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Question 1
Incorrect
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A 14-year-old male is brought in with acute severe asthma. During examination, it is noted that his peripheral pulse volume decreases during inspiration. What is the most probable reason for this clinical finding?
Your Answer: A falling heart rate on inspiration
Correct Answer: Reduced left atrial filling pressure on inspiration
Explanation:Pulsus Paradoxus
Pulsus paradoxus is a medical condition where there is an abnormal drop in blood pressure during inhalation. This occurs when the right heart responds directly to changes in intrathoracic pressure, while the filling of the left heart depends on the pulmonary vascular volume. In cases of severe airflow limitation, such as acute asthma, high respiratory rates can cause sudden negative intrathoracic pressure during inhalation. This enhances the normal fall in blood pressure, leading to pulsus paradoxus.
It is important to understand the underlying mechanisms of pulsus paradoxus to properly diagnose and treat the condition. By recognizing the relationship between intrathoracic pressure and blood pressure, healthcare professionals can provide appropriate interventions to manage the symptoms and prevent complications. With proper management, patients with pulsus paradoxus can lead healthy and fulfilling lives.
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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 72-year-old man is diagnosed with right-sided pleural effusion. The aspirated sample reveals a protein level of 15g/l. What could be the potential reason for the pleural effusion?
Your Answer: Renal failure
Explanation:Differentiating between transudate and exudate effusions in various medical conditions
Effusions can occur in various medical conditions, and it is important to differentiate between transudate and exudate effusions to determine the underlying cause. A transudate effusion is caused by increased capillary hydrostatic pressure or decreased oncotic pressure, while an exudate effusion is caused by increased capillary permeability.
In the case of renal failure, the patient has a transudative effusion as the effusion protein is less than 25 g/l. Inflammation from SLE would cause an exudate effusion, while pancreatitis and right-sided mesothelioma would also cause exudative effusions. Right-sided pneumonia would result in an exudate effusion as well.
Therefore, understanding the type of effusion can provide valuable information in diagnosing and treating various medical conditions.
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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 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: Pleural effusion
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 4
Correct
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A 20-year-old male presents to the Emergency department with left-sided chest pain and difficulty breathing that started during a football game.
Which diagnostic test is most likely to provide a conclusive diagnosis?Your Answer: Chest x ray
Explanation:Diagnosis of Pneumothorax
A pneumothorax is suspected based on the patient’s medical history. To confirm the diagnosis, a chest x-ray is the only definitive test available. An ECG is unlikely to show any abnormalities, while blood gas analysis may reveal a slightly elevated oxygen level and slightly decreased carbon dioxide level, even if the patient is not experiencing significant respiratory distress.
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This question is part of the following fields:
- Respiratory
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Question 5
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: Lung collapse
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 6
Incorrect
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A 72-year-old retired boiler maker presents to his General Practitioner with increasing shortness of breath and non-specific dull right-sided chest ache. He has a 35-pack-year history and has recently lost a little weight. On examination, there is evidence of a large right-sided pleural effusion.
Investigations:
Investigation
Result
Normal value
Sodium (Na+) 132 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 120 μmol/l 50–120 µmol/l
Haemoglobin 115 g/l 135–175 g/l
Platelets 170 × 109/l 150–400 × 109/l
Chest X-ray: large right-sided pleural effusion.
Pleural tap: pleural effusion contains occasional red blood cells, white blood cells and abnormal-looking cells which look of a sarcomatous type.
Which of the following statements fits best with the underlying condition?Your Answer: Smoking is likely to have played a significant role in the development of the effusion
Correct Answer: The vast majority of cases are associated with a history of asbestos exposure
Explanation:Understanding Mesothelioma: Causes, Treatment, and Prognosis
Mesothelioma is a type of cancer that has three major histological subtypes: sarcomatous, epithelial, and mixed. The vast majority of cases are associated with a history of direct exposure to asbestos, particularly in industries such as ship building, boiler manufacture, paper mill working, and insulation work. Patients often present with shortness of breath and chest pain on the affected side.
While smoking increases the risk of malignancy, it does not directly play a role in the development of malignant pleural effusion. Treatment often includes a combination of chemotherapy, radiotherapy, and surgery, but even with these approaches, the result is not curative. Median survival is short, with a life expectancy of around two years.
