00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - You are managing a 72-year-old male patient who has been intubated as a...

    Correct

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What is one of the four diagnostic criteria for ARDS?

      Your Answer: Presence of hypoxaemia

      Explanation:

      One of the diagnostic criteria for ARDS is the presence of hypoxemia. Other criteria include the onset of symptoms within 7 days of a clinical insult or new/worsening respiratory symptoms, bilateral opacities on chest X-ray that cannot be fully explained by other conditions, and respiratory failure that cannot be fully attributed to cardiac failure or fluid overload.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

    • This question is part of the following fields:

      • Respiratory
      20.4
      Seconds
  • Question 2 - You evaluate a 48-year-old teacher with a persistent dry cough that has been...

    Incorrect

    • You evaluate a 48-year-old teacher with a persistent dry cough that has been ongoing for several months. The patient also reports mild shortness of breath while walking around the school. They used to smoke but quit ten years ago. The patient has a normal body temperature and all other vital signs are within normal limits. During the examination, finger clubbing is noted on their hands. Chest examination reveals bilateral fine inspiratory crackles at the bases of both lungs, but no wheezing is detected. Spirometry results came back normal.

      What is the SINGLE most likely diagnosis?

      Your Answer: Bronchiectasis

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Based on the clinical features of this individual, it is highly likely that they have pulmonary fibrosis. The key to determining the correct diagnosis is to differentiate between extrinsic allergic alveolitis (EAA) and idiopathic pulmonary fibrosis (IPF), also known as cryptogenic fibrosing alveolitis (CFA).

      In this case, the gentleman does not have any occupational risk factors for EAA and exhibits digital clubbing. While clubbing is not commonly seen in EAA, it is a frequent occurrence in IPF. Therefore, based on these factors, IPF is the more probable diagnosis.

      Spirometry results in IPF can either be normal or show a restrictive pattern, whereas an obstructive pattern would be expected in COPD. The history and clinical features presented do not align with the other diagnoses mentioned in this question.

    • This question is part of the following fields:

      • Respiratory
      31885
      Seconds
  • Question 3 - A 45-year-old man presents with a sudden onset of severe asthma symptoms. You...

    Correct

    • A 45-year-old man presents with a sudden onset of severe asthma symptoms. You begin treatment for the patient, following the most recent BTS guidelines.

      According to the BTS guidelines, what is the appropriate course of action for management?

      Your Answer: Steroids should be given in all cases of acute asthma attack

      Explanation:

      The BTS guidelines for managing acute asthma in adults provide the following recommendations:

      Oxygen:
      – It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.

      β2 agonists therapy:
      – High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
      – Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
      – For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
      – In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.

      Ipratropium bromide:
      – Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      Steroid therapy:
      – Steroids should be given in adequate doses for all cases of acute asthma attacks.
      – Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.

      Other therapies:
      – Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
      – A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
      – Routine prescription of antibiotics is not necessary for patients with acute asthma.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      160.9
      Seconds
  • Question 4 - You are managing a 72-year-old male patient who has been intubated as a...

    Correct

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What measure is utilized to categorize the severity of ARDS?

      Your Answer: PaO2/FiO2 ratio

      Explanation:

      The PaO2/FiO2 ratio is a measurement used to determine the severity of Acute Respiratory Distress Syndrome (ARDS). It is calculated by dividing the arterial oxygen partial pressure (PaO2) by the fraction of inspired oxygen (FiO2). However, it is important to note that this calculation should only be done when the patient is receiving a minimum positive end-expiratory pressure (PEEP) of 5 cm water. The resulting ratio is then used to classify the severity of ARDS, with specific thresholds provided below.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

    • This question is part of the following fields:

      • Respiratory
      3.5
      Seconds
  • Question 5 - You are managing a 72-year-old patient with type 2 respiratory failure. It has...

    Incorrect

    • You are managing a 72-year-old patient with type 2 respiratory failure. It has been decided to initiate BiPAP therapy. What initial EPAP and IPAP pressure settings would you recommend?

      Your Answer: EPAP 3-5 cmH2O / IPAP 10-15 cmH2O

      Correct Answer:

      Explanation:

      When determining the initial EPAP and IPAP pressure settings for this patient, it is important to consider their specific needs and condition. In general, the EPAP pressure should be set between 3-5 cmH2O, which helps to maintain positive pressure in the airways during exhalation, preventing them from collapsing. This can improve oxygenation and reduce the work of breathing.

