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Question 1
Incorrect
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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: Computed tomography (CT) scanning of the chest
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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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 28-year-old woman presents to the Emergency Department (ED) with sudden onset of shortness of breath and chest pain. She also reports haemoptysis. An ECG shows no signs of ischaemia. Her heart rate is 88 bpm and blood pressure is 130/85 mmHg. The patient flew from Dubai to the UK yesterday. She has type I diabetes mellitus which is well managed. She had a tonsillectomy two years ago and her brother has asthma. She has been taking the combined oral contraceptive pill for six months and uses insulin for her diabetes but takes no other medications.
What is the most significant risk factor for the likely diagnosis?Your Answer: Combined oral contraceptive pill
Explanation:Assessing Risk Factors for Pulmonary Embolism in a Patient with Sudden Onset of Symptoms
This patient presents with sudden onset of shortness of breath, chest pain, and haemoptysis, suggesting a pulmonary embolism. A history of long-haul flight and use of combined oral contraceptive pill further increase the risk for this condition. However, tonsillectomy two years ago is not a current risk factor. Type I diabetes mellitus and asthma are also not associated with pulmonary embolism. A family history of malignancy may increase the risk for developing a malignancy, which in turn increases the risk for pulmonary embolism. Overall, a thorough assessment of risk factors is crucial in identifying and managing pulmonary embolism in patients with acute symptoms.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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A 42-year-old man with advanced lung disease due to cystic fibrosis (CF) is being evaluated for a possible lung transplant. What respiratory pathogen commonly found in CF patients would make him ineligible for transplantation if present?
Your Answer: Methicillin-resistant Staphylococcus aureus (MRSA)
Correct Answer: Burkholderia cenocepacia
Explanation:Common Respiratory Pathogens in Cystic Fibrosis and Their Impact on Lung Transplantation
Cystic fibrosis (CF) is a genetic disorder that affects the respiratory and digestive systems. Patients with CF are prone to chronic respiratory infections, which can lead to accelerated lung function decline and poor outcomes following lung transplantation. Here are some common respiratory pathogens in CF and their impact on lung transplantation:
Burkholderia cenocepacia: This Gram-negative bacterium is associated with poor outcomes following lung transplantation and renders a patient ineligible for transplantation in the UK.
Methicillin-resistant Staphylococcus aureus (MRSA): This Gram-positive bacterium is resistant to many antibiotics but is not usually a contraindication to lung transplantation. Attempts at eradicating the organism from the airways should be made.
Pseudomonas aeruginosa: This Gram-negative bacterium is the dominant respiratory pathogen in adults with CF and can cause accelerated lung function decline. However, it is not a contraindication to transplantation.
Aspergillus fumigatus: This fungus is commonly isolated from sputum cultures of CF patients and may be associated with allergic bronchopulmonary aspergillosis. Its presence does not necessarily mandate treatment and is not a contraindication to transplantation.
Haemophilus influenzae: This Gram-negative bacterium is commonly seen in CF, particularly in children. It is not associated with accelerated lung function decline and is not a contraindication to transplantation.
In summary, respiratory infections are a common complication of CF and can impact the success of lung transplantation. It is important for healthcare providers to monitor and manage these infections to optimize patient outcomes.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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A 10-year-old boy comes to the GP clinic with his father for an asthma check-up. He is currently on Clenil® Modulite® (beclomethasone) 100 μg twice daily as a preventer inhaler, but still needs to use his salbutamol inhaler 2-3 times a day. During the examination, he is able to complete sentences, not using any accessory muscles of respiration, his oxygen saturation is 99%, his chest is clear, and PEFR is 85% of his predicted value. What is the recommended next step in managing this patient according to the latest BTS guidelines?
Your Answer: Increase dose of Inhaled corticosteroids
Correct Answer: Add formoterol a long-acting beta agonist (LABA)
Explanation:Managing Pediatric Asthma: Choosing the Next Step in Treatment
When treating pediatric asthma, it is important to follow guidelines to ensure the best possible outcomes for the patient. According to the 2019 SIGN/BTS guidelines, the next step after low-dose inhaled corticosteroid (ICS) should be to add a long-acting beta agonist (LABA) or leukotriene receptor antagonist (LTRA) in addition to ICS. However, it is important to note that the NICE guidelines differ in that LTRA is recommended before LABA.
If the patient does not respond adequately to LABA and a trial of LTRA does not yield benefit, referral to a pediatrician is advised. Increasing the dose of ICS should only be considered after the addition of LTRA or LABA.
It is crucial to never stop ICS therapy, as adherence to therapy is a guiding principle in managing pediatric asthma. LABAs should never be used alone without ICS, as this has been linked to life-threatening asthma exacerbations. Always follow guidelines and consult with a pediatrician for the best possible treatment plan.
