosis, also known as Churg-Strauss syndrome, is characterized by asthma, peripheral and tissue eosinophilia, granuloma formation, and vasculitis of multiple organ systems. In contrast, granulomatosis with polyangiitis (GPA) involves the lungs and upper respiratory tract and is c-ANCA positive, but does not typically present with asthma-like symptoms or peripheral eosinophilia. Polyarteritis nodosa (PAN) can present with multisystem involvement, but does not typically have an asthma-like presentation or peripheral eosinophilia. Hypereosinophilic syndrome, also known as chronic eosinophilic leukemia, is characterized by persistent eosinophilia in blood and exclusion of other causes of reactive eosinophilia. Finally, microscopic polyangiitis is similar to GPA in many aspects, but does not involve granuloma formation and does not typically present with peripheral eosinophilia.
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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 10-year-old boy visits his General Practitioner complaining of feeling unwell for the past two days. He reports having a sore throat, general malaise, and nasal congestion, but no cough or fever. During the examination, his pulse rate is 70 bpm, respiratory rate 18 breaths per minute, and temperature 37.3 °C. The doctor notes tender, swollen anterior cervical lymph nodes. What investigation should the doctor consider requesting?
Your Answer: Full blood count
Correct Answer: Throat swab
Explanation:Investigations for Upper Respiratory Tract Infections: A Case Study
When a patient presents with symptoms of an upper respiratory tract infection, it is important to consider appropriate investigations to differentiate between viral and bacterial causes. In this case study, a young boy presents with a sore throat, tender/swollen lymph nodes, and absence of a cough. A McIsaac score of 3 suggests a potential for streptococcal pharyngitis.
Throat swab is a useful investigation to differentiate between symptoms of the common cold and streptococcal pharyngitis. Sputum culture may be indicated if there is spread of the infection to the lower respiratory tract. A chest X-ray is not indicated as a first-line investigation, but may be later indicated if there is a spread to the lower respiratory tract. Full blood count is not routinely indicated, as it is only likely to show lymphocytosis for viral infections. Viral testing is not conducted routinely, unless required for public health research or data in the event of a disease outbreak.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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A 20-year-old male presents to the Emergency department with left-sided chest pain and difficulty breathing that started during a football game.
Which diagnostic test is most likely to provide a conclusive diagnosis?Your Answer: Echocardiogram
Correct Answer: Chest x ray
Explanation:Diagnosis of Pneumothorax
A pneumothorax is suspected based on the patient’s medical history. To confirm the diagnosis, a chest x-ray is the only definitive test available. An ECG is unlikely to show any abnormalities, while blood gas analysis may reveal a slightly elevated oxygen level and slightly decreased carbon dioxide level, even if the patient is not experiencing significant respiratory distress.
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This question is part of the following fields:
- Respiratory
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Question 11
Correct
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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: 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 12
Incorrect
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A 28-year-old Afro-Caribbean lady undergoes a routine chest X-ray during a career-associated medical examination. The chest X-ray report reveals bilateral hilar lymphadenopathy. On closer questioning the patient admits to symptoms of fatigue and weight loss and painful blue-red nodules on her shins.
What is the most likely diagnosis in this case?Your Answer: Tuberculosis
Correct Answer: Sarcoidosis
Explanation:Differential Diagnosis for a Patient with Hilar Lymphadenopathy and Erythema Nodosum
Sarcoidosis is a condition characterized by granulomas affecting multiple systems, with lung involvement being the most common. It typically affects young adults, especially females and Afro-Caribbean populations. While the cause is unknown, infections and environmental factors have been suggested. Symptoms include weight loss, fatigue, and fever, as well as erythema nodosum and anterior uveitis. Acute sarcoidosis usually resolves without treatment, while chronic sarcoidosis requires steroids and monitoring of lung function, ESR, CRP, and serum ACE levels.
Tuberculosis is a potential differential diagnosis, as it can also present with erythema nodosum and hilar lymphadenopathy. However, the absence of a fever and risk factors make it less likely.
Lung cancer is rare in young adults and typically presents as a mass or pleural effusion on X-ray.
Pneumonia is an infection of the lung parenchyma, but the absence of infective symptoms and consolidation on X-ray make it less likely.