      The IPAP pressure, on the other hand, should be set between 10-15 cmH2O. This higher pressure during inhalation helps to overcome any resistance in the airways and ensures adequate ventilation. It also assists in improving the patient’s tidal volume and reducing carbon dioxide levels.

      Therefore, the recommended initial EPAP and IPAP pressure settings for this patient would be EPAP 3-5 cmH2O / IPAP 10-15 cmH2O. These settings provide a balance between maintaining airway patency during exhalation and ensuring sufficient ventilation during inhalation. However, it is important to regularly assess the patient’s response to therapy and adjust the settings as needed to optimize their respiratory function.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

    • This question is part of the following fields:

      • Respiratory
      52.1
      Seconds
  • Question 6 - A 4-year-old boy has been seen by one of your colleagues a few...

    Correct

    • A 4-year-old boy has been seen by one of your colleagues a few days earlier due to a persistent cough and fever that he has had for the past 10 days. The cough is a harsh, hacking cough and tends to occur in short bursts. Your colleague suspected a diagnosis of whooping cough and organized for a nasopharyngeal swab to be sent for culture.

      You review the child today with his parents having received notification from the lab that the child has a confirmed diagnosis of whooping cough. He lives with his parents and has a younger sister who is 2 years old. The mother is currently 36 weeks pregnant. The sister is up-to-date with all of her vaccinations as per the current US vaccination schedule.

      Which members of the household should receive chemoprophylaxis?

      Your Answer: The mother, father, and brother

      Explanation:

      Whooping cough is a respiratory infection caused by the bacteria Bordetella pertussis. It is highly contagious and spreads to about 90% of close household contacts. Public Health England (PHE) has identified two priority groups for managing whooping cough contacts. Group 1 includes infants under one year who have received less than three doses of the pertussis vaccine and are at risk of severe infection. Group 2 includes pregnant women at 32 weeks or more, healthcare workers dealing with infants and pregnant women, individuals working with unvaccinated infants under 4 months old, and individuals living with unvaccinated infants under 4 months old.

      According to current guidelines, antibiotic prophylaxis with a macrolide antibiotic like erythromycin should only be given to close contacts if the following criteria are met: the index case has had symptoms within the past 21 days and there is a close contact in one of the priority groups. If both criteria are met, all contacts, regardless of age and vaccination status, should be offered chemoprophylaxis. In this case, the mother falls into group 2, so the recommended action is to provide chemoprophylaxis to all household contacts, including the mother, father, and brother. Additionally, those who receive chemoprophylaxis should also consider immunization or a booster dose based on their current vaccination status.

    • This question is part of the following fields:

      • Respiratory
      214.1
      Seconds
  • Question 7 - A 45-year-old man presents with a severe exacerbation of his asthma. You have...

    Correct

    • A 45-year-old man presents with a severe exacerbation of his asthma. You have been asked to administer a loading dose of albuterol. He weighs 70 kg.
      What is the appropriate loading dose for him?

      Your Answer: 250 mg over 15 minutes

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a patient weighing 50 kg, the appropriate loading dose would be 250 mg. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

    • This question is part of the following fields:

      • Respiratory
      64.7
      Seconds
  • Question 8 - A 30 year old patient is brought to the emergency department by bystanders...

    Incorrect

    • A 30 year old patient is brought to the emergency department by bystanders after a hit and run incident. Upon examination, you observe that the patient is experiencing difficulty breathing and has tracheal deviation towards the left side. Based on these findings, you suspect the presence of a tension pneumothorax. What signs would you anticipate observing in this patient?

      Your Answer:

      Correct Answer: Elevated jugular venous pressure

      Explanation:

      Tension pneumothorax is a condition characterized by certain clinical signs. These signs include pulsus paradoxus, which is an abnormal decrease in blood pressure during inspiration; elevated JVP or distended neck veins; diaphoresis or excessive sweating; and cyanosis, which is a bluish discoloration of the skin. Tracheal deviation to the left is often observed in patients with a right-sided pneumothorax. On the affected side, hyper-resonance and absent breath sounds can be expected. Patients with tension pneumothorax typically appear agitated and distressed, and they experience noticeable difficulty in breathing. Hypotension, a pulse rate exceeding 135 bpm, pulsus paradoxus, and elevated JVP are additional signs associated with tension pneumothorax. These signs occur because the expanding pneumothorax compresses the mediastinum, leading to impaired venous return and cardiac output.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 9 - A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic...