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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 65-year-old woman presents to the Emergency Department with a productive cough, difficulty breathing, and chills lasting for 4 days. Upon examination, bronchial breathing is heard at the left lower lung base. Inflammatory markers are elevated, and a chest X-ray shows consolidation in the left lower zone. What is the most frequently encountered pathogen linked to community-acquired pneumonia?
Your Answer: Streptococcus pneumoniae
Explanation:Common Bacterial Causes of Pneumonia
Pneumonia is a lung infection that can be categorized as either community-acquired or hospital-acquired, depending on the likely causative pathogens. The most common cause of community-acquired pneumonia is Streptococcus pneumoniae, a type of Gram-positive coccus. Staphylococcus aureus pneumonia typically affects older individuals, often after they have had the flu, and can result in cavitating lesions in the upper lobes of the lungs. Mycobacterium tuberculosis can also cause cavitating lung disease, which is characterized by caseating granulomatous inflammation. This type of pneumonia is more common in certain groups, such as Asians and immunocompromised individuals, and is diagnosed through sputum smears, cultures, or bronchoscopy. Haemophilus influenzae is a Gram-negative bacteria that can cause meningitis and pneumonia, but it is much less common now due to routine vaccination. Finally, Neisseria meningitidis is typically associated with bacterial meningitis.
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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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: Massive consolidation
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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This question is part of the following fields:
- Respiratory
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Question 7
Correct
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A 50-year-old woman has a small cell lung cancer. Her serum sodium level is 128 mmol/l on routine testing (136–145 mmol/l).
What is the single most likely cause for the biochemical abnormality?Your Answer: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Explanation:Understanding the Causes of Hyponatraemia: Differential Diagnosis
Hyponatraemia is a condition characterized by low levels of sodium in the blood. There are several possible causes of hyponatraemia, including the syndrome of inappropriate antidiuretic hormone secretion (SIADH), primary adrenal insufficiency, diuretics, polydipsia, and vomiting.
SIADH is a common cause of hyponatraemia, particularly in small cell lung cancer patients. It occurs due to the ectopic production of antidiuretic hormone (ADH), which leads to impaired water excretion and water retention. This results in hyponatraemia and hypo-osmolality.
Primary adrenal insufficiency, also known as Addison’s disease, can also cause hyponatraemia, hyperkalaemia, and hypotension. However, there is no indication in the question that the patient has this condition.
Diuretics, particularly loop diuretics and bendroflumethiazide, can also cause hyponatraemia. However, there is no information to suggest that the patient is taking diuretics.
Polydipsia, or excessive thirst, can also lead to hyponatraemia. However, there is no indication in the question that the patient has this condition.
Vomiting is another possible cause of hyponatraemia, but there is no information in the question to support this as a correct answer.
In summary, hyponatraemia can have several possible causes, and a thorough differential diagnosis is necessary to determine the underlying condition.
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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 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: Compensatory
Correct Answer: Panacinar
Explanation:Different Types of Emphysema and Their Characteristics
Emphysema is a lung condition that has various forms, each with its own distinct characteristics. The four main types of emphysema are panacinar, compensatory, interstitial, centriacinar, and paraseptal.
Panacinar emphysema affects the entire acinus, from the respiratory bronchiole to the distal alveoli. It is often associated with α-1-antitrypsin deficiency.
Compensatory emphysema occurs when the lung parenchyma is scarred, but it is usually asymptomatic.
Interstitial emphysema is not a true form of emphysema, but rather occurs when air penetrates the pulmonary interstitium. It can be caused by chest wounds or alveolar tears resulting from coughing and airway obstruction.
Centriacinar emphysema is characterized by enlargement of the central portions of the acinus, specifically the respiratory bronchiole. It is often caused by exposure to coal dust and tobacco products.
Paraseptal emphysema is associated with scarring and can lead to spontaneous pneumothorax in young patients. It is more severe when it occurs in areas adjacent to the pleura, where it can cause the development of large, cyst-like structures that can rupture into the pleural cavity.
In summary, understanding the different types of emphysema and their characteristics is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 9
Correct
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A 70-year-old woman comes to the clinic with left upper-lobe cavitating consolidation and sputum samples confirm the presence of Mycobacterium tuberculosis, which is fully sensitive. There is no prior history of TB treatment. What is the most suitable antibiotic regimen?
