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  • Question 1 - A 40-year-old baker presents to his General Practitioner with rhinitis, breathlessness and wheeze....

    Incorrect

    • A 40-year-old baker presents to his General Practitioner with rhinitis, breathlessness and wheeze. He reports his symptoms have acutely worsened since he returned from a 2-week holiday in Spain. He has been experiencing these symptoms on and off for the past year. He has a fifteen-pack-year smoking history.
      What is the most likely diagnosis?

      Your Answer: Hay fever

      Correct Answer: Occupational asthma

      Explanation:

      Differential Diagnosis for a Patient with Breathlessness and Rhinitis

      Possible diagnoses for a patient presenting with breathlessness and rhinitis include occupational asthma, Legionnaires’ disease, hay fever, COPD, and pulmonary embolus. In the case of a baker experiencing worsening symptoms after returning from holiday, baker’s asthma caused by alpha-amylase allergy is the most likely diagnosis. Legionnaires’ disease, which can be contracted through contaminated water sources, may also be a possibility. Hay fever, COPD, and pulmonary embolus are less likely given the patient’s symptoms and medical history.

    • This question is part of the following fields:

      • Respiratory
      28.9
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  • Question 2 - A 55-year-old female presents with worsening dyspnoea and the need to sit down...

    Incorrect

    • A 55-year-old female presents with worsening dyspnoea and the need to sit down frequently. She has had no other health issues. The patient works in an office.
      During the physical examination, the patient is found to have clubbing and fine end-inspiratory crackles upon auscultation. A chest X-ray reveals diffuse reticulonodular shadows, particularly in the lower lobes.
      What is the most suitable next step in managing this patient?

      Your Answer: Radiotherapy

      Correct Answer: Oxygen therapy

      Explanation:

      Treatment Options for Pulmonary Fibrosis

      Pulmonary fibrosis is a condition that can be diagnosed through a patient’s medical history. When it comes to treatment options, oxygen therapy is the most appropriate as it can prevent the development of pulmonary hypertension. However, there are other treatments available such as steroids and immune modulators like azathioprine, cyclophosphamide methotrexate, and cyclosporin. In some cases, anticoagulation may also be used to reduce the risk of pulmonary embolism. It is important to consult with a healthcare professional to determine the best course of treatment for each individual case.

    • This question is part of the following fields:

      • Respiratory
      43.4
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  • Question 3 - A 41-year-old man presents with wheezing and shortness of breath. He reports no...

    Incorrect

    • A 41-year-old man presents with wheezing and shortness of breath. He reports no history of smoking or drug use. An ultrasound reveals cirrhosis of the liver, and he is diagnosed with alpha-1-antitrypsin deficiency. He undergoes a liver transplant. What type of emphysema is he now at higher risk of developing?

      Your Answer: Interstitial

      Correct Answer: Panacinar

      Explanation:

      Different Types of Emphysema and Their Characteristics

      Emphysema is a lung condition that has various forms, each with its own distinct characteristics. The four main types of emphysema are panacinar, compensatory, interstitial, centriacinar, and paraseptal.

      Panacinar emphysema affects the entire acinus, from the respiratory bronchiole to the distal alveoli. It is often associated with α-1-antitrypsin deficiency.

      Compensatory emphysema occurs when the lung parenchyma is scarred, but it is usually asymptomatic.

      Interstitial emphysema is not a true form of emphysema, but rather occurs when air penetrates the pulmonary interstitium. It can be caused by chest wounds or alveolar tears resulting from coughing and airway obstruction.

      Centriacinar emphysema is characterized by enlargement of the central portions of the acinus, specifically the respiratory bronchiole. It is often caused by exposure to coal dust and tobacco products.

      Paraseptal emphysema is associated with scarring and can lead to spontaneous pneumothorax in young patients. It is more severe when it occurs in areas adjacent to the pleura, where it can cause the development of large, cyst-like structures that can rupture into the pleural cavity.

      In summary, understanding the different types of emphysema and their characteristics is important for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Respiratory
      18.6
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  • Question 4 - A 65-year-old woman presents to a spirometry clinic with a history of progressive...

    Incorrect

    • 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: FEV1: < 80% predicted, FEV1/FVC ratio: < 0.70

      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.

    • This question is part of the following fields:

      • Respiratory
      22
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  • Question 5 - A 58-year-old Afro-Caribbean man presents to you with increasing difficulty in breathing and...

    Incorrect

    • 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: Myxoedema

      Correct 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.

    • This question is part of the following fields:

      • Respiratory
      45.8
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  • Question 6 - A 38-year-old man from Somalia presents at your general practice surgery as a...

