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Question 1
Correct
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A 25-year-old woman comes to her GP complaining of breathlessness, dry cough and occasional wheezing.
What investigation finding would indicate a diagnosis of asthma?Your Answer: Fraction exhaled nitric oxide (FeNO) 50 parts per billion (ppb)
Explanation:Diagnostic Criteria for Asthma: Key Indicators to Consider
Asthma is a chronic respiratory disease that affects millions of people worldwide. It is characterized by airway inflammation, bronchoconstriction, and increased mucous production, leading to symptoms such as wheezing, coughing, and shortness of breath. Diagnosing asthma can be challenging, as its symptoms can mimic those of other respiratory conditions. However, several key indicators can help healthcare professionals make an accurate diagnosis.
Fraction exhaled nitric oxide (FeNO) 50 parts per billion (ppb): An FeNO level > 40 ppb is indicative of asthma.
Forced expiratory volume in 1 second/forced vital capacity ratio (FEV1/FVC ratio) ≥ 75%: An obstructive FEV1/FVC ratio < 70% would support a diagnosis of asthma in this patient. A 10% or higher improvement in FEV1 following a nebulised bronchodilator: A 12% or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma. A 150 ml or higher improvement in FEV1 following a nebulised bronchodilator: A 200 ml or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma. Greater than 15% variability in peak expiratory flow rate (PEFR) on monitoring: Greater than 20% variability in PEFR on monitoring supports a diagnosis of asthma. In conclusion, healthcare professionals should consider these key indicators when diagnosing asthma. However, it is important to note that asthma is not the only cause of these indicators, and a comprehensive evaluation of the patient’s medical history, physical examination, and other diagnostic tests may be necessary to make an accurate diagnosis.
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This question is part of the following fields:
- Respiratory
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Question 2
Incorrect
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A 28-year-old man with cystic fibrosis (CF) arrives at the Emergency Department (ED) with haemoptysis. During his stay in the ED, he experiences another episode of frank haemoptysis, which measures 180 ml.
A prompt computed tomography (CT) aortogram is conducted, revealing dilated and tortuous bronchial arteries.
What action could potentially harm the management of this patient?Your Answer: Bronchial artery embolisation
Correct Answer: Non-invasive ventilation
Explanation:Treatment options for massive haemoptysis in cystic fibrosis patients
Massive haemoptysis in cystic fibrosis (CF) patients can be a life-threatening complication. Non-invasive ventilation is not recommended as it may increase the risk of aspiration of blood and disturb clot formation. IV antibiotics should be given to treat acute inflammation related to pulmonary infection. Tranexamic acid, an anti-fibrinolytic drug, can be given orally or intravenously up to four times per day until bleeding is controlled. CF patients have impaired absorption of fat-soluble vitamins, including vitamin K, which may lead to prolonged prothrombin time. In such cases, IV vitamin K should be given. Bronchial artery embolisation is often required to treat massive haemoptysis, particularly when larger hypertrophied bronchial arteries are seen on CT. This procedure is performed by an interventional vascular radiologist and may be done under sedation or general anaesthetic if the patient is in extremis.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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A 58-year-old Afro-Caribbean man presents to you with increasing difficulty in breathing and shortness of breath. A chest examination reveals decreased expansion on the right side of the chest, along with decreased breath sounds and stony dullness to percussion. A chest X-ray reveals a pleural effusion which you proceed to tap for diagnostic serum biochemistry, cytology and culture. The cytology and culture results are still awaited, although the serum biochemistry returns back showing the following:
Pleural fluid protein 55 g/dl
Pleural fluid cholesterol 4.5 g/dl
Pleural fluid lactate dehydrogenase (LDH) : serum ratio 0.7
Which of the following might be considered as a diagnosis in this patient?Your Answer: Myxoedema
Correct Answer: Sarcoidosis
Explanation:Differentiating Causes of Pleural Effusion: Sarcoidosis, Myxoedema, Meigs Syndrome, Cardiac Failure, and Nephrotic Syndrome
When analyzing a pleural effusion, the protein levels can help differentiate between potential causes. An exudate pleural effusion, with protein levels greater than 30 g/l, can be caused by inflammatory or malignant conditions such as sarcoidosis, tuberculosis, or carcinoma. However, if the protein level falls between 25 and 35 g/l, Light’s criteria should be applied to accurately differentiate. On the other hand, a transudate pleural effusion, with protein levels less than 30 g/l, can be caused by conditions such as myxoedema or cardiac failure. Meigs syndrome, a pleural effusion caused by a benign ovarian tumor, and nephrotic syndrome, which causes a transudate pleural effusion, can also be ruled out based on the biochemistry results. It is important to consider all potential causes and conduct further investigations to properly diagnose and manage the underlying condition.