Your Answer: Rifampicin/isoniazid/pyrazinamide/ethambutol for two months, then rifampicin/isoniazid for four months
Explanation:Proper Treatment for Tuberculosis
Proper treatment for tuberculosis (TB) depends on certain sensitivities. Until these sensitivities are known, empirical treatment for TB should include four drugs: rifampicin, isoniazid, pyrazinamide, and ethambutol. Treatment can be stepped down to two drugs after two months if the organism is fully sensitive. The duration of therapy for pulmonary TB is six months.
If the sensitivities are still unknown, treatment with only three drugs, such as rifampicin, isoniazid, and pyrazinamide, is insufficient for the successful treatment of TB. Initial antibiotic treatment should be rifampicin, isoniazid, pyrazinamide, and ethambutol for two months, then rifampicin and isoniazid for four months.
However, if the patient is sensitive to rifampicin and clarithromycin, treatment for TB can be rifampicin and clarithromycin for six months. It is important to note that treatment for 12 months is too long and may not be necessary for successful treatment of TB.
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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 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: Pneumothorax
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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This question is part of the following fields:
- Respiratory
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Question 11
Correct
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A 33-year-old woman presents to the Emergency Department with sudden shortness of breath and right-sided pleuritic chest pain along with dizziness. Upon examination, there is no tenderness in the chest wall and no abnormal sounds on auscultation. The calves appear normal. The electrocardiogram shows sinus tachycardia with a heart rate of 130 bpm. The D-dimer level is elevated at 0.85 mg/l. The chest X-ray is normal, and the oxygen saturation is 92% on room air. The ventilation/perfusion (V/Q) scan indicates a low probability of pulmonary embolism. What is the most appropriate next step?
Your Answer: Request a computed tomography (CT) pulmonary angiogram
Explanation:The Importance of Imaging in Diagnosing Pulmonary Embolism
Pulmonary embolism is a common medical issue that requires accurate diagnosis to initiate appropriate treatment. While preliminary investigations such as ECG, ABG, and D-dimer can raise clinical suspicion, imaging plays a crucial role in making a definitive diagnosis. V/Q imaging is often the first step, but if clinical suspicion is high, a computed tomography pulmonary angiogram (CTPA) may be necessary. This non-invasive imaging scan can detect a filling defect in the pulmonary vessel, indicating the presence of an embolus. Repeating a V/Q scan is unlikely to provide additional information. Bronchoscopy is not useful in detecting pulmonary embolism, and treating as an LRTI is not appropriate without evidence of infection. Early and accurate diagnosis is essential in managing pulmonary embolism effectively.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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An 80-year-old man comes to the Emergency Department complaining of difficulty breathing. His vital signs show a pulse rate of 105 bpm, a respiratory rate of 30 breaths per minute, and SpO2 saturations of 80% on pulse oximetry. He has a history of COPD for the past 10 years. Upon examination, there is reduced air entry bilaterally and coarse crackles. What would be the most crucial investigation to conduct next?
Your Answer: Pulmonary function tests
Correct Answer: Arterial blood gas (ABG)
Explanation:Importance of Different Investigations in Assessing Acute Respiratory Failure
When a patient presents with acute respiratory failure, it is important to conduct various investigations to determine the underlying cause and severity of the condition. Among the different investigations, arterial blood gas (ABG) is the most important as it helps assess the partial pressures of oxygen and carbon dioxide, as well as the patient’s pH level. This information can help classify respiratory failure into type I or II and identify potential causes of respiratory deterioration. In patients with a history of COPD, ABG can also determine if they are retaining carbon dioxide, which affects their target oxygen saturations.
While a chest X-ray may be considered to assess for underlying pathology, it is not the most important investigation. A D-dimer may be used to rule out pulmonary embolism, and an electrocardiogram (ECG) may be done to assess for cardiac causes of respiratory failure. However, ABG should be prioritized before these investigations.
Pulmonary function tests may be required after initial assessment of oxygen saturations to predict potential respiratory failure based on the peak expiratory flow rate. Overall, a combination of these investigations can help diagnose and manage acute respiratory failure effectively.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses concern about feeling excessively tired during the day and experiencing frequent episodes of sleepiness.
Her husband reports that she snores heavily at night and sometimes stops breathing. Additionally, her work performance has been declining, and she is at risk of losing her job.
What is the most suitable initial step in managing this patient's condition?Your Answer: Ventolin nebulisers
Correct Answer: Continuous Positive Airways Pressure (CPAP)
Explanation:Obstructive Sleep Apnoea and its Treatment
The presence of heavy snoring, apnoea attacks at night, and daytime somnolence suggests the possibility of obstructive sleep apnoea. The recommended treatment for this condition is continuous positive airway pressure (CPAP), which helps maintain airway patency during sleep. In addition to CPAP, weight loss and smoking cessation are also helpful measures. Surgery is not necessary for this condition.