Mesothelioma is a cancer associated with asbestos exposure and typically presents in older individuals. The absence of exposure and the patient’s age make it less likely.
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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 40-year-old Romanian smoker presents with a 3-month history of cough productive of blood-tinged sputum, fever, night sweats and weight loss. At presentation he is haemodynamically stable, has a fever of 37.7°C and appears cachectic. On examination, there are coarse crepitations in the right upper zone of lung. Chest radiograph reveals patchy, non-specific increased upper zone interstitial markings bilaterally together with a well-defined round opacity with a central lucency in the right upper zone and bilateral enlarged hila.
What is the most likely diagnosis?Your Answer: Squamous cell bronchial carcinoma
Correct Answer: Tuberculosis
Explanation:Differential Diagnosis for a Subacute Presentation of Pulmonary Symptoms
Tuberculosis is a growing concern, particularly in Eastern European countries where multi-drug resistant strains are on the rise. The initial infection can occur anywhere in the body, but often affects the lung apices and forms a scarred granuloma. Latent bacteria can cause reinfection years later, leading to post-primary TB. Diagnosis is based on identifying acid-fast bacilli in sputum. Treatment involves a 6-month regimen of antibiotics. Staphylococcal and Klebsiella pneumonia can also present with pneumonia symptoms and cavitating lesions, but patients would be expected to be very ill with signs of sepsis. Squamous cell bronchial carcinoma is a possibility but less likely in this case. Primary pulmonary lymphoma is rare and typically occurs in HIV positive individuals, with atypical presentation and radiographic findings. Contact screening is essential for TB.
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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 50-year-old farmer presents to his general practitioner (GP) with gradually progressive shortness of breath over the last year, along with an associated cough. He has no significant past medical history to note except for a previous back injury and is a non-smoker. He occasionally takes ibuprofen for back pain but is on no other medications. He has worked on farms since his twenties and acquired his own farm 10 years ago.
On examination, the patient has a temperature of 36.9oC and respiratory rate of 26. Examination of the chest reveals bilateral fine inspiratory crackles. His GP requests a chest X-ray, which shows bilateral reticulonodular shadowing.
Which one of the following is the most likely underlying cause of symptoms in this patient?Your Answer: Silicosis
Correct Answer: Extrinsic allergic alveolitis
Explanation:Causes of Pulmonary Fibrosis: Extrinsic Allergic Alveolitis
Pulmonary fibrosis is a condition characterized by shortness of breath and reticulonodular shadowing on chest X-ray. It can be caused by various factors, including exposure to inorganic dusts like asbestosis and beryllium, organic dusts like mouldy hay and avian protein, certain drugs, systemic diseases, and more. In this scenario, the patient’s occupation as a farmer suggests a possible diagnosis of extrinsic allergic alveolitis or hypersensitivity pneumonitis, which is caused by exposure to avian proteins or Aspergillus in mouldy hay. It is important to note that occupational lung diseases may entitle the patient to compensation. Non-steroidal anti-inflammatory drugs, silicosis, crocidolite exposure, and beryllium exposure are less likely causes in this case.
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 65-year-old woman presents to a spirometry clinic with a history of progressive dyspnea on exertion over the past six months, particularly when hurrying or walking uphill. What spirometry result would indicate a possible diagnosis of chronic obstructive pulmonary disease in this patient?
Your Answer:
Correct Answer:
Explanation:Interpreting Spirometry Results: Understanding FEV1 and FEV1/FVC Ratio
Spirometry is a common diagnostic test used to assess lung function. It measures the amount of air that can be exhaled forcefully and quickly after taking a deep breath. Two important measurements obtained from spirometry are the forced expiratory volume in 1 second (FEV1) and the ratio of FEV1 to forced vital capacity (FVC).