    Incorrect

    • A 25-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Brazil. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
      Which of the following tests should be ordered?

      Your Answer:

      Correct Answer: Doppler ultrasound scan of leg

      Explanation:

      Based on the clinical history and examination, it strongly indicates that the patient may have a pulmonary embolism caused by a deep vein thrombosis in his right leg. To confirm this, it is recommended that he undergoes a CT pulmonary angiogram and doppler ultrasound scan of his right leg.

      The typical symptoms of a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. Additionally, there may be symptoms suggesting the presence of a deep vein thrombosis. Other signs to look out for are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 10 - A 3-year-old boy is brought in by his parents with a history of...

    Incorrect

    • A 3-year-old boy is brought in by his parents with a history of breathing difficulties, fever, and a cough. He is irritable and having difficulty eating. On examination, his temperature is 38.6°C, and you hear fine inspiratory crackles throughout his chest.

      What is the SINGLE most appropriate investigation?

      Your Answer:

      Correct Answer: Nasopharyngeal aspirate

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 11 - A 45-year-old man comes in with a dry cough that has been going...

    Incorrect

    • A 45-year-old man comes in with a dry cough that has been going on for a week. He also complains of muscle aches, fatigue, and a sore throat. In the past day, he has developed diarrhea and a mild throbbing headache. During the examination, his temperature is measured at 37.8°C, and faint crackles are heard at the base of his lungs.

      What is the SINGLE most probable organism responsible for these symptoms?

      Your Answer:

      Correct Answer: Mycoplasma pneumoniae

      Explanation:

      This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features commonly associated with Mycoplasma pneumoniae infection include a flu-like illness that occurs before respiratory symptoms, fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness. It is worth noting that Mycoplasma pneumoniae is frequently linked to the development of erythema multiforme and can also be a cause of Steven-Johnson syndrome. The rash associated with erythema multiforme is characterized by multiple red lesions on the limbs that develop into target lesions a few days after the rash first appears.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 12 - A 72-year-old man presents with a severe exacerbation of his COPD. He has...

    Incorrect

    • A 72-year-old man presents with a severe exacerbation of his COPD. He has been given a loading dose of aminophylline and you now intend to establish a maintenance infusion. He weighs 70 kg.
      What is the appropriate maintenance infusion rate for him?

      Your Answer:

      Correct Answer: 25 mg/hour

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a 50 kg individual, the appropriate infusion rate would be 25 mg/hour. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 13 - A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell...

    Incorrect

    • A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell and has experienced recent weight loss. Additionally, she has developed a rash. Her medical history includes a diagnosis of asthma last year and allergic rhinitis. On examination, she has a normal body temperature, her blood pressure is 180/95, and she has a purpuric rash primarily on her legs. During chest examination, a few scattered wheezes are heard.

      Recently, she had a blood test, and the results are as follows:
      - Hemoglobin (Hb): 10.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 23.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 8.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Lymphocytes: 2.1 x 109/l (normal range: 1.3-3.5 x 109/l)
      - Eosinophils: 15.7 x 109/l (normal range: 0.04-0.44 x 109/l)
      - C-reactive protein (CRP): 107 mg/l (normal range: <5 mg/l)
      - Sodium (Na): 142 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.6 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 255 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 14.8 mmol/l (normal range: 2.5-7.5 mmol/l)

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Churg-Strauss syndrome

      Explanation:

      This individual has presented with haemoptysis and a purpuric rash, alongside a history of asthma and allergic rhinitis. Blood tests have revealed elevated inflammatory markers, pronounced eosinophilia, and acute renal failure. The most likely diagnosis in this case is Churg-Strauss syndrome.

      Churg-Strauss syndrome is a rare autoimmune vasculitis that affects small and medium-sized blood vessels. The American College of Rheumatology has established six criteria for diagnosing Churg-Strauss syndrome. The presence of at least four of these criteria is highly indicative of the condition:

      1. Asthma (wheezing, expiratory rhonchi)
      2. Eosinophilia of more than 10% in peripheral blood
      3. Paranasal sinusitis
      4. Pulmonary infiltrates (which may be transient)
      5. Histological confirmation of vasculitis with extravascular eosinophils
      6. Mononeuritis multiplex or polyneuropathy

      Churg-Strauss syndrome can affect various organ systems, with the most common clinical features including:

      – Constitutional symptoms: fever, fatigue, weight loss, and arthralgia
      – Respiratory symptoms: asthma, haemoptysis, allergic rhinitis, and sinusitis
      – Cardiovascular symptoms: heart failure, myocarditis, and myocardial infarction
      – Gastrointestinal symptoms: gastrointestinal bleeding, bowel ischaemia, and appendicitis
      – Dermatological symptoms: purpura, livedo reticularis, and skin nodules
      – Renal symptoms: glomerulonephritis, renal failure, and hypertension
      – Neurological symptoms: mononeuritis multiplex

      Investigations often reveal eosinophilia, anaemia, elevated CRP and ESR, elevated creatinine, and elevated serum IgE levels. Approximately 70% of patients test positive for p-ANCA.