Long-term oxygen therapy is indicated for individuals with chronic hypoxia associated with chronic respiratory disease to prevent the development of pulmonary hypertension. However, bronchodilators are not useful in this case. It is important to seek medical attention if any of these symptoms are present to receive proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 14
Correct
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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: 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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This question is part of the following fields:
- Respiratory
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Question 15
Correct
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You are reviewing a patient who attends the clinic with a respiratory disorder.
Which of the following conditions would be suitable for long-term oxygen therapy (LTOT) for an elderly patient?Your Answer: Chronic obstructive pulmonary disease (COPD)
Explanation:Respiratory Conditions and Oxygen Therapy: Guidelines for Treatment
Chronic obstructive pulmonary disease (COPD), opiate toxicity, asthma, croup, and myasthenia gravis are respiratory conditions that may require oxygen therapy. The British Thoracic Society recommends assessing the need for home oxygen therapy in COPD patients with severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, or oxygen saturation of 92% or below when breathing air. Opiate toxicity can cause respiratory compromise, which may require naloxone, but this needs to be considered carefully in palliative patients. Asthmatic patients who are acutely unwell and require oxygen should be admitted to hospital for assessment, treatment, and ventilation support. Croup, a childhood respiratory infection, may require hospital admission if oxygen therapy is needed. Myasthenia gravis may cause neuromuscular respiratory failure during a myasthenic crisis, which is a life-threatening emergency requiring intubation and ventilator support and not amenable to home oxygen therapy.
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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 30-year-old man is brought to the Emergency Department after he suddenly collapsed while playing soccer, complaining of pleuritic chest pain and difficulty in breathing. Upon examination, the patient appears pale and short of breath. His pulse rate is 120 bpm and blood pressure is 105/60 mmHg. Palpation reveals a deviated trachea to the right, without breath sounds over the left lower zone on auscultation. Percussion of the left lung field is hyper-resonant.
What would be the most appropriate immediate management for this patient?Your Answer: Oxygen and aspirate using a 12G needle inserted into the second intercostal space mid-axillary line
Correct Answer: Oxygen and aspirate using a 16G cannula inserted into the second anterior intercostal space mid-clavicular line
Explanation:A pneumothorax is a condition where air accumulates in the pleural space between the parietal and visceral pleura. It can be primary or secondary, with the latter being more common in patients over 50 years old, smokers, or those with underlying lung disease. Symptoms include sudden chest pain, breathlessness, and, in severe cases, pallor, tachycardia, and hypotension. Primary spontaneous pneumothorax is more common in young adult smokers and often recurs. Secondary pneumothorax is associated with various lung diseases, including COPD and α-1-antitrypsin deficiency. A tension pneumothorax is a medical emergency that can lead to respiratory or cardiovascular compromise. Diagnosis is usually made through chest X-ray, but if a tension pneumothorax is suspected, treatment should be initiated immediately. Management varies depending on the size and type of pneumothorax, with larger pneumothoraces requiring aspiration or chest drain insertion. The safest location for chest drain insertion is the fifth intercostal space mid-axillary line within the safe triangle.
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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 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: New-onset confusion with AMTS of 9
Correct 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 18
Incorrect
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A 28-year-old man with cystic fibrosis (CF) arrives at the Emergency Department (ED) with haemoptysis. During his stay in the ED, he experiences another episode of frank haemoptysis, which measures 180 ml.
A prompt computed tomography (CT) aortogram is conducted, revealing dilated and tortuous bronchial arteries.
What action could potentially harm the management of this patient?Your Answer: Tranexamic acid
Correct Answer: Non-invasive ventilation
Explanation:Treatment options for massive haemoptysis in cystic fibrosis patients
Massive haemoptysis in cystic fibrosis (CF) patients can be a life-threatening complication. Non-invasive ventilation is not recommended as it may increase the risk of aspiration of blood and disturb clot formation. IV antibiotics should be given to treat acute inflammation related to pulmonary infection. Tranexamic acid, an anti-fibrinolytic drug, can be given orally or intravenously up to four times per day until bleeding is controlled. CF patients have impaired absorption of fat-soluble vitamins, including vitamin K, which may lead to prolonged prothrombin time. In such cases, IV vitamin K should be given. Bronchial artery embolisation is often required to treat massive haemoptysis, particularly when larger hypertrophied bronchial arteries are seen on CT. This procedure is performed by an interventional vascular radiologist and may be done under sedation or general anaesthetic if the patient is in extremis.
