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  • Question 1 - A 55-year-old woman comes to her doctor complaining of wheezing, chest tightness, cough,...

    Correct

    • A 55-year-old woman comes to her doctor complaining of wheezing, chest tightness, cough, and difficulty breathing for the past three days. She reports that this started shortly after being exposed to a significant amount of hydrogen sulfide at work. She has no prior history of respiratory issues and is a non-smoker. What would be the most suitable initial management approach to alleviate her symptoms?

      Your Answer: Inhaled bronchodilators

      Explanation:

      Management of Reactive Airway Dysfunction Syndrome (RADS)

      Reactive airway dysfunction syndrome (RADS) is a condition that presents with asthma-like symptoms within 24 hours of exposure to irritant gases, vapours or fumes. To diagnose RADS, pre-existing respiratory conditions must be absent, and symptoms must occur after a single exposure to high concentrations of irritants. A positive methacholine challenge test and possible airflow obstruction on pulmonary function tests are also indicative of RADS.

      Inhaled bronchodilators, such as salbutamol, are the first-line treatment for RADS. Cromolyn sodium may be added in select cases, while inhaled corticosteroids are used if bronchodilators are ineffective. Oral steroids are not as effective in RADS as they are in asthma. High-dose vitamin D may be useful in some cases, but it is not routinely recommended for initial management.

      In summary, the management of RADS involves the use of inhaled bronchodilators as the first-line treatment, with other medications added in if necessary. A proper diagnosis is crucial to ensure appropriate management of this condition.

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      • Respiratory
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  • Question 2 - A 65-year-old man complains of worsening shortness of breath. During examination, the left...

    Incorrect

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

      Your Answer: CT thorax

      Correct Answer: Ultrasound-guided pleural fluid aspiration

      Explanation:

      Left Pleural Effusion Diagnosis

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

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  • Question 3 - A 67-year-old woman has had bowel surgery two days ago. She is currently...

    Correct

    • A 67-year-old woman has had bowel surgery two days ago. She is currently on postoperative day one, and you are called to see her as she has developed sudden-onset shortness of breath. She denies any coughing but complains of chest discomfort. The surgical scar appears clean. Upon examination, the patient is afebrile; vital signs are stable other than rapid and irregular heartbeat and upon auscultation, the chest sounds are clear. The patient does not have any other significant past medical history, aside from her breast cancer for which she had a mastectomy five years ago. She has no family history of any heart disease.
      What is the patient’s most likely diagnosis?

      Your Answer: Pulmonary embolism

      Explanation:

      Differential Diagnosis for Sudden Onset Shortness of Breath postoperatively

      When a patient experiences sudden onset shortness of breath postoperatively, it is important to consider various differential diagnoses. One possible diagnosis is pulmonary embolism, which is supported by the patient’s chest discomfort. Anaphylaxis is another potential diagnosis, but there is no mention of an allergen exposure or other signs of a severe allergic reaction. Pneumonia is unlikely given the absence of fever and clear chest sounds. Lung fibrosis is also an unlikely diagnosis as it typically presents gradually and is associated with restrictive respiratory diseases. Finally, cellulitis is not a probable diagnosis as there are no signs of infection and the surgical wound is clean. Overall, a thorough evaluation is necessary to determine the underlying cause of the patient’s sudden onset shortness of breath.

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  • Question 4 - You are on call in the Emergency Department when an ambulance brings in...

    Incorrect

    • You are on call in the Emergency Department when an ambulance brings in an elderly man who was found unconscious in his home, clutching an empty bottle of whiskey. On physical examination, he is febrile with a heart rate of 110 bpm, blood pressure of 100/70 mmHg and pulse oximetry of 89% on room air. You hear crackles in the right lower lung base and note dullness to percussion in those areas. His breath is intensely malodorous, and there appears to be dried vomit in his beard.
      What is the most likely organism causing his pneumonia?

      Your Answer: Legionella pneumophila

      Correct Answer: Mixed anaerobes

      Explanation:

      Types of Bacteria that Cause Pneumonia

      Pneumonia is a serious respiratory infection that can be caused by various types of bacteria. One common cause is the ingestion of large quantities of alcohol, which can lead to vomiting and aspiration of gastric contents. This can result in pneumonia caused by Gram-negative anaerobes from the oral flora or gastric contents, which produce foul-smelling short-chain fatty acids.

      Other types of bacteria that can cause pneumonia include Streptococcus pneumoniae, the most common cause of severe bacterial pneumonia requiring hospitalization. It is a Gram-positive, catalase-negative coccus. Staphylococcus aureus is a less common cause of pneumonia, often seen after influenzae infection. It is a Gram-positive, coagulase-positive coccus.

      Legionella pneumophila causes Legionnaires’ disease, a severe pneumonia that typically affects older people and is contracted through contaminated air conditioning ducts or showers. The best stain for this organism is a silver stain. Chlamydia pneumoniae causes an ‘atypical’ pneumonia with bilateral diffuse infiltrates, and the chest radiograph often looks worse than is indicated by the patient’s presentation. C. pneumoniae is an obligate intracellular organism.