Identifying an obstructive disease pattern
In chronic obstructive pulmonary disease (COPD), the airways are obstructed, resulting in a reduced FEV1. However, the lung volume is relatively normal, and therefore the FVC will be near normal too. COPD is diagnosed as an FEV1 < 80% predicted and an FEV1/FVC < 0.70. Understanding the clinical scenario While an FEV1 < 30% predicted and an FEV1/FVC < 0.70 indicate an obstructive picture, it is important to refer to the clinical scenario. Shortness of breath on mild exertion, particularly walking up hills or when hurrying, is likely to relate to an FEV1 between 50-80%, defined by NICE as moderate airflow obstruction. Differentiating between obstructive and restrictive lung patterns An FVC < 80% expected value is indicative of a restrictive lung pattern. In COPD, the FVC is usually preserved or increased, hence the FEV1/FVC ratio decreases. An FEV1 of <0.30 indicates severe COPD, but it is not possible to have an FEV1/FVC ratio of > 0.70 with an FEV1 this low in COPD. It is important to note, however, that in patterns of restrictive lung disease, you can have a reduced FEV1 with a normal FEV1/FVC ratio.
Conclusion
Interpreting spirometry results requires an understanding of FEV1 and FEV1/FVC ratio. Identifying an obstructive disease pattern, understanding the clinical scenario, and differentiating between obstructive and restrictive lung patterns are crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Respiratory
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Question 16
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:
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 17
Incorrect
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A 65-year-old man presents with haemoptysis over the last 2 days. He has had a productive cough for 7 years, which has gradually worsened. Over the last few winters, he has been particularly bad and required admission to hospital. Past medical history includes pulmonary tuberculosis (TB) at age 20. On examination, he is cyanotic and clubbed, and has florid crepitations in both lower zones.
What is the most likely diagnosis?Your Answer:
Correct Answer: Bronchiectasis
Explanation:Diagnosing Respiratory Conditions: Bronchiectasis vs. Asthma vs. Pulmonary Fibrosis vs. COPD vs. Lung Cancer
Bronchiectasis is the most probable diagnosis for a patient who presents with copious sputum production, recurrent chest infections, haemoptysis, clubbing, cyanosis, and florid crepitations at both bases that change with coughing. This condition is often exacerbated by a previous history of tuberculosis.
Asthma, on the other hand, is characterized by reversible obstruction of airways due to bronchial muscle contraction in response to various stimuli. The absence of wheezing, the patient’s age, and the presence of haemoptysis make asthma an unlikely diagnosis in this case.
Pulmonary fibrosis involves parenchymal fibrosis and interstitial remodelling, leading to shortness of breath and a non-productive cough. Patients with pulmonary fibrosis may develop clubbing, basal crepitations, and a dry cough, but the acute presentation and haemoptysis in this case would not be explained.
Chronic obstructive pulmonary disease (COPD) is a progressive disorder characterized by airway obstruction, chronic bronchitis, and emphysema. However, the absence of wheezing, smoking history, and acute new haemoptysis make COPD a less likely diagnosis.
Lung cancer is a possibility given the haemoptysis and clubbing, but the long history of productive cough, florid crepitations, and previous history of TB make bronchiectasis a more likely diagnosis. Overall, a thorough evaluation of symptoms and medical history is necessary to accurately diagnose respiratory conditions.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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A 68-year-old retired electrician presents with complaints of progressive dyspnea, unintentional weight loss, and two episodes of hemoptysis in the past week. He has a history of smoking 40 pack years. Upon examination, there is stony dullness at the right base with absent breath sounds and decreased vocal resonance.
Which of the following statements about mesothelioma is most accurate?Your Answer:
Correct Answer: It may have a lag period of up to 45 years between exposure and diagnosis
Explanation:Understanding Mesothelioma: Causes, Diagnosis, and Prognosis
Mesothelioma is a type of cancer that affects the pleura, and while it can be caused by factors other than asbestos exposure, the majority of cases are linked to this cause. Asbestos was commonly used in various industries until the late 1970s/early 1980s, and the lag period between exposure and diagnosis can be up to 45 years. This means that the predicted peak of incidence of mesothelioma in the UK is around 2015-2020.
Contrary to popular belief, smoking does not cause mesothelioma. However, smoking and asbestos exposure can act as synergistic risk factors for bronchial carcinoma. Unfortunately, there is no known cure for mesothelioma, and the 5-year survival rate is less than 5%. Treatment is supportive and palliative, with an emphasis on managing symptoms and improving quality of life.
Diagnosis is usually made through CT imaging, with or without thoracoscopic-guided biopsy. Open lung biopsy is only considered if other biopsy methods are not feasible. Mesothelioma typically presents with a malignant pleural effusion, which can be difficult to distinguish from a pleural tumor on a plain chest X-ray. The effusion will be an exudate.