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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 54-year-old woman presents to the Emergency Department with sudden chest pain and difficulty breathing. She has a history of factor V Leiden mutation and has smoked 20 packs of cigarettes per year. Upon examination, the patient has a fever of 38.0 °C, blood pressure of 134/82 mmHg, heart rate of 101 bpm, respiratory rate of 28 breaths/minute, and oxygen saturation of 90% on room air. Both lungs are clear upon auscultation. Cardiac examination reveals a loud P2 and a new systolic murmur at the left lower sternal border. The patient also has a swollen and red right lower extremity. An electrocardiogram (ECG) taken in the Emergency Department was normal, and troponins were within the normal range.
Which of the following chest X-ray findings is consistent with the most likely underlying pathology in this patient?Your Answer: Lower lobe opacities with blunting of the costophrenic angle on posterior–anterior (PA) chest film and opacities along the left lateral thorax on left lateral decubitus film
Correct Answer: Wedge-shaped opacity in the right middle lobe
Explanation:Radiological Findings and Their Significance in Diagnosing Medical Conditions
Wedge-shaped opacity in the right middle lobe
A wedge-shaped opacity in the right middle lobe on a chest X-ray could indicate a pulmonary embolism, which is a blockage in a lung artery. This finding is particularly significant in patients with risk factors for clotting, such as a history of smoking or factor V Leiden mutation.
Diffuse bilateral patchy, cloudy opacities
Diffuse bilateral patchy, cloudy opacities on a chest X-ray could suggest acute respiratory distress syndrome or pneumonia. These conditions can cause inflammation and fluid buildup in the lungs, leading to the appearance of cloudy areas on the X-ray.
Rib-notching
Rib-notching is a radiological finding that can indicate coarctation of the aorta, a narrowing of the main artery that carries blood from the heart. Dilated vessels in the chest can obscure the ribs, leading to the appearance of notches on the X-ray.
Cardiomegaly
Cardiomegaly, or an enlarged heart, can be seen on a chest X-ray and may indicate heart failure. This condition occurs when the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body.
Lower lobe opacities with blunting of the costophrenic angle on PA chest film and opacities along the left lateral thorax on left lateral decubitus film
Lower lobe opacities with blunting of the costophrenic angle on a posterior-anterior chest X-ray and opacities along the left lateral thorax on a left lateral decubitus film can indicate pleural effusion. This condition occurs when fluid accumulates in the space between the lungs and the chest wall, causing the lung to collapse and leading to the appearance of cloudy areas on the X-ray. The location of the opacities can shift depending on the patient’s position.
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This question is part of the following fields:
- Respiratory
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Question 20
Correct
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A 61-year-old electrician presents with a 4-month history of cough and weight loss. On further questioning, the patient reports experiencing some episodes of haemoptysis. He has a long-standing history of hypothyroidism, which is well managed with thyroxine 100 µg daily. The patient smokes ten cigarettes a day and has no other significant medical history. Blood tests and an X-ray are carried out, which reveal possible signs of asbestosis. A CT scan is ordered to investigate further.
What is the typical CT scan finding of asbestosis in the lung?Your Answer: Honeycombing of the lung with parenchymal bands and pleural plaques
Explanation:Differentiating Lung Diseases: Radiological Findings
Asbestosis is a lung disease characterized by interstitial pneumonitis and fibrosis, resulting in honeycombing of the lungs with parenchymal bands and pleural plaques. Smoking can accelerate its presentation. On a chest X-ray, bilateral reticulonodular opacities in the lower zones are observed, while a CT scan shows increased interlobular septae, parenchymal bands, and honeycombing. Silicosis, on the other hand, presents with irregular linear shadows and hilar lymphadenopathy, which can progress to PMF with compensatory emphysema. Tuberculosis is characterized by cavitation of upper zones, while pneumoconiosis shows parenchymal nodules and lower zone emphysema. Proper diagnosis is crucial in determining the appropriate treatment and management of these lung diseases.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A 68-year-old man with chronic obstructive pulmonary disease (COPD) visits his general practitioner (GP) complaining of increased wheezing, breathlessness, and a dry cough. He is able to speak in complete sentences.
During the examination, the following observations are made:
Temperature 37.2 °C
Respiratory rate 18 breaths per minute
Blood pressure 130/70 mmHg
Heart rate 90 bpm
Oxygen saturations 96% on room air
He has diffuse expiratory wheezing.
What is the most appropriate course of action for this patient?Your Answer: Refer to hospital medical team for admission
Correct Answer: Prednisolone
Explanation:Treatment Options for Acute Exacerbation of COPD
When a patient presents with evidence of an acute non-infective exacerbation of COPD, treatment with oral corticosteroids is appropriate. Short-acting bronchodilators may also be necessary. If the patient’s observations are not grossly deranged, they can be managed in the community with instructions to seek further medical input if their symptoms worsen.