      In summary, understanding the different types of bacteria that can cause pneumonia is crucial for proper diagnosis and treatment.

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  • Question 5 - A 32-year-old woman visits her General Practitioner seeking assistance to quit smoking. She...

    Correct

    • A 32-year-old woman visits her General Practitioner seeking assistance to quit smoking. She has been smoking ten cigarettes daily for the last 14 years and has no significant medical history. However, she is currently in her second trimester of pregnancy. What is the most suitable first-line smoking cessation option for this patient?

      Your Answer: Behavioural therapy

      Explanation:

      Smoking Cessation Options for Pregnant Women: A Review of Medications and Therapies

      When it comes to quitting smoking during pregnancy or postpartum, behavioural therapy is the recommended first-line approach by the National Institute for Health and Care Excellence (NICE). Smoking cessation clinics can provide support for women who wish to quit smoking. Clonidine, a medication used for high blood pressure and drug withdrawal, has some effect on smoking cessation but is not licensed or recommended for this use by NICE. Bupropion, which reduces cravings and withdrawal effects, is contraindicated during pregnancy and breastfeeding. Nicotine replacement therapy can be used in pregnancy, but women should be informed of the risks and benefits and only used if behavioural support is ineffective. Varenicline, a medication that reduces cravings and the pleasurable effects of tobacco products, is contraindicated during pregnancy and breastfeeding due to its toxicity in studies. It is important for healthcare providers to discuss the available options with pregnant women and provide individualized recommendations for smoking cessation.

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  • Question 6 - A 58-year-old woman presents with a history of recurrent cough, haemoptysis, and copious...

    Incorrect

    • A 58-year-old woman presents with a history of recurrent cough, haemoptysis, and copious amounts of mucopurulent sputum for the past 10 years. Sputum analysis shows mixed flora with anaerobes present. During childhood, she experienced multiple episodes of pneumonia.

      What is the probable diagnosis for this patient?

      Your Answer: Idiopathic pulmonary fibrosis

      Correct Answer: Bronchiectasis

      Explanation:

      Recognizing Bronchiectasis: Symptoms and Indicators

      Bronchiectasis is a respiratory condition that can be identified through several symptoms and indicators. One of the most common signs is the production of large amounts of sputum, which can be thick and difficult to cough up. Additionally, crackles may be heard when listening to the chest with a stethoscope. In some cases, finger clubbing may also be present. This occurs when the fingertips become enlarged and rounded, resembling drumsticks.

      It is important to note that bronchiectasis can be caused by a variety of factors, including childhood pneumonia or previous tuberculosis. These conditions can lead to damage in the airways, which can result in bronchiectasis.

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  • Question 7 - A 32-year-old female with a 10 year history of asthma presents with increasing...

    Incorrect

    • A 32-year-old female with a 10 year history of asthma presents with increasing dyspnoea after returning from a trip to Australia. She has not had a period in three months. On examination, she has a fever of 37.5°C, a pulse rate of 110/min, a blood pressure of 106/74 mmHg, and saturations of 93% on room air. Her respiratory rate is 24/min and auscultation of the chest reveals vesicular breath sounds. Peak flow is 500 L/min and her ECG shows no abnormalities except for a heart rate of 110 bpm. A chest x-ray is normal. What is the most likely diagnosis?

      Your Answer: Thyrotoxicosis

      Correct Answer: Pulmonary embolism

      Explanation:

      Risk Factors and Symptoms of Pulmonary Embolism

      This patient presents with multiple risk factors for pulmonary embolism, including air travel and likely pregnancy. She is experiencing tachycardia and hypoxia, which require further explanation. However, there are no indications of a respiratory tract infection or acute asthma. It is important to note that an ECG and CXR may appear normal in cases of pulmonary embolism or may only show baseline tachycardia on the ECG. Therefore, it is crucial to consider the patient’s risk factors and symptoms when evaluating for pulmonary embolism. Proper diagnosis and treatment are essential to prevent potentially life-threatening complications.

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      • Respiratory
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  • Question 8 - A 30-year-old woman comes to the General Practice Clinic complaining of feeling unwell...

    Incorrect

    • A 30-year-old woman comes to the General Practice Clinic complaining of feeling unwell for the past few days. She has been experiencing nasal discharge, sneezing, fatigue, and a cough. Her 3-year-old daughter recently recovered from very similar symptoms. During the examination, her pulse rate is 62 bpm, respiratory rate 18 breaths per minute, and temperature 37.2 °C. What is the probable causative organism for her symptoms?