      The mainstay of treatment for Churg-Strauss syndrome is high-dose steroids. In cases with life-threatening complications, cyclophosphamide and azathioprine are often administered.

      Polyarteritis nodosa is another vasculitic disorder that affects small and medium-sized blood vessels. It can impact the gastrointestinal tract, kidneys, skin, and joints, but it is not typically associated with rhinitis or asthma.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 14 - A 32-year-old woman with a documented history of asthma arrives with severe difficulty...

    Incorrect

    • A 32-year-old woman with a documented history of asthma arrives with severe difficulty breathing and wheezing. After initial assessment, it is determined that she is experiencing a life-threatening asthma attack, and she is immediately transferred to the resuscitation area. An arterial blood gas is obtained to aid in her treatment.
      What type of acid-base imbalance would you anticipate as a result of this life-threatening asthma episode?

      Your Answer:

      Correct Answer: Respiratory acidosis

      Explanation:

      The following list provides a summary of common causes for different acid-base disorders.

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. It can also occur due to pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

      Metabolic alkalosis can be caused by vomiting, potassium depletion (often due to diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can occur due to lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction) or ketoacidosis (such as in diabetes, starvation, or alcohol excess). It can also be a result of renal failure or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).

      Metabolic acidosis with a normal anion gap can be caused by conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 15 - A 25-year-old woman presents to the emergency department with a complaint of progressive...

    Incorrect

    • A 25-year-old woman presents to the emergency department with a complaint of progressive lip swelling that began 1 hour ago. Upon reviewing her medical history, it is noted that she has a previous diagnosis of hereditary angioedema (HAE). The following findings have been documented:

      - Blood pressure: 120/80 mmHg
      - Pulse rate: 90 beats per minute
      - Respiratory rate: 16 breaths per minute
      - Temperature: 37.5 degrees Celsius

      What is the primary concern regarding this patient?

      Your Answer:

      Correct Answer: Airway obstruction

      Explanation:

      The primary concern regarding this patient is airway obstruction. The patient’s complaint of progressive lip swelling, along with her previous diagnosis of hereditary angioedema (HAE), suggests that she may be experiencing an allergic reaction. Angioedema can cause swelling in various parts of the body, including the lips, tongue, and throat. If the swelling progresses and affects the airway, it can lead to difficulty breathing and potentially block the airway completely. This can be a life-threatening emergency and requires immediate intervention to ensure the patient’s airway remains open and they can breathe properly.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 16 - You assess a patient who complained of chest discomfort and difficulty breathing. Upon...

    Incorrect

    • You assess a patient who complained of chest discomfort and difficulty breathing. Upon examination, it is determined that the patient has developed a spontaneous pneumothorax on the right side, and an unsuccessful pleural aspiration was attempted. The pneumothorax remains significant in size, and the patient continues to experience breathlessness. A Seldinger chest tube is inserted, but shortly after, it begins to drain bright red blood.

      Which complication is the most probable cause of this occurrence?

      Your Answer:

      Correct Answer: Intercostal artery laceration

      Explanation:

      Intercostal artery laceration during the insertion of a chest drain is a potentially life-threatening complication. Although rare, it occurs more frequently than other complications mentioned. To minimize the risk of damage to underlying structures and unsightly scarring, the British Thoracic Society (BTS) recommends inserting chest drains within the safe triangle. This triangle is defined by the base of the axilla, the lateral border of the latissimus dorsi, the lateral border of the pectoralis major, and the 5th intercostal space.

      Possible complications associated with the insertion of small-bore chest drains include puncture of the intercostal artery, organ perforation due to over-introduction of the dilator into the chest cavity, hospital-acquired pleural infection from non-aseptic techniques, inadequate stay suture leading to the chest tube falling out, and tube blockage, which may be more common with smaller bore Argyle drains.