    Incorrect

    • 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: Tuberculin skin test

      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.

    • This question is part of the following fields:

      • Respiratory
      29.1
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  • Question 7 - A 65-year-old man complains of worsening shortness of breath. During examination, the left...

    Correct

    • A 65-year-old man complains of worsening shortness of breath. During examination, the left base has a stony dull percussion note. A chest x-ray reveals opacification in the lower lobe of the left lung. What is the most suitable test for this patient?

      Your Answer: Ultrasound-guided pleural fluid aspiration

      Explanation:

      Left Pleural Effusion Diagnosis

      A left pleural effusion is present in this patient, which is likely to be significant in size. To diagnose this condition, a diagnostic aspiration is necessary. The fluid obtained from the aspiration should be sent for microscopy, culture, and cytology to determine the underlying cause of the effusion. Proper diagnosis is crucial in determining the appropriate treatment plan for the patient. Therefore, it is essential to perform a diagnostic aspiration and analyze the fluid obtained to provide the best possible care for the patient.

    • This question is part of the following fields:

      • Respiratory
      28.5
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  • Question 8 - A 45-year-old woman with known asthma presents to the Emergency Department with severe...

    Incorrect

    • A 45-year-old woman with known asthma presents to the Emergency Department with severe breathlessness and wheeze.
      Which of the following is the most concerning finding on examination and initial investigations?

      Your Answer: Inability to complete sentences in one breath

      Correct Answer: PaCO2 5.5 kPa

      Explanation:

      Assessing the Severity of an Acute Asthma Exacerbation

      When assessing the severity of an acute asthma exacerbation, several factors must be considered. A PaCO2 level of 5.5 kPa in an acutely exacerbating asthmatic is a worrying sign and is a marker of a life-threatening exacerbation. A respiratory rate of 30 breaths per minute or higher is a sign of acute severe asthma, while poor respiratory effort is a sign of life-threatening asthma. Peak expiratory flow rate (PEFR) can also be used to help assess the severity of an acute exacerbation of asthma. A PEFR of 33-35% best or predicted is a sign of acute severe asthma, while a PEFR < 33% best or predicted is a sign of life-threatening asthma. A heart rate of 140 bpm or higher is a feature of acute severe asthma, while arrhythmia and/or hypotension are signs of life-threatening asthma. Inability to complete sentences in one breath is a sign of acute severe asthma, while an altered conscious level is a sign of life-threatening asthma. By considering these factors, healthcare professionals can accurately assess the severity of an acute asthma exacerbation and provide appropriate treatment.

    • This question is part of the following fields:

      • Respiratory
      17.1
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  • Question 9 - As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed....

    Correct

    • As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed. You learn that he spent all his working life in a factory. The following results are available:
      Measured Expected
      FEV1 (L) 2.59 3.46
      FVC (L) 3.16 4.21
      Ratio (%) 82 81
      Which of the following is the most likely cause?

      Your Answer: Asbestosis

      Explanation:

      Possible Respiratory Diagnoses Based on Pulmonary Function Testing Results

      Based on the patient’s age and history of factory work, along with a restrictive defect on pulmonary function testing, asbestosis is the most likely diagnosis. Other possible respiratory diagnoses include allergic bronchopulmonary aspergillosis (ABPA), asthma, emphysema, and bronchiectasis. ABPA and asthma are associated with an obstructive picture on pulmonary function tests, while emphysema and bronchiectasis are also possible differentials based on the history but are associated with an obstructive lung defect. However, it would be unusual for an individual to have their first presentation of asthma at 72 years old. Therefore, a thorough evaluation of the patient’s medical history, physical examination, and additional diagnostic tests may be necessary to confirm the diagnosis.

    • This question is part of the following fields:

      • Respiratory
      51.5
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  • Question 10 - A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing,...

    Correct

    • 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.

    • This question is part of the following fields:

      • Respiratory
      43
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  • Question 11 - A 61-year-old man presents to the Respiratory Clinic with a history of two...

    Incorrect

    • A 61-year-old man presents to the Respiratory Clinic with a history of two episodes of right-sided bronchial pneumonia in the past 2 months, which have not completely resolved. He has been a heavy smoker, consuming 30 cigarettes per day since he was 16 years old. On examination, he has signs consistent with COPD and right-sided consolidation on respiratory examination. His BMI is 18. Further investigations reveal a right hilar mass measuring 4 x 2 cm in size on chest X-ray, along with abnormal laboratory values including low haemoglobin, elevated WCC, and corrected calcium levels. What is the most likely diagnosis?