Antibiotics are not indicated for non-infective exacerbations of COPD. However, if the patient has symptoms of an infective exacerbation, antibiotics may be prescribed based on the Anthonisen criteria.
Referral to a hospital medical team for admission is not necessary unless the patient is haemodynamically unstable, hypoxic, or experiencing respiratory distress.
A chest X-ray is not required unless there is suspicion of underlying pneumonia or pneumothorax. If the patient fails to respond to therapy or develops new symptoms, a chest X-ray may be considered at a later stage.
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This question is part of the following fields:
- Respiratory
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Question 22
Correct
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A 40-year-old woman has presented with recurrent respiratory distress over the last 4 years. She has also complained of wheezing at night and coughing up of tenacious sputum, which was occasionally black. Blood reports showed:
Investigation Result Normal value
Haemoglobin 112g/dl 115–155 g/l
White cell count (WCC) 12 × 109/l 4–11 × 109/l
Neutrophil count 6.0 × 109/l 2.5–7.58 × 109/l
Eosinophil count 1.5 × 109/l 0–0.4 × 109/l
Lymphocyte count 4.1 × 109/l 1.0–4.5 × 109/l
Serum immunoglobulin E (IgE) 2800 IU/l 1–87 IU/l
Which of the following is the most likely finding on a chest computerised tomography (CT) scan?Your Answer: Central cystic/varicose bronchiectasis in multiple lobes
Explanation:Understanding Different Types of Bronchiectasis and Their Possible Underlying Causes
Bronchiectasis is a condition where the bronchial tubes in the lungs become permanently damaged and widened, leading to chronic cough, sputum production, and recurrent infections. However, bronchiectasis can have different patterns and locations, which may indicate different underlying causes or associated conditions. Here are some examples:
– Central cystic/varicose bronchiectasis in multiple lobes: This may suggest allergic bronchopulmonary aspergillosis (ABPA) or allergic bronchopulmonary mycosis (ABPM), which are allergic reactions to Aspergillus fungi. ABPA can also occur without bronchiectasis, but the presence of bronchiectasis can worsen the prognosis. Other possible differentials include sarcoidosis, Churg–Strauss syndrome, bronchocentric granulomatosis, or eosinophilic pneumonia.
– Bronchiectasis mainly in upper lobes: This may be seen in chronic asthma, but usually, it is focal and limited to one or two lobes.
– Central bronchiectasis in mainly a single lobe: This may also suggest chronic asthma.
– Lower lobe fibrosis in both lungs: This may suggest interstitial lung disease, which is a group of conditions that cause inflammation and scarring of the lung tissue.
– Diffuse bronchiectasis involving mid-lung fields: This may suggest immotile Ciliary syndrome, which is a genetic disorder that affects the function of Ciliary, the tiny hair-like structures that help move mucous out of the airways.In summary, the location and pattern of bronchiectasis can provide clues to the underlying cause or associated conditions, but further tests and evaluations are needed to confirm the diagnosis and guide the treatment.
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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 50-year-old woman presents to her General Practitioner with increasing shortness of breath. She has also suffered from dull right iliac fossa pain over the past few months. Past history of note includes tuberculosis at the age of 23 and rheumatoid arthritis. On examination, her right chest is dull to percussion, consistent with a pleural effusion, and her abdomen appears swollen with a positive fluid thrill test. She may have a right adnexal mass.
Investigations:
Investigation
Result
Normal value
Chest X-ray Large right-sided pleural effusion
Haemoglobin 115 g/l 115–155 g/l
White cell count (WCC) 6.8 × 109/l 4–11 × 109/l
Platelets 335 × 109/l 150–400 × 109/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 5.4 mmol/l 3.5–5.0 mmol/l
Creatinine 175 μmol/l 50–120 µmol/l
Bilirubin 28 μmol/l 2–17 µmol/l
Alanine aminotransferase 25 IU/l 5–30 IU/l
Albumin 40 g/l 35–55 g/l
CA-125 250 u/ml 0–35 u/ml
Pleural aspirate: occasional normal pleural cells, no white cells, protein 24 g/l.
Which of the following is the most likely diagnosis?Your Answer: Ovarian carcinoma with lung secondaries
Correct Answer: Meig’s syndrome
Explanation:Possible Causes of Pleural Effusion: Meig’s Syndrome, Ovarian Carcinoma, Reactivation of Tuberculosis, Rheumatoid Arthritis, and Cardiac Failure
Pleural effusion is a condition where fluid accumulates in the pleural space, the area between the lungs and the chest wall. There are various possible causes of pleural effusion, including Meig’s syndrome, ovarian carcinoma, reactivation of tuberculosis, rheumatoid arthritis, and cardiac failure.