      When using an intercostal approach, it is important to place the chest drain closer to the superior border of the rib below in the intercostal space. This positioning helps avoid injury to the intercostal neurovascular bundle located under the costal groove of the rib above.

      For more information, refer to the British Thoracic Society pleural disease guidelines.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 17 - A 72-year-old man presents with a severe exacerbation of his COPD. You have...

    Incorrect

    • A 72-year-old man presents with a severe exacerbation of his COPD. You have been asked to administer a loading dose of aminophylline. He weighs 70 kg.
      What is the appropriate loading dose for him?

      Your Answer:

      Correct Answer: 300 mg over 15 minutes

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a patient weighing 60 kg, the appropriate loading dose would be 300 mg. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 18 - A 45-year-old woman presents with increasing shortness of breath at rest and severe...

    Incorrect

    • A 45-year-old woman presents with increasing shortness of breath at rest and severe left shoulder pain. The pain travels down the inner side of her left arm and into her ring and little finger. She has a long history of smoking, having smoked 30 packs of cigarettes per year. During the examination, her voice sounds hoarse and there is muscle wasting in her left hand and forearm. Additionally, she has a left-sided ptosis and miosis.

      What is the MOST suitable initial test to perform?

      Your Answer:

      Correct Answer: Chest X-ray

      Explanation:

      This individual, who has been smoking for a long time, is likely to have squamous cell carcinoma of the lung located at the right apex. This particular type of cancer is causing Pancoast’s syndrome. Pancoast’s syndrome typically presents with rib erosion, leading to severe shoulder pain, as well as Horner’s syndrome due to the infiltration of the lower part of the brachial plexus. Additionally, there may be hoarseness of the voice and a ‘bovine cough’ due to a concurrent recurrent laryngeal nerve palsy.

      The classic description of Horner’s syndrome includes the following clinical features on the same side as the tumor: miosis (constricted pupil), ptosis (drooping eyelid), anhidrosis (lack of sweating), and enophthalmos (sunken appearance of the eye). A chest X-ray would be able to detect the presence of the apical tumor and confirm the diagnosis.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 19 - A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing...

    Incorrect

    • A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing and chest pain that worsens with deep breaths. The results of his arterial blood gas (ABG) on room air are as follows:

      pH: 7.48
      pO2: 7.4 kPa
      PCO2: 3.1 kPa
      HCO3-: 24.5 mmol/l

      Which ONE statement about his ABG is correct?

      Your Answer:

      Correct Answer: He has a respiratory alkalosis

      Explanation:

      Arterial blood gas (ABG) interpretation is crucial in evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analysers, they generally fall within the following ranges: pH of 7.35 – 7.45, pO2 of 10 – 14 kPa, PCO2 of 4.5 – 6 kPa, HCO3- of 22 – 26 mmol/l, and base excess of -2 – 2 mmol/l.

      In this particular case, the patient’s medical history raises concerns about a potential diagnosis of pulmonary embolism. The relevant ABG findings are as follows: significant hypoxia (indicating type 1 respiratory failure), elevated pH (alkalaemia), low PCO2, and normal bicarbonate levels. These findings suggest that the patient is experiencing primary respiratory alkalosis.

      By analyzing the ABG results, healthcare professionals can gain valuable insights into a patient’s respiratory function and acid-base status, aiding in the diagnosis and management of various conditions.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 20 - A 6-year-old girl has recently been diagnosed with whooping cough. Her parents would...

    Incorrect

    • A 6-year-old girl has recently been diagnosed with whooping cough. Her parents would like to ask you some questions.

      Which SINGLE statement about whooping cough is true?

      Your Answer:

      Correct Answer: Encephalopathy is a recognised complication

      Explanation:

      Whooping cough, also known as pertussis, is a respiratory infection caused by the bacteria Bordetella pertussis. It is transmitted through respiratory droplets and has an incubation period of approximately 7-21 days. This highly contagious disease can be transmitted to about 90% of close household contacts.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, resembles a mild respiratory infection with symptoms such as low-grade fever and a runny nose. Although a cough may be present, it is usually mild and not as severe as in the next stage. The catarrhal stage typically lasts for about a week.

      The second stage, called the paroxysmal stage, is when the characteristic paroxysmal cough develops as the catarrhal symptoms begin to subside. During this stage, coughing occurs in spasms, often preceded by an inspiratory whoop and followed by a series of rapid expiratory coughs. Other symptoms may include vomiting, subconjunctival hemorrhages, and petechiae. Patients generally feel well between spasms, and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery during this period. The later stages are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, herniae, syncopal episodes, encephalopathy, and seizures.