In early stages of cancer, radiation therapy combined with surgical treatment can be very effective, but in later stages, it is only effective in providing symptom relief. Radiation therapy alone will not be curative in 40% of cases. Understanding the causes, treatment options, and prognosis of mesothelioma is crucial for patients and their families.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 56-year-old woman presents to the Emergency Department with a 2-week history of productive cough with green sputum and a one day history of palpitations. She also had some rigors and fever. On examination:
Result Normal
Respiratory rate (RR) 26 breaths/min 12–18 breaths/min
Sats 96% on air 94–98%
Blood pressure (BP) 92/48 mmHg <120/80 mmHg
Heart rate (HR) 130 bpm 60–100 beats/min
Some bronchial breathing at left lung base, heart sounds normal however with an irregularly irregular pulse. electrocardiogram (ECG) showed fast atrial fibrillation (AF). She was previously fit and well.
Which of the following is the most appropriate initial management?Your Answer: Bisoprolol
Correct Answer: Intravenous fluids
Explanation:Treatment for AF in a Patient with Sepsis
In a patient with sepsis secondary to pneumonia, the new onset of AF is likely due to the sepsis. Therefore, the priority is to urgently treat the sepsis with intravenous fluids and broad-spectrum antibiotics. If the AF persists after the sepsis is treated, other options for AF treatment can be considered. Bisoprolol and digoxin are not the first-line treatments for AF in this case. Oral antibiotics are not recommended for septic patients. Flecainide may be considered if the AF persists after the sepsis is treated.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 29-year-old electrician was referred to the hospital by his general practitioner. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for the past three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. On the day of referral, he reported mild dyspnea, a global headache, myalgia, and arthralgia. During the examination, a maculopapular rash was observed on his upper body, and fine crackles were audible in the left mid-zone of his chest. Mild neck stiffness was also noted. His vital signs showed a fever of 39°C and a blood pressure of 120/70 mmHg.
The following investigations were conducted:
- Hb: 84 g/L (130-180)
- WBC: 8 ×109/L (4-11)
- Platelets: 210 ×109/L (150-400)
- Reticulocytes: 8% (0.5-2.4)
- Na: 137 mmol/L (137-144)
- K: 4.2 mmol/L (3.5-4.9)
- Urea: 5.0 mmol/L (2.5-7.5)
- Creatinine: 110 µmol/L (60-110)
- Bilirubin: 19 µmol/L (1-22)
- Alk phos: 130 U/L (45-105)
- AST: 54 U/L (1-31)
- GGT: 48 U/L (<50)
The chest x-ray revealed patchy consolidation in both mid-zones. What is the most appropriate course of treatment?Your Answer: Co-trimoxazole
Correct Answer: Clarithromycin
Explanation:Mycoplasma Pneumonia: Symptoms, Complications, and Treatment
Mycoplasma pneumonia is a type of pneumonia that commonly affects individuals aged 15-30 years. It is characterized by systemic upset, dry cough, and fever, with myalgia and arthralgia being common symptoms. Unlike other types of pneumonia, the white blood cell count is often within the normal range. In some cases, Mycoplasma pneumonia can also cause extrapulmonary manifestations such as haemolytic anaemia, renal failure, hepatitis, myocarditis, meningism and meningitis, transverse myelitis, cerebellar ataxia, and erythema multiforme.
One of the most common complications of Mycoplasma pneumonia is haemolytic anaemia, which is associated with the presence of cold agglutinins found in up to 50% of cases. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies in paired sera. Treatment typically involves the use of macrolide antibiotics such as clarithromycin or erythromycin, with tetracycline or doxycycline being alternative options.
In summary, Mycoplasma pneumonia is a type of pneumonia that can cause a range of symptoms and complications, including haemolytic anaemia and extrapulmonary manifestations. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies, and treatment typically involves the use of macrolide antibiotics.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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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: Asthma
Correct 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 10
Incorrect
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A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?
Your Answer: Occupational asthma
Correct Answer: Suboptimal therapy
Explanation:Differentiating Between Respiratory Conditions: A Guide
When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.
Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.
Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.
Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.
Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.
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This question is part of the following fields:
- Respiratory
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