      Your Answer: influenzae virus

      Correct Answer: Rhinovirus

      Explanation:

      Identifying the Most Common Causative Organisms of the Common Cold

      The common cold is a viral infection that affects millions of people worldwide. Among the different viruses that can cause the common cold, rhinoviruses are the most common, responsible for 30-50% of cases annually. influenzae viruses can also cause milder symptoms that overlap with those of the common cold, accounting for 5-15% of cases. Adenoviruses and enteroviruses are less common causes, accounting for less than 5% of cases each. Respiratory syncytial virus is also a rare cause of the common cold, accounting for only 5% of cases annually. When trying to identify the causative organism of a common cold, it is important to consider the patient’s symptoms, recent exposure to sick individuals, and prevalence of different viruses in the community.

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      • Respiratory
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  • Question 9 - A 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists...

    Incorrect

    • A 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists in the Emergency Department, but he is not short of breath. There is no past medical history of note. Observations are recorded:
      temperature 36.6 °C
      heart rate (HR) 90 bpm
      blood pressure (BP) 115/80 mmHg
      respiratory rate (RR) 18 breaths/minute
      oxygen saturation (SaO2) 99%.
      A chest X-ray reveals a 1.5 cm sliver of air in the pleural space of the right lung.
      Which of the following is the most appropriate course of action?

      Your Answer: Admit for a trial of nebulised salbutamol and observation

      Correct Answer: Consider prescribing analgesia and discharge home with information and advice

      Explanation:

      Management Options for Primary Pneumothorax

      Primary pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. Here are some management options for primary pneumothorax:

      Prescribe analgesia and discharge home with information and advice: This option can be considered if the patient is not breathless and has only a small defect. The patient can be discharged with pain relief medication and given information and advice on how to manage the condition at home.

      Admit for a trial of nebulised salbutamol and observation: This option is not indicated for a patient with primary pneumothorax, as a trial of salbutamol is not effective in treating this condition.

      Aspirate the air with a needle and syringe: This option should only be attempted if the patient has a rim of air of >2 cm on the chest X-ray or is breathless. Aspiration can be attempted twice at a maximum, after which a chest drain should be inserted.

      Insert a chest drain: This option should be done if the second attempt of aspiration is unsuccessful. Once air has stopped leaking, the drain should be left in for a further 24 hours prior to removal and discharge.

      Insert a 16G cannula into the second intercostal space: This option is used for tension pneumothoraces and is not indicated for primary pneumothorax.

      In conclusion, the management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. It is important to choose the appropriate management option to ensure the best outcome for the patient.

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  • Question 10 - A 60-year-old male smoker with severe rheumatoid arthritis comes to the clinic complaining...

    Correct

    • A 60-year-old male smoker with severe rheumatoid arthritis comes to the clinic complaining of a dry cough and increasing difficulty in breathing over the past few months. During the examination, he appears to be mildly cyanosed and has end inspiratory crepitations. A chest x-ray reveals widespread reticulonodular changes. What is the most probable diagnosis?

      Your Answer: Rheumatoid lung

      Explanation:

      Diagnosis and Differential Diagnosis of Pulmonary Fibrosis

      Pulmonary fibrosis is suspected in a patient with a history and examination features that suggest the condition. Rheumatoid lung is a common cause of pulmonary fibrosis, especially in severe rheumatoid disease and smokers. The reported changes on the chest X-ray are consistent with the diagnosis. However, to diagnose respiratory failure, a blood gas result is necessary.

      On the other hand, bronchial asthma is characterized by reversible airways obstruction, which leads to fluctuation of symptoms and wheezing on auscultation. The history of the patient is not consistent with chronic obstructive pulmonary disease (COPD). Pneumonia, on the other hand, is suggested by infective symptoms, pyrexia, and consolidation on CXR.

      In summary, the diagnosis of pulmonary fibrosis requires a thorough history and examination, as well as imaging studies. Differential diagnosis should include other conditions that present with similar symptoms and signs, such as bronchial asthma, COPD, and pneumonia.

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  • Question 11 - A 38-year-old male presents with complaints of difficulty breathing. During the physical examination,...

    Correct

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

      Your Answer: Pulmonary fibrosis

      Explanation:

      Respiratory and Other Causes of Clubbing of the Fingers

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

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

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  • Question 12 - A 55-year old complains of difficulty breathing. A CT scan of the chest...

    Incorrect

    • A 55-year old complains of difficulty breathing. A CT scan of the chest reveals the presence of an air-crescent sign. Which microorganism is commonly linked to this sign?