In conclusion, understanding the causes, diagnosis, and prognosis of mesothelioma is crucial for early detection and management of this devastating disease.
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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 35-year-old woman had a productive cough due to upper respiratory tract infection two weeks ago. She experienced a burning sensation in her chest during coughing. About a week ago, she coughed up a teaspoonful of yellow sputum with flecks of blood. The next morning, she had a small amount of blood-tinged sputum but has not had any subsequent haemoptysis. Her cough is resolving, and she is starting to feel better. She has no history of respiratory problems and has never smoked cigarettes. On examination, there are no abnormalities found in her chest, heart, or abdomen. Her chest x-ray is normal.
What would be your recommendation at this point?Your Answer:
Correct Answer: Observation only
Explanation:Acute Bronchitis
Acute bronchitis is a type of respiratory tract infection that causes inflammation in the bronchial tubes. This condition is usually caused by viral infections, with up to 95% of cases being attributed to viruses such as adenovirus, coronavirus, and influenzae viruses A and B. While antibiotics are often prescribed for acute bronchitis, there is little evidence to suggest that they provide significant relief or shorten the duration of the illness.
Other viruses that can cause acute bronchitis include parainfluenza virus, respiratory syncytial virus, coxsackievirus A21, rhinovirus, and viruses that cause rubella and measles. It is important to note that in cases where there is no evidence of bronchoconstriction or bacterial infection, and the patient is not experiencing respiratory distress, observation is advised.
Overall, the causes and symptoms of acute bronchitis can help individuals take the necessary steps to manage their condition and prevent its spread to others.
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This question is part of the following fields:
- Respiratory
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Question 20
Incorrect
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A 32-year-old woman visits her General Practitioner seeking assistance to quit smoking. She has been smoking ten cigarettes daily for the last 14 years and has no significant medical history. However, she is currently in her second trimester of pregnancy. What is the most suitable first-line smoking cessation option for this patient?
Your Answer:
Correct Answer: Behavioural therapy
Explanation:Smoking Cessation Options for Pregnant Women: A Review of Medications and Therapies
When it comes to quitting smoking during pregnancy or postpartum, behavioural therapy is the recommended first-line approach by the National Institute for Health and Care Excellence (NICE). Smoking cessation clinics can provide support for women who wish to quit smoking. Clonidine, a medication used for high blood pressure and drug withdrawal, has some effect on smoking cessation but is not licensed or recommended for this use by NICE. Bupropion, which reduces cravings and withdrawal effects, is contraindicated during pregnancy and breastfeeding. Nicotine replacement therapy can be used in pregnancy, but women should be informed of the risks and benefits and only used if behavioural support is ineffective. Varenicline, a medication that reduces cravings and the pleasurable effects of tobacco products, is contraindicated during pregnancy and breastfeeding due to its toxicity in studies. It is important for healthcare providers to discuss the available options with pregnant women and provide individualized recommendations for smoking cessation.
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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 78-year-old man with known alcohol dependence presents to the Emergency Department with a few weeks of productive cough, weight loss, fever and haemoptysis. He is a heavy smoker, consuming 30 cigarettes per day. On a chest X-ray, multiple nodules 1-3 mm in size are visible throughout both lung fields. What is the best treatment option to effectively address the underlying cause of this man's symptoms?
Your Answer:
Correct Answer: Anti-tuberculous (TB) chemotherapy
Explanation:Choosing the Right Treatment: Evaluating Options for a Patient with Suspected TB
A patient presents with a subacute history of fever, productive cough, weight loss, and haemoptysis, along with a chest X-ray description compatible with miliary TB. Given the patient’s risk factors for TB, such as alcohol dependence and smoking, anti-TB chemotherapy is the most appropriate response, despite the possibility of lung cancer. IV antibiotics may be used until sputum staining and culture results are available, but systemic chemotherapy would likely lead to overwhelming infection and death. Tranexamic acid may be useful for significant haemoptysis, but it will not treat the underlying diagnosis. acyclovir is not indicated, as the patient does not have a history of rash, and a diagnosis of miliary TB is more likely than varicella pneumonia. Careful evaluation of the patient’s history and symptoms is crucial in choosing the right treatment.