      Your Answer: Small cell bronchial carcinoma

      Correct Answer: Squamous cell carcinoma of the bronchus

      Explanation:

      Types of Bronchial Carcinomas

      Bronchial carcinomas are a type of lung cancer that originates in the bronchial tubes. There are several types of bronchial carcinomas, each with their own characteristics and treatment options.

      Squamous cell carcinoma of the bronchus is the most common type of bronchial carcinoma, accounting for 42% of cases. It typically occurs in the central part of the lung and is strongly associated with smoking. Patients with squamous cell carcinoma may also present with hypercalcemia.

      Bronchial carcinoids are rare and slow-growing tumors that arise from the bronchial mucosa. They are typically benign but can become malignant in some cases.

      Large cell bronchial carcinoma is a heterogeneous group of tumors that lack the organized features of other lung cancers. They tend to grow quickly and are often found in the periphery of the lung.

      Small cell bronchial carcinoma is a highly aggressive type of lung cancer that grows rapidly and spreads early. It is strongly associated with smoking and is often found in the central part of the lung.

      Adenocarcinoma of the bronchus is the least associated with smoking and typically presents with lesions in the lung peripheries rather than near the bronchus.

      In summary, the type of bronchial carcinoma a patient has can vary greatly and can impact treatment options and prognosis. It is important for healthcare providers to accurately diagnose and classify the type of bronchial carcinoma to provide the best possible care for their patients.

    • This question is part of the following fields:

      • Respiratory
      47.7
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  • Question 12 - A 40-year-old patient visits his GP complaining of a dry cough that has...

    Incorrect

    • 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: Bronchiectasis

      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.

    • This question is part of the following fields:

      • Respiratory
      63.4
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  • Question 13 - A 25-year-old refuse collector arrives at the Emergency Department complaining of sudden breathlessness....

    Incorrect

    • A 25-year-old refuse collector arrives at the Emergency Department complaining of sudden breathlessness. He has no prior history of respiratory issues or trauma, but does admit to smoking around ten cigarettes a day since his early teenage years. Upon examination, the doctor suspects a potential spontaneous pneumothorax and proceeds to insert a chest drain for treatment. In terms of the intercostal spaces, which of the following statements is accurate?

      Your Answer:

      Correct Answer: The direction of fibres of the external intercostal muscle is downwards and medial

      Explanation:

      Anatomy of the Intercostal Muscles and Neurovascular Bundle

      The intercostal muscles are essential for respiration, with the external intercostal muscles aiding forced inspiration. These muscles have fibers that pass obliquely downwards and medial from the lower border of the rib above to the smooth upper border of the rib below. The direction of these fibers can be remembered as having one’s hands in one’s pockets.

      The intercostal neurovascular bundle, which includes the vein, artery, and nerve, lies in a groove on the undersurface of each rib, running in the plane between the internal and innermost intercostal muscles. The vein, artery, and nerve lie in that order, from top to bottom, under cover of the lower border of the rib.

      When inserting a needle or trocar for drainage or aspiration of fluid from the pleural cavity, it is important to remember that the neurovascular bundle lies in a groove just above each rib. Therefore, the needle or trocar should be inserted just above the rib to avoid the main vessels and nerves. Remember the phrase above the rib below to ensure proper insertion.

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      • Respiratory
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  • Question 14 - A 28-year-old man with a history of cystic fibrosis is experiencing deteriorating respiratory...

    Incorrect

    • 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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      • Respiratory
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  • Question 15 - A 50-year-old woman is brought to the Emergency Department after falling down the...

    Incorrect

    • A 50-year-old woman is brought to the Emergency Department after falling down the stairs at home. She complains of ‘rib pain’ and is moved to the resus room from triage, as she was unable to complete full sentences due to shortness of breath. Sats on room air were 92%. You are asked to see her urgently as the nursing staff are concerned about her deterioration.
      On examination, she appears distressed; blood pressure is 85/45, heart rate 115 bpm, respiratory rate 38 and sats 87% on air. Her left chest does not appear to be moving very well, and there are no audible breath sounds on the left on auscultation.
      What is the most appropriate next step in immediate management of this patient?

      Your Answer:

      Correct Answer: Needle thoracocentesis of left chest

      Explanation:

      Needle Thoracocentesis for Tension Pneumothorax

      Explanation:
      In cases of traumatic chest pain, it is important to keep an open mind regarding other injuries. However, if a patient rapidly deteriorates with signs of shock, hypoxia, reduced chest expansion, and no breath sounds audible on the affected side of the chest, a tension pneumothorax should be suspected. This is an immediately life-threatening condition that requires immediate intervention.