      To diagnose whooping cough, nasopharyngeal swabs can be cultured in a medium called Bordet-Gengou agar, which contains blood, potato extract, glycerol, and an antibiotic to isolate Bordetella pertussis.

      Although antibiotics do not alter the clinical course of the infection, they can reduce the period of infectiousness and help prevent further spread.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 21 - A 32-year-old woman presents with a history of increased wheezing over the past...

    Incorrect

    • A 32-year-old woman presents with a history of increased wheezing over the past two days. She suffers from seasonal allergies in the spring months, which has been worse than usual over recent weeks. When auscultating her chest, you can hear scattered polyphonic wheezes. Her peak flow at presentation was 275 L/min, and her best ever peak flow is 500 L/min. After a single salbutamol nebulizer, her peak flow improves to 455 L/min, and she feels much better.
      Which of the following drug treatments should be administered next?

      Your Answer:

      Correct Answer: Oral prednisolone

      Explanation:

      This individual has presented with an episode of acute asthma. Upon assessment, his initial peak flow is measured at 55% of his personal best, indicating a moderate exacerbation. In such cases, it is recommended to administer steroids, with a suggested dose of prednisolone 40-50 mg taken orally as the initial management step.

      Currently, the use of nebulized magnesium sulfate is not recommended for the treatment of acute asthma in adults. However, according to the current ALS guidelines, in severe or life-threatening asthma cases, IV aminophylline can be considered after seeking senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.

      In situations where inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation, IV salbutamol can be considered at a slow dose of 250 mcg. However, it should be noted that there is currently no evidence supporting the use of leukotriene receptor antagonists, like montelukast, in the management of acute asthma.

      The BTS guidelines classify acute asthma into four categories: moderate, acute severe, life-threatening, and near-fatal. Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the individual’s best or predicted value, with no features of acute severe asthma. Acute severe asthma is identified by a PEFR of 33-50% of the best or predicted value, along with respiratory rate >25/min, heart rate >110/min, or the inability to complete sentences in one breath.

      Life-threatening asthma is indicated by a PEFR <33% of the best or predicted value, SpO2 <92%, PaO2 <8 kPa, normal PaCO2 (4.6-6.0 kPa), and additional symptoms such as silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension. Near-fatal asthma is characterized by raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 22 - A 3-year-old girl presents with stridor and a barking cough. Her mother reports...

    Incorrect

    • A 3-year-old girl presents with stridor and a barking cough. Her mother reports that she has had a slight cold for a few days and her voice had been hoarse. Her vital signs are as follows: temperature 38.1°C, heart rate 135, respiratory rate 30, oxygen saturation 97% on room air. Her chest examination is unremarkable, but you observe the presence of stridor at rest.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Croup

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 23 - A 72-year-old man comes in with increasing shortness of breath. During the examination,...

    Incorrect

    • A 72-year-old man comes in with increasing shortness of breath. During the examination, it is noted that he has reduced chest movement on the right side. Dullness to percussion and decreased breath sounds are also observed over the right lower lobe. A chest X-ray confirms the presence of a significant pleural effusion. You plan to perform a percutaneous needle aspiration.

      Which ONE statement about percutaneous needle aspiration is accurate?

      Your Answer:

      Correct Answer: The needle should be inserted just above the upper border of the chosen rib

      Explanation:

      A pleural effusion refers to the accumulation of excess fluid in the pleural cavity, which is the fluid-filled space between the parietal and visceral pleura. Normally, this cavity contains about 5-10 ml of lubricating fluid that allows the pleurae to slide over each other and helps the lungs fill with air as the thorax expands. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons: to investigate pleural effusion and to provide relief from breathlessness caused by pleural effusion. According to the guidelines from the British Thoracic Society (BTS), pleural aspiration should be reserved for the investigation of unilateral exudative pleural effusions. It should not be done if unilateral or bilateral transudative effusion is suspected, unless there are atypical features or a lack of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

      During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line at the back (approximately 10 cm to the side of the spine), one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 24 - A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting,...

    Incorrect

    • A 42-year-old man presents with a high temperature, difficulty breathing, diarrhea and vomiting, fatigue, and fainting. He has recently returned from a wellness retreat in France. The patient is referred to the medical team on duty and admitted to the hospital. They suspect a potential diagnosis of Legionnaires' disease.
      What is the definitive test used to confirm a case of Legionnaires' disease?