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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 67-year-old man comes to the Chest Clinic after being referred by his GP for a chronic cough. He complains of a dry cough that has been ongoing for 10 months and is accompanied by increasing shortness of breath. Despite multiple rounds of antibiotics, he has not experienced significant improvement. He has never smoked and denies any coughing up of blood. He used to work as a teacher and has not been exposed to any environmental dust or chemicals.
His GP ordered a chest X-ray, which reveals reticular shadowing affecting both lung bases. Upon examination, he has clubbed fingers and fine-end inspiratory crackles. His heart sounds are normal, and he is saturating at 94% on room air with a regular heart rate of 80 bpm and regular respiratory rate of 20. There is no peripheral oedema.
What is the most probable diagnosis?Your Answer: Idiopathic pulmonary fibrosis
Explanation:Differential Diagnosis for Shortness of Breath and Clubbing: Idiopathic Pulmonary Fibrosis as the Likely Diagnosis
Shortness of breath and clubbing can be indicative of various respiratory and cardiac conditions. In this case, the most likely diagnosis is idiopathic pulmonary fibrosis, as evidenced by fine-end inspiratory crackles on examination, X-ray findings of bi-basal reticulonodular shadowing in a typical distribution, and the presence of clubbing. Bronchiectasis is another possible diagnosis, but the lack of purulent phlegm and coarse crackles, as well as chest X-ray findings inconsistent with dilated, thick-walled bronchi, make it less likely. Carcinoma of the lung is also a consideration, but the absence of a smoking history and chest X-ray findings make it less probable. Chronic obstructive pulmonary disease (COPD) is unlikely without a smoking history and the absence of wheeze on examination. Congestive cardiac failure (CCF) can cause shortness of breath, but clubbing is typically only present in cases of congenital heart disease with right to left shunts, which is not demonstrated in this case. Overall, idiopathic pulmonary fibrosis is the most likely diagnosis based on the clinical presentation and diagnostic findings.
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This question is part of the following fields:
- Respiratory
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Question 5
Correct
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A 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: 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 6
Correct
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A 52-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents to the Emergency Department with an acute exacerbation. He is experiencing severe shortness of breath and his oxygen saturation levels are at 74% on room air. The medical team initiates treatment with 15 litres of high-flow oxygen and later transitions him to controlled oxygen supplementation via a 28% venturi mask. What is the optimal target range for his oxygen saturation levels?
Your Answer: 88–92%
Explanation:Understanding Oxygen Saturation Targets for Patients with COPD
Patients with COPD have specific oxygen saturation targets that differ from those without respiratory problems. The correct range for a COPD patient is 88-92%, as they rely on low oxygen concentrations to drive their respiratory effort. Giving them too much oxygen can potentially remove their drive to breathe and worsen their respiratory situation. In contrast, unwell individuals who are not at risk of type 2 respiratory failure have a target of 94-98%. A saturation target of 80% is too low and can cause hypoxia and damage to end organs. Saturations of 90-94% may indicate a need for oxygen therapy, but it may still be too high for a patient with COPD. It is vital to obtain an arterial blood gas (ABG) in hypoxia to check if the patient is a chronic CO2 retainer. Understanding these targets is crucial in managing patients with COPD and ensuring their respiratory effort is not compromised.
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This question is part of the following fields:
- Respiratory
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Question 7
Correct
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Emily is a 6-year-old overweight girl brought in by concerned parents who are worried about her loud snoring and frequent interruptions in breathing which have been getting progressively worse. Her parents have been receiving complaints from the school teachers about her disruptive and inattentive behaviour in class. On examination, Emily has a short, thick neck and mildly enlarged tonsils but no other abnormalities.
What is the next best step in management?Your Answer: Order an overnight polysomnographic study
Explanation:Childhood Obstructive Sleep Apnoea: Diagnosis and Treatment Options
Childhood obstructive sleep apnoea (OSA) is a pathological condition that requires prompt diagnosis and treatment. A polysomnographic study should be performed before booking for an operation, as adenotonsillectomy is the treatment of choice for childhood OSA.