      Your Answer: Mycobacterium avium intracellulare

      Correct Answer: Aspergillus

      Explanation:

      Radiological Findings in Pulmonary Infections: Air-Crescent Sign and More

      Different pulmonary infections can cause distinct radiological findings that aid in their diagnosis and management. Here are some examples:

      – Aspergillosis: This fungal infection can lead to the air-crescent sign, which shows air filling the space left by necrotic lung tissue as the immune system fights back. It indicates a sign of recovery and is found in about half of cases. Aspergilloma, a different form of aspergillosis, can also present with a similar radiological finding called the monad sign.
      – Mycobacterium avium intracellulare: This organism causes non-tuberculous mycobacterial infection in the lungs, which tends to affect patients with pre-existing chronic obstructive pulmonary disease or immunocompromised states.
      – Staphylococcus aureus: This bacterium can cause cavitating lung lesions and abscesses, which appear as round cavities with an air-fluid level.
      – Pseudomonas aeruginosa: This bacterium can cause pneumonia in patients with chronic lung disease, and CT scans may show ground-glass attenuation, bronchial wall thickening, peribronchial infiltration, and pleural effusions.
      – Mycobacterium tuberculosis: This bacterium may cause cavitation in the apical regions of the lungs, but it does not typically lead to the air-crescent sign.

      Understanding these radiological findings can help clinicians narrow down the possible causes of pulmonary infections and tailor their treatment accordingly.

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  • Question 13 - A 68-year-old woman presents to the Emergency Department with a 48-hour history of...

    Correct

    • A 68-year-old woman presents to the Emergency Department with a 48-hour history of shortness of breath and an increased volume and purulence of sputum. She has a background history of chronic obstructive pulmonary disease (COPD), hypertension and ischaemic heart disease. Her observations show: heart rate (HR) 116 bpm, blood pressure (BP) 124/68 mmHg, respiratory rate (RR) 18 breaths per minute and oxygen saturation (SaO2) 94% on 2l/min via nasal cannulae. She is commenced on treatment for an infective exacerbation of COPD with nebulised bronchodilators, intravenous antibiotics, oral steroids and controlled oxygen therapy with a Venturi mask. After an hour of therapy, the patient is reassessed. Her observations after an hour are: BP 128/74 mmHg, HR 124 bpm, RR 20 breaths per minute and SaO2 93% on 24% O2 via a Venturi mask. Arterial blood gas sampling is performed:
      Investigation Result Normal value
      pH 7.28 7.35–7.45
      PO2 8.6 kPa 10.5–13.5 kPa
      pCO2 8.4 kPa 4.6–6.0 kPa
      cHCO3- (P)C 32 mmol/l 24–30 mmol/l
      Lactate 1.4 mmol/l 0.5–2.2 mmol/l
      Sodium (Na+) 134 mmol/l 135–145 mmol/l
      Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
      Chloride (Cl-) 116 mmol/l 98-106 mmol/l
      Glucose 5.4 mmol/l 3.5–5.5 mmol/l
      Following this review and the arterial blood gas results, what is the most appropriate next step in this patient’s management?

      Your Answer: The patient should be considered for non-invasive ventilation (NIV)

      Explanation:

      Management of Respiratory Acidosis in COPD Patients

      The management of respiratory acidosis in COPD patients requires careful consideration of the individual’s condition. In this scenario, the patient should be considered for non-invasive ventilation (NIV) as recommended by the British Thoracic Society. NIV is particularly indicated in patients with a pH of 7.25–7.35. Patients with a pH of <7.25 may benefit from NIV but have a higher risk for treatment failure and therefore should be considered for management in a high-dependency or intensive care setting. However, NIV is not indicated in patients with impaired consciousness, severe hypoxaemia or copious respiratory secretions. It is important to note that a ‘Do Not Resuscitate Order’ should not be automatically made for patients with COPD. Each decision regarding resuscitation should be made on an individual basis. Intubation and ventilation should not be the first line of treatment in this scenario. A trial of NIV would be the most appropriate next step, as it has been demonstrated to reduce the need for intensive care management in this group of patients. Increasing the patient’s oxygen may be appropriate in type 1 respiratory failure, but in this case, NIV is the recommended approach. Intravenous magnesium therapy is not routinely recommended in COPD and is only indicated in the context of acute asthma. In conclusion, the management of respiratory acidosis in COPD patients requires a tailored approach based on the individual’s condition. NIV should be considered as the first line of treatment in this scenario.

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  • Question 14 - A 75-year-old woman presents to a respiratory outpatient clinic with a dry cough...

    Correct

    • A 75-year-old woman presents to a respiratory outpatient clinic with a dry cough and shortness of breath that has been ongoing for 6 months. Despite being a non-smoker, her husband is a pigeon breeder. Upon examination, she has an SpO2 of 95% on room air and clubbing is present. Chest examination reveals symmetrical and bilateral reduced chest expansion with fine end-inspiratory crepitations. A chest radiograph shows increased interstitial markings in the lower zones of both lungs. High-resolution computed tomography (HRCT) confirms these findings and also shows bibasal honeycombing. There is no lymphadenopathy present on CT. What is the most likely diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis (usual interstitial pneumonia)

      Explanation:

      Differential Diagnosis for Interstitial Lung Disease: A Case Study

      Interstitial lung disease (ILD) is a group of lung disorders that affect the interstitium, the tissue and space surrounding the air sacs in the lungs. Idiopathic pulmonary fibrosis (IPF) is the most common type of ILD, characterized by chronic inflammation of the lung interstitium with lower zone predominance. This article discusses the differential diagnosis for ILD, using a case study of a patient presenting with subacute dry cough, exertional dyspnea, and general malaise and fatigue.