      There is no time to wait for confirmation on a chest X-ray or to set up a chest drain. Instead, needle thoracocentesis should be performed on the affected side of the chest. A large-bore cannula is inserted in the second intercostal space, mid-clavicular line, on the affected side. This can provide rapid relief and should be followed up with the insertion of a chest drain.

      It is important to note that there is no role for respiratory consultation or nebulisers in this scenario. Rapid intervention is key to preventing cardiac arrest and improving patient outcomes.

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      • Respiratory
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  • Question 16 - A 63-year-old male smoker arrived in the Emergency Department by ambulance. He had...

    Incorrect

    • A 63-year-old male smoker arrived in the Emergency Department by ambulance. He had become increasingly breathless at home, and despite receiving high-flow oxygen in the ambulance he is no better. He has a flapping tremor of his hands, a bounding pulse and palmar erythema.
      What is the most likely cause of his symptoms?

      Your Answer:

      Correct Answer: Hypercapnia

      Explanation:

      Understanding Hypercapnia: A Possible Cause of Breathlessness and Flapping Tremor in COPD Patients

      Hypercapnia is a condition that can occur in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure. It is caused by the retention of carbon dioxide (CO2) due to a relative loss of surface area for gas exchange within the lungs. This can lead to bronchospasm and inflammation, which can further exacerbate the problem. In some cases, patients with chronic hypoxia and hypercapnia may become dependent on hypoxia to drive respiration. If high concentrations of oxygen are given, this drive may be reduced or lost completely, leading to hypoventilation, reduced minute ventilation, accumulation of CO2, and subsequent respiratory acidosis (type 2 respiratory failure).

      External signs of hypercapnia include reduced Glasgow Coma Scale (GCS) score, flapping tremor (asterixis), palmar erythema, and bounding pulses (due to CO2-induced vasodilation). While other conditions such as hepatic encephalopathy, Parkinson’s disease, delirium tremens, and hyperthyroidism can also cause tremors and other symptoms, they do not typically cause breathlessness or the specific type of tremor seen in hypercapnia.

      It is important for healthcare professionals to recognize the signs and symptoms of hypercapnia in COPD patients, as prompt intervention can help prevent further complications and improve outcomes.

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      • Respiratory
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  • Question 17 - You are the Foundation Year 2 doctor on a general practice (GP) attachment...

    Incorrect

    • You are the Foundation Year 2 doctor on a general practice (GP) attachment when a 65-year-old man presents, complaining of malaise, cough and breathlessness. He says these symptoms have been present for 2 days, and he has brought up some yellow-coloured sputum on a few occasions. He reports no pain and no palpitations and is coping at home, although he has taken 2 days off work. He has no long-standing conditions but smokes five cigarettes a day and has done so for the last 15 years. He has no known allergies. On examination, he is alert and orientated, and has a respiratory rate of 22 breaths per minute, a blood pressure of 126/84 mmHg and a temperature of 38.1 °C. There is bronchial breathing and crepitations on auscultation, particularly on the right-hand side of the chest, and heart sounds are normal.
      What would be the most appropriate management for this patient?

      Your Answer:

      Correct Answer: 5-day course of amoxicillin

      Explanation:

      Treatment and Management of Community-Acquired Pneumonia

      Community-acquired pneumonia is a common respiratory infection that can be effectively managed in the community with appropriate treatment and management. The severity of the infection can be assessed using the CRB-65 score, which takes into account confusion, respiratory rate, blood pressure, and age. A score of zero indicates low severity and suggests that oral antibiotics and community treatment should suffice. However, admission to hospital may be necessary in certain cases.

      The first-choice antibiotic for community-acquired pneumonia is amoxicillin, although a macrolide may be considered in patients with penicillin allergy. Flucloxacillin may be added if there is suspicion of a staphylococcal infection or associated influenzae.

      It is important to provide safety-netting advice to patients, advising them to return if symptoms worsen or do not improve on antibiotics. Additionally, the absence of wheeze on auscultation and no history of respiratory disease suggests that a salbutamol inhaler is not necessary.

      While the CURB-65 score is commonly used, the CRB-65 score is more practical in community settings as it does not require laboratory analysis. Overall, prompt and appropriate treatment and management can effectively manage community-acquired pneumonia in the community.

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      • Respiratory
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  • Question 18 - A 65-year-old man presents with haemoptysis over the last 2 days. He has...

    Incorrect

    • 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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      • Respiratory
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  • Question 19 - A 32-year-old postal worker with asthma visits his GP for his annual asthma...