Meig’s syndrome is characterized by the association of a benign ovarian tumor and a transudate pleural effusion. The pleural effusion resolves when the tumor is removed, although a raised CA-125 is commonly found.
Ovarian carcinoma with lung secondaries is another possible cause of pleural effusion. However, if no malignant cells are found on thoracocentesis, this diagnosis becomes less likely.
Reactivation of tuberculosis may also lead to pleural effusion, but this would be accompanied by other symptoms such as weight loss, night sweats, and fever.
Rheumatoid arthritis can produce an exudative pleural effusion, but this presentation is different from the transudate seen in Meig’s syndrome. In addition, white cells would be present due to the inflammatory response.
Finally, cardiac failure can result in bilateral pleural effusions.
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This question is part of the following fields:
- Respiratory
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Question 24
Correct
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A 45-year-old woman presents with sudden-onset shortness of breath and pleuritic chest pain. After workup, including blood tests, an electrocardiogram (ECG) and a chest X-ray, a diagnosis of pulmonary embolism (PE) is suspected.
In which situation might a ventilation/perfusion (V/Q) scan be preferred to a computerised tomography pulmonary angiogram (CTPA) to confirm a diagnosis of PE?Your Answer: Renal impairment
Explanation:Choosing the Right Imaging Test for Suspected Pulmonary Embolism: Considerations and Limitations
When evaluating a patient with suspected pulmonary embolism (PE), choosing the appropriate imaging test can be challenging. Several factors need to be considered, including the patient’s medical history, clinical presentation, and available resources. Here are some examples of how different patient characteristics can influence the choice of imaging test:
Renal impairment: A V/Q scan may be preferred over a CTPA in patients with renal impairment, as the latter uses radiocontrast that can be nephrotoxic.
Abnormal chest X-ray: If the chest X-ray is abnormal, a V/Q scan may not be the best option, as it can be difficult to interpret. A CTPA would be more appropriate in this case.
Wells PE score of 3: The Wells score alone does not dictate the choice of imaging test. A D-dimer blood test should be obtained first, and if positive, a CTPA or V/Q scan may be necessary.
Weekend admission: Availability of imaging tests may be limited during weekends. A CTPA scan may be more feasible than a V/Q scan, as the latter requires nuclear medicine facilities that may not be available out of hours.
History of COPD: In patients with lung abnormalities such as severe COPD, a V/Q scan may be challenging to interpret. A CTPA would be a better option in this case.
In summary, choosing the right imaging test for suspected PE requires careful consideration of the patient’s characteristics and available resources. Consultation with a radiologist may be necessary in some cases.
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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 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: Respiratory rate 30 breaths per minute
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.
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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 50-year-old patient came in with worsening shortness of breath. A CT scan of the chest revealed a lesion in the right middle lobe of the lung. The radiologist described the findings as an area of ground-glass opacity surrounded by denser lung tissue.
What is the more common name for this sign?Your Answer: Halo sign
Correct Answer: Atoll sign
Explanation:Radiological Signs in Lung Imaging: Atoll, Halo, Kerley B, Signet Ring, and Tree-in-Bud
When examining CT scans of the lungs, radiologists look for specific patterns that can indicate various pathologies. One such pattern is the atoll sign, also known as the reversed halo sign. This sign is characterized by a region of ground-glass opacity surrounded by denser tissue, forming a crescent or annular shape that is at least 2 mm thick. It is often seen in cases of cryptogenic organizing pneumonia (COP), but can also be caused by tuberculosis or other infections.
Another important sign is the halo sign, which is seen in angioinvasive aspergillosis. This sign appears as a ground-glass opacity surrounding a pulmonary nodule or mass, indicating alveolar hemorrhage.
Kerley B lines are another pattern that can be seen on lung imaging, indicating pulmonary edema. These lines are caused by fluid accumulation in the interlobular septae at the periphery of the lung.
The signet ring sign is a pattern seen in bronchiectasis, where a dilated bronchus and accompanying pulmonary artery branch are visible in cross-section. This sign is characterized by a marked dilation of the bronchus, which is not seen in the normal population.
Finally, the tree-in-bud sign is a pattern seen in endobronchial tuberculosis or other endobronchial pathologies. This sign appears as multiple centrilobular nodules with a linear branching pattern, and can also be seen in cases of cystic fibrosis or viral pneumonia.
Overall, understanding these radiological signs can help clinicians diagnose and treat various lung pathologies.
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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 35-year-old man with acquired immune deficiency syndrome (AIDS) presents to the Emergency Department with fever, dyspnea, and overall feeling unwell. The attending physician suspects Pneumocystis jirovecii pneumonia. What is the most characteristic clinical feature of this condition?