      Idiopathic Pulmonary Fibrosis (IPF)
      IPF is characterized by chronic inflammation of the lung interstitium with lower zone predominance. Patients present with subacute dry cough, exertional dyspnea, and general malaise and fatigue. Clinical examination reveals fine end-inspiratory crepitations throughout the chest with lower zone predominance. Radiological findings include reduced lung volumes and bilateral increased interstitial markings with lower zone predominance on chest X-ray (CXR), and honeycombing and microcyst formation in the lung bases on high-resolution CT (HRCT). Lung transplantation is the only definitive treatment, while steroids are not indicated.

      Tuberculosis
      Tuberculosis presents with chronic cough, haemoptysis, fever, and night sweats. Imaging shows cavitating lesions ± lymphadenopathy.

      Bronchiectasis
      Bronchiectasis presents with productive cough, recurrent chest infections, and haemoptysis. CXR findings are often non-specific, but dilated, thick-walled (ectatic) bronchi are easily seen on HRCT.

      Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)
      Hypersensitivity pneumonitis may be caused by airborne irritants to lung parenchyma, such as pigeon breeding. Changes are classically found in lung apices, making it less likely than IPF/UIP.

      Sarcoidosis
      End-stage sarcoidosis may present with lung fibrosis, but this does not spare the apices and typically affects the middle and upper zones of the lung.

      In conclusion, the differential diagnosis for ILD includes IPF, tuberculosis, bronchiectasis, hypersensitivity pneumonitis, and sarcoidosis. Accurate diagnosis is crucial for appropriate treatment and management of these conditions.

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  • Question 15 - A 72-year-old man is diagnosed with right-sided pleural effusion. The aspirated sample reveals...

    Correct

    • 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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  • Question 16 - A 28-year-old female patient presents to your clinic seeking help to quit smoking....

    Correct

    • A 28-year-old female patient presents to your clinic seeking help to quit smoking. Despite several attempts in the past, she has been unsuccessful. She has a medical history of bipolar disorder and well-managed epilepsy, for which she takes lamotrigine. She currently smokes 15 cigarettes per day and is especially interested in the health benefits of quitting smoking since she has recently found out that she is pregnant. As her physician, you decide to prescribe a suitable medication to assist her in her efforts. What would be the most appropriate treatment option?

      Your Answer: Nicotine gum

      Explanation:

      Standard treatments for nicotine dependence do not include amitriptyline, fluoxetine, or gabapentin. Nicotine replacement therapy (NRT) can be helpful for motivated patients, but it is not a cure for addiction and may require multiple attempts. Bupropion and varenicline are other smoking cessation aids, but they have multiple side effects and may not be suitable for all patients. NICE guidelines recommend discussing the best method of smoking cessation with the patient, but NRT is considered safer in pregnancy.

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  • Question 17 - A 65-year-old lady is admitted with severe pneumonia and, while on the ward,...

    Incorrect

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

      Your Answer: Chest X-ray

      Correct Answer: Computed tomography (CT) pulmonary angiogram

      Explanation:

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

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

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

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

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

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

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  • Question 18 - A 50-year-old man presents with a chronic cough and shortness of breath. He...

    Correct

    • A 50-year-old man presents with a chronic cough and shortness of breath. He has recently developed a red/purple nodular rash on both shins. He has a history of mild asthma and continues to smoke ten cigarettes per day. On examination, he has mild wheezing and red/purple nodules on both shins. His blood pressure is 135/72 mmHg, and his pulse is 75/min and regular. The following investigations were performed: haemoglobin, white cell count, platelets, erythrocyte sedimentation rate, sodium, potassium, creatinine, and corrected calcium. His chest X-ray shows bilateral hilar lymphadenopathy. What is the most likely underlying diagnosis?

      Your Answer: Sarcoidosis

      Explanation:

      Differential Diagnosis for a Patient with Chest Symptoms, Erythema Nodosum, and Hypercalcaemia: Sarcoidosis vs. Other Conditions

      When a patient presents with chest symptoms, erythema nodosum, hypercalcaemia, and signs of systemic inflammation, sarcoidosis is a likely diagnosis. To confirm the diagnosis, a transbronchial biopsy is usually performed to demonstrate the presence of non-caseating granulomata. Alternatively, skin lesions or lymph nodes may provide a source of tissue for biopsy. Corticosteroids are the main treatment for sarcoidosis.

      Other conditions that may be considered in the differential diagnosis include asthma, bronchial carcinoma, chronic obstructive pulmonary disease (COPD), and primary hyperparathyroidism. However, the presence of erythema nodosum and bilateral hilar lymphadenopathy are more suggestive of sarcoidosis than these other conditions. While hypercalcaemia may be a symptom of primary hyperparathyroidism, the additional symptoms and findings in this patient suggest a more complex diagnosis.