    Incorrect

    • A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?

      Your Answer:

      Correct Answer: Suboptimal therapy

      Explanation:

      Differentiating Between Respiratory Conditions: A Guide

      When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.

      Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.

      Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.

      Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.

      Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.

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  • Question 20 - A 38-year-old male presents with complaints of difficulty breathing. During the physical examination,...

    Incorrect

    • A 38-year-old male presents with complaints of difficulty breathing. During the physical examination, clubbing of the fingers is observed. What medical condition is commonly associated with clubbing?

      Your Answer:

      Correct Answer: Pulmonary fibrosis

      Explanation:

      Respiratory and Other Causes of Clubbing of the Fingers

      Clubbing of the fingers is a condition where the tips of the fingers become enlarged and the nails curve around the fingertips. This condition is often associated with respiratory diseases such as carcinoma of the lung, bronchiectasis, mesothelioma, empyema, and pulmonary fibrosis. However, it is not typically associated with chronic obstructive airway disease (COAD). Other causes of clubbing of the fingers include cyanotic congenital heart disease, inflammatory bowel disease, and infective endocarditis.

      In summary, clubbing of the fingers is a physical manifestation of various underlying medical conditions. It is important to identify the underlying cause of clubbing of the fingers in order to provide appropriate treatment and management.

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  • Question 21 - A 32-year-old office worker attends Asthma Clinic for her annual asthma review. She...

    Incorrect

    • A 32-year-old office worker attends Asthma Clinic for her annual asthma review. She takes a steroid inhaler twice daily, which seems to control her asthma well. Occasionally, she needs to use her salbutamol inhaler, particularly if she has been exposed to allergens.
      What is the primary mechanism of action of the drug salbutamol in the treatment of asthma?

      Your Answer:

      Correct Answer: β2-adrenoceptor agonist

      Explanation:

      Pharmacological Management of Asthma: Understanding the Role of Different Drugs

      Asthma is a chronic inflammatory condition of the airways that causes reversible airway obstruction. The pathogenesis of asthma involves the release of inflammatory mediators due to IgE-mediated degranulation of mast cells. Pharmacological management of asthma involves the use of different drugs that target specific receptors and pathways involved in the pathogenesis of asthma.

      β2-adrenoceptor agonists are selective drugs that stimulate β2-adrenoceptors found in bronchial smooth muscle, leading to relaxation of the airways and increased calibre. Salbutamol is a commonly used short-acting β2-adrenoceptor agonist, while salmeterol is a longer-acting drug used in more severe asthma.

      α1-adrenoceptor antagonists, which mediate smooth muscle contraction in blood vessels, are not used in the treatment of asthma. β1-adrenoceptor agonists, found primarily in cardiac tissue, are not used in asthma management either, as they increase heart rate and contractility.

      β2-adrenoceptor antagonists, also known as β blockers, cause constriction of the airways and should be avoided in asthma due to the risk of bronchoconstriction. Muscarinic antagonists, such as ipratropium, are useful adjuncts in asthma management as they block the muscarinic receptors in bronchial smooth muscle, leading to relaxation of the airways.

      Other drugs used in asthma management include steroids (oral or inhaled), leukotriene receptor antagonists (such as montelukast), xanthines (such as theophylline), and sodium cromoglycate. Understanding the role of different drugs in asthma management is crucial for effective treatment and prevention of exacerbations.

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  • Question 22 - A 25-year-old lady with a history of asthma is brought to the Emergency...

    Incorrect

    • A 25-year-old lady with a history of asthma is brought to the Emergency Department with an acute asthma attack. She has previously been admitted to the intensive therapy unit (ITU) with the same problem. Treatment is commenced with high-flow oxygen and regular nebulisers.
      Which of the following is a feature of life-threatening asthma?

      Your Answer:

      Correct Answer: Normal PaCO2

      Explanation:

      Assessment of Severity in Acute Asthma Attacks

      Acute asthma is a serious medical emergency that can lead to fatalities. To assess the severity of an asthma attack, several factors must be considered. Severe asthma is characterized by a peak flow of 33-50% of predicted or best, a respiratory rate of over 25 breaths per minute, a heart rate of over 110 beats per minute, and the inability to complete sentences. On the other hand, life-threatening asthma is indicated by a peak flow of less than 33% of predicted or best, a silent chest, cyanosis, and arterial blood gas showing high or normal PaCO2, which reflects reduced respiratory effort. Additionally, arterial blood gas showing hypoxia (PaO2 <8 kPa) or acidosis is also a sign of life-threatening asthma. Any life-threatening features require immediate critical care and senior medical review. A peak expiratory flow rate of less than 50% of predicted or best is a feature of an acute severe asthma attack. However, a pulse rate of 105 bpm is not a marker of severity in asthma due to its lack of specificity. Respiratory alkalosis, which is a condition characterized by low carbon dioxide levels, is actually a reassuring picture on the blood gas. In contrast, a normal carbon dioxide level would be a concern if the person is working that hard. Finally, the inability to complete full sentences is another feature of acute severe asthma.