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This question is part of the following fields:
- Respiratory
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Question 22
Incorrect
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A 5-year-old girl comes to her general practice clinic with her mother. She has been experiencing nasal congestion, sneezing, and a sore throat for the past few days. During the examination, her pulse rate is 80 bpm, respiratory rate is 20 breaths per minute, and temperature is 36.9 °C. She has no significant medical history. What is the probable diagnosis?
Your Answer:
Correct Answer: Common cold
Explanation:Possible Diagnosis for a Young Girl with Respiratory Symptoms
A young girl is experiencing respiratory symptoms, including sore throat, sneezing, and nasal congestion. Here are some possible diagnoses to consider:
1. Common cold: This is a common viral infection that can cause mild fever, especially in children.
2. Hay fever: This is an allergic reaction to specific allergens, such as pollen, that can cause similar symptoms to the common cold, but with a chronic and fluctuating course.
3. Infectious mononucleosis: This is a viral infection that can cause fatigue, fever, laryngitis, and a rash, but is less likely in this case.
4. influenzae: This is a seasonal viral infection that can cause more severe symptoms, such as high fever, headache, and muscle aches.
5. Meningitis: This is a serious bacterial infection that can cause non-specific respiratory symptoms, but also tachycardia, hypotension, high fever, photophobia, neck stiffness, and petechial rash, which are not mentioned here.
Possible Diagnoses for a Young Girl with Respiratory Symptoms
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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 28-year-old man with a history of cystic fibrosis is experiencing deteriorating respiratory symptoms and is subsequently diagnosed with aspergillus infection. What is a common pulmonary manifestation of Aspergillus infection?
Your Answer:
Correct Answer: Allergic asthma
Explanation:Pulmonary Manifestations of Aspergillosis
Aspergillosis is a fungal infection caused by Aspergillus. It can affect various organs in the body, including the lungs. The pulmonary manifestations of aspergillosis include allergic reactions, bronchocentric granulomatosis, necrotising aspergillosis, extrinsic allergic alveolitis, aspergilloma, and bronchial stump infection.
Allergic reactions can manifest as allergic asthma or allergic bronchopulmonary aspergillosis (ABPA). Patients may experience recurrent wheezing, fever, and transient opacities on chest X-ray. In later stages, bronchiectasis may develop.
Bronchocentric granulomatosis is characterised by granuloma of bronchial mucosa with eosinophilic infiltrates. Chest X-ray shows a focal upper lobe lesion, and there may be haemoptysis.
Necrotising aspergillosis is usually found in immunocompromised patients. Chest X-ray shows spreading infiltrates, and there is invasion of blood vessels.
Extrinsic allergic alveolitis, also known as hypersensitivity pneumonitis, may occur in certain professions like malt workers. Four to 8 hours after exposure, there is an allergic reaction characterised by fever, chill, malaise, and dyspnoea. Serum IgE concentrations are normal.
Aspergilloma is saprophytic colonisation in pre-existing cavities. Haemoptysis is the most frequent symptom. Chest X-ray shows Monod’s sign, and gravitational change of position of the mass can be demonstrated.
Bronchial stump infection is usually found in post-surgery cases when silk suture is used. If nylon suture is used, this problem is eliminated. This can also occur in lung transplants at the site of anastomosis of bronchi.
Understanding the Pulmonary Manifestations of Aspergillosis
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This question is part of the following fields:
- Respiratory
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Question 24
Incorrect
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After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the respiratory consultant discusses the anatomy of the lungs with a group of undergraduate students.
With regard to the lungs, which one of the following statements is accurate?Your Answer:
Correct Answer: The lungs receive a dual blood supply
Explanation:Facts about the Anatomy of the Lungs
The lungs are a vital organ responsible for respiration. Here are some important facts about their anatomy:
– The lungs receive a dual blood supply from the pulmonary artery and the bronchial arteries. A pulmonary embolus may only result in infarction when the circulation is already inadequate.
– The left lung has two lobes, while the right lung has three. The horizontal fissure is present only in the right lung.
– Each lung has ten bronchopulmonary segments, which can be selectively removed surgically if diseased.