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  • Question 19 - A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough,...

    Correct

    • A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough, and low-grade fever. He has a medical history of hypertension and was hospitalized six months ago for an acute inferior myocardial infarction complicated by left ventricular failure and arrhythmia. His chest x-ray reveals diffuse interstitial pneumonia, and further investigations show an ESR of 110 mm/h, FEV1 of 90%, FVC of 70%, and KCO of 60%. What is the most likely cause of these findings?

      Your Answer: Amiodarone

      Explanation:

      Side Effects of Amiodarone

      Amiodarone is a medication that is known to cause several side effects. Among these, pneumonitis and pulmonary fibrosis are the most common. These conditions are characterized by a progressively-worsening dry cough, pleuritic chest pain, dyspnoea, and malaise. Other side effects of amiodarone include neutropenia, hepatitis, phototoxicity, slate-grey skin discolouration, hypothyroidism, hyperthyroidism, arrhythmias, corneal deposits, peripheral neuropathy, and myopathy. It is important to be aware of these potential side effects when taking amiodarone, and to seek medical attention if any of these symptoms occur. Proper monitoring and management can help to minimize the risk of serious complications.

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  • Question 20 - A previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the...

    Incorrect

    • A previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the broken hip that she sustained as a result of falling down stairs. Upon discharge to a nursing home 10 days later, she is unable to ambulate fully and, about a month later, she dies suddenly.
      Which of the following is most likely to be the immediate cause of death found at post-mortem examination?

      Your Answer: Carcinoma of the uterus

      Correct Answer: Pulmonary embolism

      Explanation:

      Likely Cause of Sudden Death in an Elderly Patient with Fracture

      Immobilisation after a fracture in elderly patients increases the risk of developing deep vein thrombosis (DVT), which can lead to pulmonary embolism. In the case of a sudden death, pulmonary embolism is the most likely cause. Pneumonia with pneumococcus is also a risk for elderly patients in hospital, but the absence of signs and symptoms of infection makes it less likely. Tuberculosis is also unlikely as there were no signs of an infectious disease. Congestive heart failure is a possibility in the elderly, but it is unlikely to cause sudden death in this scenario. While malignancy is a risk for older patients, immobilisation leading to pulmonary thromboembolism is the most likely cause of sudden death in this case.

    • This question is part of the following fields:

      • Respiratory
      75.7
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  • Question 21 - A 55-year-old female presents with worsening dyspnoea and the need to sit down...

    Incorrect

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

      Your Answer: Chemotherapy

      Correct Answer: Oxygen therapy

      Explanation:

      Treatment Options for Pulmonary Fibrosis

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

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      • Respiratory
      31.3
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  • Question 22 - A 49-year-old Caucasian woman presents with a severe acute attack of bronchial asthma....

    Incorrect

    • A 49-year-old Caucasian woman presents with a severe acute attack of bronchial asthma. For 1 week, she has had fever, malaise, anorexia and weight loss. She has tingling and numbness in her feet and hands. On examination, palpable purpura is present and nodular lesions are present on the skin. Investigations revealed eosinophilia, elevated erythrocyte sedimentation rate (ESR), fibrinogen, and α-2-globulin, positive p-ANCA, and a chest X-ray reveals pulmonary infiltrates.
      Which one of the following is the most likely diagnosis?

      Your Answer: Polyarteritis nodosa (PAN)

      Correct Answer: Allergic granulomatosis (Churg-Strauss syndrome)

      Explanation:

      Comparison of Vasculitis Conditions with Eosinophilia

      Eosinophilia is a common feature in several vasculitis conditions, but the clinical presentation and histopathologic features can help differentiate between them. Allergic granulomatosis, also known as Churg-Strauss syndrome, is characterized by asthma, peripheral and tissue eosinophilia, granuloma formation, and vasculitis of multiple organ systems. In contrast, granulomatosis with polyangiitis (GPA) involves the lungs and upper respiratory tract and is c-ANCA positive, but does not typically present with asthma-like symptoms or peripheral eosinophilia. Polyarteritis nodosa (PAN) can present with multisystem involvement, but does not typically have an asthma-like presentation or peripheral eosinophilia. Hypereosinophilic syndrome, also known as chronic eosinophilic leukemia, is characterized by persistent eosinophilia in blood and exclusion of other causes of reactive eosinophilia. Finally, microscopic polyangiitis is similar to GPA in many aspects, but does not involve granuloma formation and does not typically present with peripheral eosinophilia.

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      • Respiratory
      107.1
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  • Question 23 - A 45-year-old woman with known asthma presents to the Emergency Department with severe...

    Correct

    • 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: 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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      • Respiratory
      214.5
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  • Question 24 - A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses...

    Correct

    • 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: 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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      • Respiratory
      77.4
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  • Question 25 - A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a...