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  • Question 23 - A 10-year-old boy is brought to the Emergency Department after aspirating a peanut...

    Incorrect

    • A 10-year-old boy is brought to the Emergency Department after aspirating a peanut an hour earlier. He has a non-productive cough and shortness of breath. On arrival in the Emergency Department, he is tachypnoeic and has an oxygen saturation of 90% on room air. A chest X-ray demonstrates a complete whiteout of the right lung and the trachea is seen deviated to the right of the midline.
      Which of the following processes is most likely causing the findings seen on the chest X-ray?

      Your Answer:

      Correct Answer: Atelectasis

      Explanation:

      Differentiating Acute Aspiration from Other Pulmonary Conditions

      When a patient presents with acute aspiration, it is important to differentiate it from other pulmonary conditions. The most likely process in acute aspiration is atelectasis due to bronchial obstruction. This occurs when the main stem bronchus is blocked, preventing gas from entering the affected lung and causing it to collapse. A chest X-ray will show complete whiteout of the hemithorax and ipsilateral tension on the mediastinum, leading to shifting of the trachea towards the affected lung.

      Pneumonia is less likely to develop so acutely and typically presents with productive cough and fever. Pneumothorax, on the other hand, would not cause a whiteout of the hemithorax and would instead show a line in the lung space with decreased lung markings peripherally. Pleural effusion could cause similar symptoms but would cause a contralateral mediastinal shift and is often associated with other systemic conditions. Pulmonary edema, which often occurs in the context of left heart failure, presents with cough and shortness of breath, but patients will have crackles on auscultation and are unlikely to have a mediastinal shift on chest X-ray.

      Therefore, understanding the differences between these conditions is crucial in accurately diagnosing and treating acute aspiration.

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  • Question 24 - A 58-year-old man presents to the Emergency Department with increasing shortness of breath...

    Incorrect

    • A 58-year-old man presents to the Emergency Department with increasing shortness of breath and cough for the last two days. The patient reports feeling fevers and chills and although he has a chronic cough, this has now become productive of yellow sputum over the last 36 hours. He denies chest pain. His past medical history is significant for chronic obstructive pulmonary disease (COPD) for which he has been prescribed various inhalers that he is not compliant with. He currently smokes 15 cigarettes per day and does not drink alcohol.
      His observations and blood tests results are shown below:
      Investigation Result Normal value
      Temperature 36.9 °C
      Blood pressure 143/64 mmHg
      Heart rate 77 beats per minute
      Respiratory rate 32 breaths per minute
      Sp(O2) 90% (room air)
      White cell count 14.9 × 109/l 4–11 × 109/l
      C-reactive protein 83 mg/l 0–10 mg/l
      Urea 5.5 mmol/l 2.5–6.5 mmol/l
      Physical examination reveals widespread wheeze throughout his lungs without other added sounds. There is no dullness or hyperresonance on percussion of the chest. His trachea is central.
      Which of the following is the most appropriate next investigation?

      Your Answer:

      Correct Answer: Chest plain film

      Explanation:

      The patient is experiencing shortness of breath, cough with sputum production, and widespread wheeze, along with elevated inflammatory markers. This suggests an infective exacerbation of COPD or community-acquired pneumonia. A chest X-ray should be ordered urgently to determine the cause and prescribe appropriate antibiotics. Treatment for COPD exacerbation includes oxygen therapy, nebulizers, oral steroids, and antibiotics. Blood cultures are not necessary at this stage unless the patient has fevers. A CTPA is not needed as the patient’s symptoms are not consistent with PE. Pulmonary function tests are not necessary in acute management. Sputum culture may be necessary if the patient’s CURB-65 score is ≥3 or if the score is 2 and antibiotics have not been given yet. The patient’s CURB-65 score is 1.

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  • Question 25 - A 27-year-old man comes to the doctor complaining of anorexia, decreased appetite, night...

    Incorrect

    • A 27-year-old man comes to the doctor complaining of anorexia, decreased appetite, night sweats, and weight loss over the last six months. He has been coughing up phlegm and experiencing occasional fevers for the past month. A chest X-ray reveals a sizable (4.5 cm) cavity in the upper left lobe. What diagnostic test would provide a conclusive diagnosis?