      Your Answer:

      Correct Answer: Isolation and culture from a sputum sample

      Explanation:

      The guidelines from the British Thoracic Society (BTS) recommend conducting investigations for Legionella infection in the following cases: severe community-acquired pneumonia, patients with specific risk factors, and during outbreaks of community-acquired pneumonia. To confirm a case, the Public Health England (PHE) requires one of the following: isolation and culture of Legionella species from clinical specimens (typically sputum), seroconversion with a four-fold increase in titre of indirect immunofluorescent antibody test (IFAT) using a validated technique, or confirmation of Legionella pneumophila urinary antigen using validated reagents or kits. The gold standard for confirmation is the isolation and culture of Legionella species, while cases of Pontiac fever are usually culture-negative. The HPA considers a case presumptive if there is a clinical diagnosis of pneumonia with a single high titre of 128 using IFAT, or a single titre of 64 in an outbreak. A positive result by direct immunofluorescence on a clinical specimen using validated monoclonal antibodies is also considered a presumptive case.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 25 - A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing,...

    Incorrect

    • A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing, and wheezing. Blood tests reveal an elevated packed cell volume (PCV). A chest X-ray shows more than 6 ribs visible above the diaphragm in the midclavicular line. An arterial blood gas indicates slightly low pO2 levels.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: COPD

      Explanation:

      Based on the provided information, it is highly probable that this patient is suffering from chronic obstructive pulmonary disease (COPD). This conclusion is supported by several factors. Firstly, the patient has a history of chronic productive cough and wheezing, which are common symptoms of COPD. Additionally, the patient has a long-term smoking history, which is a major risk factor for developing this condition.

      Furthermore, the patient’s raised packed cell volume (PCV) is likely a result of chronic hypoxemia, a common complication of COPD. This indicates that the patient’s body is trying to compensate for the low oxygen levels in their blood.

      Moreover, the chest X-ray reveals evidence of hyperinflation, which is a characteristic finding in patients with COPD. This suggests that the patient’s lungs are overinflated and not functioning optimally.

      Lastly, the arterial blood gas analysis shows hypoxemia, indicating that the patient has low levels of oxygen in their blood. This is another significant finding that aligns with a diagnosis of COPD.

      In summary, based on the patient’s history, smoking habits, raised PCV, chest X-ray findings, and arterial blood gas results, it is highly likely that they have COPD.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 26 - A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty...

    Incorrect

    • A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the bird exhibit. During the examination, a reddish macular rash is observed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.

      What is the specific name of the rash on his face that is associated with this condition?

      Your Answer:

      Correct Answer: Horder’s spots

      Explanation:

      Psittacosis is a type of infection that can be transmitted from animals to humans, caused by a bacterium called Chlamydia psittaci. It is most commonly seen in people who own domestic birds, as well as those who work in pet shops or zoos. The typical symptoms of psittacosis include pneumonia that is acquired within the community, along with flu-like symptoms. Many patients also experience severe headaches and sensitivity to light. Enlargement of the spleen is a common finding in about two-thirds of individuals with this infection.

      Infected individuals often develop a rash on their face, known as Horder’s spots, which appear as reddish macules. In some cases, erythema nodosum and erythema multiforme may also occur. The recommended treatment for psittacosis is a course of tetracycline or doxycycline for a period of 2-3 weeks.

      On the other hand, rose spots are typically observed in cases of typhoid fever. These spots have a similar appearance to Horder’s spots but are usually found on the trunk rather than the face. Erythema marginatum is a pale red rash seen in rheumatic fever, while malar flush, also known as ‘mitral facies’, refers to the reddish discoloration of the cheeks commonly seen in individuals with mitral stenosis. Lastly, erythema chronicum migrans is the distinctive rash seen in Lyme disease, characterized by a circular rash with a central ‘bulls-eye’ appearance that spreads outward from the site of a tick bite.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 27 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Incorrect

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After conducting a clinical evaluation, you determine that he has community-acquired pneumonia. He has no significant medical history and no reported drug allergies.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer:

      Correct Answer: Amoxicillin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 28 - A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18...

    Incorrect

    • A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18 kg.
      As per the BTS guidelines, what dosage of prednisolone should be prescribed for him?