    Correct

    • A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a sudden ‘pop’ followed by the onset of pain and shortness of breath.
      Upon examination, the patient appears to be struggling to breathe with a respiratory rate of 40 breaths per minute. Diminished breath sounds are heard on the right side of the chest during auscultation.
      Diagnostic tests reveal a PaO2 of 8.2 kPa (normal range: 10.5-13.5 kPa) and a PaCO2 of 3.3 kPa (normal range: 4.6-6.0 kPa). A chest X-ray shows a 60% right-sided pneumothorax.
      What is the most appropriate course of treatment for this patient?

      Your Answer: 14F chest drain insertion over a Seldinger wire

      Explanation:

      Safe and Effective Chest Drain Insertion Techniques for Pneumothorax Management

      Pneumothorax, the presence of air in the pleural cavity, can cause significant respiratory distress and requires prompt management. Chest drain insertion is a common procedure used to treat pneumothorax, but the technique used depends on the size and cause of the pneumothorax. Here are some safe and effective chest drain insertion techniques for managing pneumothorax:

      1. Narrow-bore chest drain insertion over a Seldinger wire: This technique is appropriate for large spontaneous pneumothorax without trauma. It involves inserting a narrow-bore chest drain over a Seldinger wire, which is a minimally invasive technique that reduces the risk of complications.

      2. Portex chest drain insertion: Portex chest drains are a safer alternative to surgical chest drains in traumatic cases. This technique involves inserting a less traumatic chest drain that is easier to manage and less likely to cause complications.

      3. Avoid chest drain insertion using a trochar: Chest drain insertion using a trochar is a dangerous technique that can cause significant pressure damage to surrounding tissues. It should be avoided.

      4. Avoid repeated air aspiration: Although needle aspiration is a management option for symptomatic pneumothorax, repeated air aspiration is not recommended. It can cause complications and is less effective than chest drain insertion.

      In conclusion, chest drain insertion is an effective technique for managing pneumothorax, but the technique used should be appropriate for the size and cause of the pneumothorax. Narrow-bore chest drain insertion over a Seldinger wire and Portex chest drain insertion are safer alternatives to more invasive techniques. Chest drain insertion using a trochar and repeated air aspiration should be avoided.

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      • Respiratory
      113.2
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  • Question 26 - A 38-year-old woman presents to the Emergency department with a two-week history of...

    Incorrect

    • A 38-year-old woman presents to the Emergency department with a two-week history of palpitations and breathlessness. She has a past medical history of diabetes mellitus, which is well controlled on metformin 850 mg bd, and longstanding hypertension for which she has been on therapy for several years. Her current medications include captopril 50 mg bd, furosemide 40 mg od, and nifedipine 20 mg bd. She recently consulted her GP with symptoms of breathlessness, and he increased the dose of furosemide to 80 mg od.

      On examination, the patient is overweight and appears distressed. She is afebrile, with a pulse of 120, regular, and a blood pressure of 145/95 mmHg. Heart sounds 1 and 2 are normal without added sounds or murmurs. Respiratory rate is 28/minute, and the chest is clear to auscultation. The rest of the examination is normal.

      Investigations:
      - Hb: 134 g/L (normal range: 115-165)
      - WBC: 8.9 ×109/L (normal range: 4-11)
      - Platelets: 199 ×109/L (normal range: 150-400)
      - Sodium: 139 mmol/L (normal range: 137-144)
      - Potassium: 4.4 mmol/L (normal range: 3.5-4.9)
      - Urea: 5.8 mmol/L (normal range: 2.5-7.5)
      - Creatinine: 110 µmol/L (normal range: 60-110)
      - Glucose: 5.9 mmol/L (normal range: 3.0-6.0)
      - Arterial blood gases on air:
      - pH: 7.6 (normal range: 7.36-7.44)
      - O2 saturation: 99%
      - PaO2: 112 mmHg/15 kPa (normal range: 75-100)
      - PaCO2: 13.7 mmHg/1.8 kPa (normal range: 35-45)
      - Standard bicarbonate: 20 mmol/L (normal range: 20-28)
      - Base excess: -7.0 mmol/L (normal range: ±2)

      What is the appropriate treatment for this patient?

      Your Answer: Nebulised bronchodilators

      Correct Answer: Calming reassurance

      Explanation:

      Managing Respiratory Alkalosis in Patients with Panic Attacks

      Patients experiencing hyperventilation may develop respiratory alkalosis, which can be managed by creating a calming atmosphere and providing reassurance. However, the traditional method of breathing into a paper bag is no longer recommended. Instead, healthcare providers should focus on stabilizing the patient’s breathing and addressing any underlying anxiety or panic.

      It’s important to note that panic attacks can cause deranged ABG results, including respiratory alkalosis. Therefore, healthcare providers should be aware of this potential complication and take appropriate measures to manage the patient’s symptoms. While paper bag rebreathing may be effective in some cases, it should be administered with caution, especially in patients with respiratory or cardiac pathology.