      Your Answer:

      Correct Answer: Sputum sample

      Explanation:

      Diagnostic Methods for Tuberculosis

      Tuberculosis (TB) is a bacterial infection that primarily affects the lungs. The diagnosis of TB relies on various diagnostic methods. Here are some of the commonly used diagnostic methods for TB:

      Sputum Sample: The examination and culture of sputum or other respiratory tract specimens can help diagnose pulmonary TB. The growth of Mycobacterium tuberculosis from respiratory secretions confirms the diagnosis.

      Blood Cultures: Blood cultures are rarely positive in TB. A probable diagnosis can be based on typical clinical and chest X-ray findings, together with either sputum positive for acid-fast bacilli or typical histopathological findings on biopsy material.

      Computed Tomography (CT) Scanning of the Chest: CT imaging can provide clinical information and be helpful in ascertaining the likelihood of TB, but it will not provide a definitive diagnosis.

      Mantoux Test: The Mantoux test is primarily used to diagnose latent TB. It may be strongly positive in active TB, but it does not give a definitive diagnosis of active TB. False-positive tests can occur with previous Bacillus Calmette–Guérin (BCG) vaccination and infection with non-tuberculous mycobacteria. False-negative results can occur in overwhelming TB, immunocompromised, previous TB, and some viral illnesses like measles and chickenpox.

      Serum Inflammatory Markers: Serum inflammatory markers are not specific enough to diagnose TB if raised.

      In conclusion, a combination of diagnostic methods is often used to diagnose TB. The definitive diagnosis requires the growth of Mycobacterium tuberculosis from respiratory secretions.

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  • Question 26 - A 65-year-old lady is admitted with severe pneumonia and, while on the ward,...

    Incorrect

    • A 65-year-old lady is admitted with severe pneumonia and, while on the ward, develops a warm, erythematosus, tender and oedematous left leg. A few days later, her breathing, which was improving with antibiotic treatment, suddenly deteriorated.
      Which one of the following is the best diagnostic test for this patient?

      Your Answer:

      Correct Answer: Computed tomography (CT) pulmonary angiogram

      Explanation:

      The Best Imaging Method for Dual Pathology: Resolving Pneumonia and Pulmonary Embolus

      Computed tomography (CT) pulmonary angiography is the best imaging method for a patient with dual pathology of resolving pneumonia and a pulmonary embolus secondary to a deep vein thrombosis. This method uses intravenous contrast to image the pulmonary vessels and can detect a filling defect within the bright pulmonary arteries, indicating a pulmonary embolism.

      A V/Q scan, which looks for a perfusion mismatch, may indicate a pulmonary embolism, but would not be appropriate in this case due to the underlying pneumonia making interpretation difficult.

      A D-dimer test should be performed, but it is non-specific and may be raised due to the pneumonia. It should be used together with the Wells criteria to consider imaging.

      A chest X-ray should be performed to ensure there is no worsening pneumonia or pneumothorax, but in this case, a pulmonary embolism is the most likely diagnosis and therefore CTPA is required.

      An arterial blood gas measurement can identify hypoxia and hypocapnia associated with an increased respiratory rate, but this is not specific to a pulmonary embolism and many pulmonary diseases can cause this arterial blood gas picture.

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  • Question 27 - What condition is typically linked to obstructive sleep apnea? ...

    Incorrect

    • What condition is typically linked to obstructive sleep apnea?

      Your Answer:

      Correct Answer: Hypersomnolence

      Explanation:

      Symptoms and Associations of Obstructive Sleep Apnoea

      Obstructive sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Other common symptoms include personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less frequent symptom. The condition may be associated with acromegaly, myxoedema, obesity, and micrognathia/retrognathia. Sleep apnoea is a serious condition that can lead to complications such as hypertension, cardiovascular disease, and stroke.

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  • Question 28 - A 65 year-old man, who had recently undergone a full bone marrow transplantation...