Your Answer: Presence of cervical lymphadenopathy
Correct Answer: Desaturation on exercise
Explanation:Understanding Pneumocystis jirovecii Pneumonia: Symptoms and Diagnosis
Pneumocystis jirovecii pneumonia is a fungal infection that affects the lungs. While it is rare in healthy individuals, it is a significant concern for those with weakened immune systems, such as AIDS patients, organ transplant recipients, and individuals undergoing certain types of therapy. Here are some key symptoms and diagnostic features of this condition:
Desaturation on exercise: One of the hallmark symptoms of P. jirovecii pneumonia is a drop in oxygen levels during physical activity. This can be measured using pulse oximetry before and after walking up and down a hallway.
Cavitating lesions on chest X-ray: While a plain chest X-ray may show diffuse interstitial opacification, P. jirovecii pneumonia can also present as pulmonary nodules that cavitate. High-resolution computerised tomography (HRCT) is the preferred imaging modality.
Absence of cervical lymphadenopathy: Unlike some other respiratory infections, P. jirovecii pneumonia typically does not cause swelling of the lymph nodes in the neck.
Non-productive cough: Patients with P. jirovecii pneumonia may experience a dry, non-productive cough due to the thick, viscous nature of the secretions in the lungs.
Normal pulmonary function tests: P. jirovecii pneumonia does not typically cause an obstructive pattern on pulmonary function tests.
By understanding these symptoms and diagnostic features, healthcare providers can more effectively diagnose and treat P. jirovecii pneumonia in at-risk patients.
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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 28-year-old woman presents to her Occupational Health Service. She works in the sterile supplies group at her local hospital. Over the past few months, she has noticed increasing shortness of breath with cough and wheeze during the course of a working week, but improves when she takes a week off on holiday. On examination at the general practitioner’s surgery, after a few weeks off, her chest is clear.
Peak flow diary:
Monday p.m 460 l/min (85% predicted)
Tuesday p.m 440 l/min
Wednesday p.m 400 l/min
Thursday p.m 370 l/min
Friday p.m 350 l/min
Saturday a.m 420 l/min
Which of the following is the most appropriate treatment choice?Your Answer: Salbutamol inhaler as required (prn)
Correct Answer: Redeployment to another role if possible
Explanation:Managing Occupational Asthma: Redeployment and Avoiding Suboptimal Treatment Options
Based on the evidence from the patient’s peak flow diary, it is likely that they are suffering from occupational asthma. This could be due to a number of agents, such as glutaraldehyde used in hospital sterilisation units. The best course of action would be to redeploy the patient to another role, if possible, and monitor their peak flows at work. Starting medical management for asthma would not be the optimal choice in this case. Other causes of occupational asthma include isocyanates, metals, animal antigens, plant products, acid anhydrides, biological enzymes, and wood dusts. While salbutamol inhaler may provide temporary relief, it is not a long-term solution. Inhaled steroids like beclomethasone or fluticasone/salmeterol may help manage symptoms, but since the cause has been identified, they would not be the most appropriate course of action. A 7-day course of oral prednisolone would only provide temporary relief and is not a realistic long-term treatment option.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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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: Pulse rate 105 bpm
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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This question is part of the following fields:
- Respiratory
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Question 30
Correct
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A 35-year-old woman with a history of asthma and eczema visits her General Practitioner and inquires about the reason for her continued wheezing hours after being exposed to pollen. She has a known allergy to tree pollen.
What is the most suitable explanation for this?Your Answer: Inflammation followed by mucosal oedema
Explanation:Understanding the Mechanisms of Allergic Asthma
Allergic asthma is a condition that is mediated by immunoglobulin E (IgE). When IgE binds to an antigen, it triggers mast cells to release histamine, leukotrienes, and prostaglandins, which cause bronchospasm and vasodilation. This leads to inflammation and edema of the mucosal lining of the airways, resulting in persistent symptoms or late symptoms after an acute asthma attack.
While exposure to another allergen could trigger an asthma attack, it is not the most appropriate answer if you are only aware of a known allergy to tree pollen. Smooth muscle hypertrophy may occur in the long-term, but the exact mechanism and functional effects of airway remodeling in asthma are not fully understood. Pollen stuck on Ciliary would act as a cough stimulant, clearing the pollen from the respiratory tract. Additionally, the Ciliary would clear the pollen up the respiratory tract as part of the mucociliary escalator.
It is important to note that pollen inhaled into the respiratory system is not systemically absorbed. Instead, it binds to immune cells and exhibits immune effects through cytokines produced by Th1 and Th2 cells. Understanding the mechanisms of allergic asthma can help individuals manage their symptoms and prevent future attacks.
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This question is part of the following fields:
- Respiratory
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