      Your Answer:

      Correct Answer: 30 mg

      Explanation:

      The BTS guidelines for acute asthma in children recommend administering oral steroids early in the treatment of asthma attacks. It is advised to give a dose of 20 mg prednisolone for children aged 2–5 years and a dose of 30–40 mg for children over 5 years old. If a child is already taking maintenance steroid tablets, they should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the medication, the dose of prednisolone should be repeated. In cases where a child is unable to keep down orally ingested medication, intravenous steroids should be considered. Typically, treatment for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering off the medication is not necessary unless the steroid course exceeds 14 days. For more information, refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 29 - A 6-year-old girl presents with a history of a persistent cough that has...

    Incorrect

    • A 6-year-old girl presents with a history of a persistent cough that has been present for the past four weeks. The cough occurs in quick bursts with a deep breath in followed by a series of forceful coughs. She occasionally vomits after coughing. Her mother reports that the cough is more severe at night.

      During the examination, her chest sounds clear, but you observe two small subconjunctival hemorrhages and some tiny red spots on her face.

      What is the MOST suitable test to perform in this case?

      Your Answer:

      Correct Answer: Serology for anti-pertussis toxin IgG antibody levels

      Explanation:

      This presentation strongly suggests a diagnosis of whooping cough, which is an infection of the upper respiratory tract caused by the bacteria Bordetella pertussis. The disease is highly contagious and is transmitted through respiratory droplets. The incubation period is typically 7-21 days, and it is estimated that about 90% of close household contacts will become infected.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, is similar to a mild respiratory infection with symptoms such as low-grade fever and a runny nose. A cough may be present, but it is usually not as severe as in the second stage. This phase typically lasts about a week.

      The second stage, called the paroxysmal stage, is characterized by the development of a distinctive cough. The coughing occurs in spasms, often preceded by an inspiratory whoop sound. These spasms are followed by a series of rapid, hacking coughs. Patients may also experience vomiting and develop subconjunctival hemorrhages and petechiae. Between spasms, patients generally feel well and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) has specific recommendations for testing for whooping cough based on the age of the patient, the time since onset of illness, and the severity of the presentation.

      For infants under 12 months of age, hospitalized patients should be tested using PCR testing. Non-hospitalized patients within two weeks of onset should be investigated with culture of a nasopharyngeal swab or aspirate. Non-hospitalized patients presenting over two weeks after onset should be tested using serology for anti-pertussis toxin IgG antibody levels.

      For children over 12 months of age and adults, patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Patients aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after onset should have oral fluid testing for anti-pertussis toxin IgG antibody levels.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 30 - A 45-year-old Irish woman comes in with a complaint of increasingly severe shortness...

    Incorrect

    • A 45-year-old Irish woman comes in with a complaint of increasingly severe shortness of breath. During the interview, she mentions experiencing joint pain for several months and having painful skin lesions on both shins. A chest X-ray is performed, which shows bilateral hilar lymphadenopathy.
      What is the specific syndrome she is experiencing?

      Your Answer:

      Correct Answer: Löfgren’s syndrome

      Explanation:

      The patient presents with a medical history and physical examination findings that are consistent with a diagnosis of Löfgren’s syndrome, which is a specific subtype of sarcoidosis. This syndrome is most commonly observed in women in their 30s and 40s, and it is more prevalent among individuals of Nordic and Irish descent.

      Löfgren’s syndrome is typically characterized by a triad of clinical features, including bilateral hilar lymphadenopathy seen on chest X-ray, erythema nodosum, and arthralgia, with a particular emphasis on ankle involvement. Additionally, other symptoms commonly associated with sarcoidosis may also be present, such as a dry cough, breathlessness, fever, night sweats, malaise, weight loss, Achilles tendonitis, and uveitis.

      In order to further evaluate this patient’s condition, it is recommended to refer them to a respiratory specialist for additional investigations. These investigations may include measuring the serum calcium level, as it may be elevated, and assessing the serum angiotensin-converting enzyme (ACE) level, which may also be elevated. A high-resolution CT scan can be performed to assess the extent of involvement and identify specific lymph nodes for potential biopsy. If there are any atypical features, a lymph node biopsy may be necessary. Lung function tests can be conducted to evaluate the patient’s vital capacity, and an MRI scan of the ankles may also be considered.

      Fortunately, the prognosis for Löfgren’s syndrome is generally very good, and it is considered a self-limiting and benign condition. The patient can expect to recover within a timeframe of six months to two years.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (5/7) 71%
Passmed