– The right bronchus is shorter, wider, and more vertical than the left bronchus, making it more likely for foreign bodies to enter it. Aspiration pneumonia and abscess formation are common in the apical segment of the right lower lobe.Important Facts about the Anatomy of the Lungs
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This question is part of the following fields:
- Respiratory
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Question 25
Incorrect
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A 40-year-old patient visits his GP complaining of a dry cough that has persisted for 3 months. He has been smoking 20 cigarettes daily for the past 12 years and has no other medical history. Upon examination, no abnormalities are found, and his vital signs, including pulse rate, respiratory rate, blood pressure, temperature, and oxygen saturation, are all normal. Spirometry results reveal a forced expiratory volume in 1 second (FEV1) of 3.6 litres (predicted = 3.55 litres) and a forced vital capacity of 4.8 litres (predicted 4.72 litres). What is the most probable diagnosis?
Your Answer:
Correct Answer: Asthma
Explanation:Differential diagnosis of a dry cough in a young patient
A dry cough is a common symptom that can have various underlying causes. In a young patient with a ten-pack-year history of smoking and a 3-month duration of symptoms, several possibilities should be considered and ruled out based on clinical evaluation and diagnostic tests.
One possibility is asthma, especially if the cough is the main or only symptom. In this case, spirometry may be normal, but peak flow monitoring before and after inhaled steroid therapy can help confirm the diagnosis by showing an improvement in peak flow rate and/or a reduction in variability.
Chronic obstructive pulmonary disease (COPD) is less likely in a young patient, but spirometry can reveal obstructive patterns if present.
Community-acquired pneumonia is unlikely given the chronicity of symptoms and the absence of typical signs such as productive cough and inspiratory crackles.
Angina is an uncommon cause of a dry cough, and it usually presents with chest tightness on exertion rather than at night.
Bronchiectasis can cause a productive cough and crackles on auscultation, which are not present in this case.
Therefore, based on the available information, asthma seems to be the most likely diagnosis, but further evaluation may be needed to confirm it and exclude other possibilities.
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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 47-year-old woman has been hospitalized with haemoptysis and epistaxis. On her chest X-ray, there are several rounded lesions with alveolar shadowing. Her serum test shows a positive result for cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA). What is the probable diagnosis?
Your Answer:
Correct Answer: Granulomatosis with polyangiitis (GPA)
Explanation:Differential Diagnosis for Pulmonary Granulomas and Positive c-ANCA: A Case Study
Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease that often presents with granulomatous lung disease and alveolar capillaritis. Symptoms include cough, dyspnea, hemoptysis, and chest pain. Chest X-ray and computed tomography can show rounded lesions that may cavitate, while bronchoscopy can reveal granulomatous inflammation. In this case study, the chest radiograph appearances, epistaxis, and positive c-ANCA are more indicative of GPA than lung cancer, echinococcosis, systemic lupus erythematosus, or tuberculosis. While SLE can also cause pulmonary manifestations, cavitating lesions are not typical. Positive c-ANCA is associated with GPA, while SLE is associated with positive antinuclear antibodies, double-stranded DNA antibodies, and extractable nuclear antigens.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A 65-year-old man with rheumatoid arthritis has been on long term therapy to manage his condition. He complains of worsening shortness of breath and a chest x-ray reveals 'bilateral interstitial shadowing'. Which medication is the probable culprit for his symptoms?
Your Answer:
Correct Answer: Methotrexate
Explanation:Methotrexate as a Cause and Treatment for Pulmonary Fibrosis
Pulmonary fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. Methotrexate, a chemotherapy drug, is a known cause of pulmonary fibrosis. However, it is also sometimes used as a treatment for idiopathic pulmonary fibrosis as a steroid sparing agent.
According to medical research, other chemotherapy drugs such as alkylating agents, asparaginase, bleomycin, and procarbazine have also been linked to pulmonary parenchymal or pleural reactions in patients with malignant diseases. In addition, drug-related interstitial pneumonia should be considered in rheumatoid arthritis patients who are taking methotrexate or newer drugs like leflunomide.
Despite its potential risks, methotrexate can be a useful treatment option for some patients with pulmonary fibrosis. However, it is important for healthcare providers to carefully monitor patients for any adverse reactions and adjust treatment plans accordingly.