      In summary, managing respiratory alkalosis in patients with panic attacks requires a holistic approach that addresses both the physical and emotional aspects of the condition. By creating a calming environment and providing reassurance, healthcare providers can help stabilize the patient’s breathing and prevent further complications.

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      • Respiratory
      43.2
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  • Question 27 - A 68-year-old man with known bronchial carcinoma presents to hospital with confusion. A...

    Incorrect

    • A 68-year-old man with known bronchial carcinoma presents to hospital with confusion. A computed tomography (CT) scan of the brain was reported as normal: no evidence of metastases. His serum electrolytes were as follows:
      Investigation Result Normal value
      Sodium (Na+) 114 mmol/l 135–145 mmol/l
      Potassium (K+) 3.9 mmol/l 3.5–5.0 mmol/l
      Urea 5.2 mmol/l 2.5–6.5 mmol/l
      Creatinine 82 μmol/l 50–120 µmol/l
      Urinary sodium 54 mmol/l
      Which of the subtype of bronchial carcinoma is he most likely to have been diagnosed with?

      Your Answer: Squamous cell

      Correct Answer: Small cell

      Explanation:

      Different Types of Lung Cancer and Their Association with Ectopic Hormones

      Lung cancer is a complex disease that can be divided into different types based on their clinical and biological characteristics. The two main categories are non-small cell lung cancers (NSCLCs) and small cell lung cancer (SCLC). SCLC is distinct from NSCLCs due to its origin from amine precursor uptake and decarboxylation (APUD) cells, which have an endocrine lineage. This can lead to the production of various peptide hormones, causing paraneoplastic syndromes such as the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and Cushing syndrome.

      Among NSCLCs, squamous cell carcinoma is commonly associated with ectopic parathyroid hormone, leading to hypercalcemia. Large cell carcinoma and bronchoalveolar cell carcinoma are NSCLCs that do not produce ectopic hormones. Adenocarcinoma, another type of NSCLC, also does not produce ectopic hormones.

      Understanding the different types of lung cancer and their association with ectopic hormones is crucial for proper management and treatment of the disease.

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      • Respiratory
      77.9
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  • Question 28 - A 62-year-old man presents to Accident and Emergency with complaints of chest pain...

    Incorrect

    • A 62-year-old man presents to Accident and Emergency with complaints of chest pain and shortness of breath, which is predominantly worse on the right side. He has been experiencing these symptoms for about 24 hours, but they have worsened since he woke up this morning. The patient reports that the pain is worse on inspiration and that he has never experienced chest pain before. He is mostly bedridden due to obesity but has no history of respiratory issues. The patient is currently receiving treatment for newly diagnosed prostate cancer. There is a high suspicion that he may have a pulmonary embolus (PE). His vital signs are as follows:
      Temperature 36.5 °C
      Blood pressure 136/82 mmHg
      Heart rate 124 bpm
      Saturations 94% on room air
      His 12-lead electrocardiogram (ECG) shows sinus tachycardia and nothing else.
      What would be the most appropriate initial step in managing this case?

      Your Answer:

      Correct Answer: Rivaroxaban

      Explanation:

      Treatment Options for Suspected Pulmonary Embolism

      Pulmonary embolism (PE) is a serious medical condition that requires prompt diagnosis and treatment. In cases where there is a high clinical suspicion of a PE, treatment with treatment-dose direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban or low-molecular-weight heparin (LMWH) should be administered before diagnostic confirmation of a PE on computed tomography (CT) pulmonary angiography (CTPA). Thrombolysis with alteplase may be necessary in certain cases where there is a massive PE with signs of haemodynamic instability or right heart strain on ECG. Intravenous (IV) unfractionated heparin is not beneficial in treating a PE. While a chest X-ray may be useful in the workup for pleuritic chest pain, the priority in suspected PE cases should be administering treatment-dose DOAC or LMWH.

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      • Respiratory
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  • Question 29 - You have a telephone consultation with a 28-year-old male who wants to start...

    Incorrect

    • You have a telephone consultation with a 28-year-old male who wants to start trying to conceive. He has a history of asthma and takes salbutamol 100mcg as needed.
      Which of the following would be most important to advise?

      Your Answer:

      Correct Answer: Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy

      Explanation:

      Women who are taking antiepileptic medication and are planning to conceive should be prescribed a daily dose of 5mg folic acid instead of the standard 400mcg. This high-dose folic acid should be taken from before conception until the 12th week of pregnancy to reduce the risk of neural tube defects. It is important to refer these women to specialist care, but they should continue to use effective contraception until they have had a full assessment. Despite the medication, it is still likely that they will have a normal pregnancy and healthy baby. If trying to conceive, women should start taking folic acid as soon as possible, rather than waiting for a positive pregnancy test.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

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      • Respiratory
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  • Question 30 - A 72-year-old retired boiler maker presents to his General Practitioner with increasing shortness...

    Incorrect

    • 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:

      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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      • Respiratory
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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (14/27) 52%
Passmed