    Incorrect

    • A 65 year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. There was an associated dry cough, but no fever. Examination revealed scattered wheezes and some expiratory high-pitched sounds. C-reactive protein (CRP) level was normal. Mantoux test was negative. Spirometry revealed the following report:
      FEV1 51%
      FVC 88%
      FEV1/FVC 58%
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Bronchiolitis obliterans (BO)

      Explanation:

      Respiratory Disorders: Bronchiolitis Obliterans, ARDS, Pneumocystis Pneumonia, COPD Exacerbation, and Idiopathic Pulmonary Hypertension

      Bronchiolitis obliterans (BO) is a respiratory disorder that may occur after bone marrow, heart, or lung transplant. It presents with an obstructive pattern on spirometry, low DLCO, and hypoxia. CT scan shows air trapping, and chest X-ray may show interstitial infiltrates with hyperinflation. BO may also occur in connective tissue diseases, such as rheumatoid arthritis, and idiopathic variety called cryptogenic organising pneumonia (COP). In contrast, acute respiratory distress syndrome (ARDS) patients deteriorate quickly, and pneumocystis pneumonia usually presents with normal clinical findings. Infective exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a productive cough and raised CRP, while idiopathic pulmonary hypertension has a restrictive pattern and inspiratory fine crepitations.

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  • Question 29 - An 80-year-old woman came to the Emergency Department complaining of severe dyspnoea. A...

    Incorrect

    • An 80-year-old woman came to the Emergency Department complaining of severe dyspnoea. A chest X-ray showed an opaque right hemithorax. She had no history of occupational exposure to asbestos. Her husband worked in a shipyard 35 years ago, but he had no lung issues. She has never been a smoker. Upon thorax examination, there was reduced movement on the right side, with absent breath sounds and intercostal fullness.
      What is the probable reason for the radiological finding?

      Your Answer:

      Correct Answer: Mesothelioma

      Explanation:

      Pleural Pathologies: Mesothelioma and Differential Diagnoses

      Workers who are exposed to asbestos are at a higher risk of developing lung pathologies such as asbestosis and mesothelioma. Indirect exposure can also occur when family members come into contact with asbestos-covered clothing. This condition affects both the lungs and pleural space, with short, fine asbestos fibers transported by the lymphatics to the pleural space, causing irritation and leading to plaques and fibrosis. Pleural fibrosis can also result in rounded atelectasis, which can mimic a lung mass on radiological imaging.

      Mesothelioma, the most common type being epithelial, typically occurs 20-40 years after asbestos exposure and is characterized by exudative and hemorrhagic pleural effusion with high levels of hyaluronic acid. Treatment options are generally unsatisfactory, with local radiation and chemotherapy being used with variable results. Tuberculosis may also present with pleural effusion, but other systemic features such as weight loss, night sweats, and cough are expected. Lung collapse would show signs of mediastinal shift and intercostal fullness would not be typical. Pneumonectomy is not mentioned in the patient’s past, and massive consolidation may show air bronchogram on X-ray and bronchial breath sounds.

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  • Question 30 - A 75-year-old man with chronic obstructive pulmonary disease (COPD) comes in for a...

    Incorrect

    • A 75-year-old man with chronic obstructive pulmonary disease (COPD) comes in for a review of his home oxygen therapy. The results of his arterial blood gas (ABG) are as follows:
      Investigation Result Normal range
      pH 7.34 7.35–7.45
      pa(O2) 8.0 kPa 10.5–13.5 kPa
      pa(CO2) 7.6 kPa 4.6–6.0 kPa
      HCO3- 36 mmol 24–30 mmol/l
      Base excess +4 mmol −2 to +2 mmol
      What is the best interpretation of this man's ABG results?

      Your Answer:

      Correct Answer: Respiratory acidosis with partial metabolic compensation

      Explanation:

      Understanding Arterial Blood Gas (ABG) Results: A Five-Step Approach

      Arterial Blood Gas (ABG) results provide valuable information about a patient’s acid-base balance and oxygenation status. Understanding ABG results requires a systematic approach. The Resuscitation Council (UK) recommends a five-step approach to assessing ABGs.

      Step 1: Assess the patient and their oxygenation status. A pa(O2) level of >10 kPa is considered normal.

      Step 2: Determine if the patient is acidotic (pH <7.35) or alkalotic (pH >7.45).

      Step 3: Evaluate the respiratory component of the acid-base balance. A high pa(CO2) level (>6.0) suggests respiratory acidosis or compensation for metabolic alkalosis, while a low pa(CO2) level (<4.5) suggests respiratory alkalosis or compensation for metabolic acidosis. Step 4: Evaluate the metabolic component of the acid-base balance. A high bicarbonate (HCO3) level (>26 mmol) suggests metabolic alkalosis or renal compensation for respiratory acidosis, while a low bicarbonate level (<22 mmol) suggests metabolic acidosis or renal compensation for respiratory alkalosis. Step 5: Interpret the results in the context of the patient’s clinical history and presentation. It is important to note that ABG results should not be interpreted in isolation. A thorough clinical assessment is necessary to fully understand a patient’s acid-base balance and oxygenation status.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (3/12) 25%
Passmed