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This question is part of the following fields:
- Respiratory
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Question 28
Incorrect
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A 38-year-old man from Somalia presents at your general practice surgery as a temporary resident. He has noticed some lumps on the back of his neck recently. He reports having a productive cough for the last 3 months, but no haemoptysis. He has lost 3 kg in weight in the last month. He is a non-smoker and lives with six others in a flat. His chest X-ray shows several large calcified, cavitating lesions bilaterally.
What is the GOLD standard investigation for active disease, given the likely diagnosis?Your Answer:
Correct Answer: Sputum culture
Explanation:The patient in question has several risk factors for tuberculosis (TB), including being from an ethnic minority and living in overcrowded accommodation. The presence of symptoms and chest X-ray findings of bilateral large calcified, cavitating lesions strongly suggest a diagnosis of TB. The gold standard investigation for TB is to send at least three spontaneous sputum samples for culture and microscopy, including one early morning sample. Treatment should be initiated without waiting for culture results if clinical symptoms and signs of TB are present. Treatment involves a 6-month course of antibiotics, with the first 2 months consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampicin. Even if culture results are negative, the full course of antibiotics should be completed. Public health must be notified of the diagnosis for contact tracing and surveillance. Pulmonary function testing is useful for assessing the severity of lung disease but is not used in the diagnosis of TB. Tissue biopsy is not recommended as the gold standard investigation for TB, but may be useful in some cases of extrapulmonary TB. The tuberculin skin test is used to determine if a patient has ever been exposed to TB, but is not the gold standard investigation for active TB. Interferon-γ release assays measure a person’s immune reactivity to TB and can suggest the likelihood of M tuberculosis infection.
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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 65-year-old man presents to the Emergency Department with sudden breathlessness and haemoptysis. He had just returned from a trip to Thailand and had been complaining of pain in his left leg. His oxygen saturation is 88% on room air, blood pressure is 95/70 mmHg, and heart rate is 120 bpm. He has a history of hypertension managed with lifestyle measures only and used to work as a construction worker. While receiving initial management, the patient suddenly becomes unresponsive, stops breathing, and has no pulse. Despite prolonged resuscitation efforts, the patient is declared dead after 40 minutes. Which vessel is most likely to be affected, leading to this patient's death?
Your Answer:
Correct Answer: Pulmonary artery
Explanation:Differentiating Thrombosis in Varicose Veins: Symptoms and Diagnosis
Pulmonary artery thrombosis is a serious condition that can cause sudden-onset breathlessness, haemoptysis, pleuritic chest pain, and cough. It is usually caused by a deep vein thrombosis that travels to the pulmonary artery. Computed tomography pulmonary angiogram (CTPA) is the preferred imaging modality for diagnosis.
Pulmonary vein thrombosis is a rare condition that is typically associated with lobectomy, metastatic carcinoma, coagulopathies, and lung transplantation. Patients usually present with gradual onset dyspnoea, lethargy, and peripheral oedema.
Azygos vein thrombosis is a rare occurrence that is usually associated with azygos vein aneurysms and hepatobiliary pathologies. It is rarely fatal.
Brachiocephalic vein thrombosis is usually accompanied by arm swelling, pain, and limitation of movement. It is less likely to progress to a pulmonary embolus than lower limb deep vein thrombosis.
Coronary artery thrombus resulting in myocardial infarction (MI) is characterised by cardiac chest pain, hypotension, and sweating. Haemoptysis is not a feature of MI. Electrocardiographic changes and serum troponin and cardiac enzyme levels are typically seen in MI, but not in pulmonary embolism.
In summary, the symptoms and diagnosis of thrombosis vary depending on the affected vein. It is important to consider the patient’s medical history and perform appropriate imaging and laboratory tests for accurate diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 30
Incorrect
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What is the most effective tool for assessing a patient who is suspected of having occupational asthma?
Your Answer:
Correct Answer: Serial measurements of ventilatory function performed before, during, and after work
Explanation:Occupational Asthma
Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable airflow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases. To diagnose occupational asthma, several investigations are conducted, including serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. A consistent fall in peak flow values and increased intraday variability on working days, along with improvement on days away from work, confirms the diagnosis of occupational asthma. It is important to understand the causes and symptoms of occupational asthma to prevent and manage this condition effectively.
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This question is part of the following fields:
- Respiratory
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