The clinical presentation of childhood OSA is non-specific but typically includes symptoms such as mouth breathing, abnormal breathing during sleep, poor sleep with frequent awakening or restlessness, nocturnal enuresis, nightmares, difficulty awakening, excessive daytime sleepiness or hyperactivity, and behavioural problems. However, parents should be reassured that snoring loudly is very normal in children his age and that his behaviour pattern will improve as he matures.
Before any intervention is undertaken, the patient should be first worked up for OSA with a polysomnographic study. While dental splints may have a small role to play in OSA, they are not the ideal treatment option. Intranasal budesonide is an option for mild to moderate OSA, but it is only a temporising measure and not a proven effective long-term treatment.
In conclusion, childhood OSA requires prompt diagnosis and treatment. Adenotonsillectomy is the treatment of choice, but a polysomnographic study should be performed before any intervention is undertaken. Parents should be reassured that snoring loudly is normal in children his age, and other treatment options such as dental splints and intranasal budesonide should be considered only after a thorough evaluation.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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A middle-aged man is brought into the Emergency Department after a road traffic collision (RTC). During examination, he is found to be tachycardic at 120 bpm, sweating profusely, and pale. His right side has decreased breath sounds and chest movement, and his trachea is deviated to the left. You are requested to insert a large-bore cannula.
Where would you position it in this patient?Your Answer: In the second intercostal space, mid-clavicular line, on the side of the decreased breath sounds
Explanation:To treat a tension pneumothorax, emergency intervention is required. A large-bore cannula should be inserted into the second intercostal space, mid-clavicular line, on the side where breath sounds are decreased to relieve pressure in the pleural space. This is the correct location for needle decompression. However, it is important to note that definitive management involves inserting an intercostal chest drain. Inserting a needle into the fifth intercostal space, mid-axillary line of the chest, on the side of the decreased breath sounds is incorrect for needle decompression, but it is where the chest drain will be inserted afterwards. Inserting a needle into the second intercostal space, mid-axillary line of the chest, on the side with normal breath sounds is the correct space, but the wrong location and wrong side of the body. It would be challenging to insert a needle into this location in reality. Inserting a needle into the third intercostal space, mid-clavicular line, on the side of the decreased breath sounds is the correct anatomical line, but the incorrect intercostal space. Similarly, inserting a needle into the sixth intercostal space, mid-clavicular line, on the side of the chest with decreased breath sounds is the correct anatomical line, but the wrong intercostal space.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 35-year-old woman of Chinese descent is referred to a Respiratory Physician by her General Practitioner due to a productive cough with mucopurulent sputum and occasional blood tinges. She has also been experiencing shortness of breath lately. Her medical history shows that she had a similar episode of shortness of breath and productive cough a year ago, and had multiple bouts of pneumonia during childhood. What is the most reliable test to confirm the probable diagnosis for this patient?
Your Answer: Chest X-ray
Correct Answer: High-resolution computed tomography (HRCT) chest
Explanation:Diagnostic Tests for Bronchiectasis: Understanding Their Uses and Limitations
Bronchiectasis is a respiratory condition that can be challenging to diagnose. While there are several diagnostic tests available, each has its own uses and limitations. Here, we will discuss the most common tests used to diagnose bronchiectasis and their respective roles in clinical practice.
High-Resolution Computed Tomography (HRCT) Chest
HRCT chest is considered the gold-standard imaging test for diagnosing bronchiectasis. It can identify bronchial dilation with or without airway thickening, which are the main findings associated with this condition. However, more specific findings may also point to the underlying cause of bronchiectasis.Chest X-Ray
A chest X-ray is often the first imaging test ordered for patients with respiratory symptoms. While it can suggest a diagnosis of bronchiectasis, it is not the gold-standard diagnostic test.Autoimmune Panel
Autoimmune diseases such as rheumatoid arthritis, Sjögren syndrome, and inflammatory bowel disease can cause systemic inflammation in the lungs that underlies the pathology of bronchiectasis. While an autoimmune panel may be conducted if bronchiectasis is suspected, it is not very sensitive for this condition and is not the gold standard.Bronchoscopy
Bronchoscopy may be used in certain cases of bronchiectasis, particularly when there is localized bronchiectasis due to an obstruction. It can help identify the site of the obstruction and its potential cause, such as foreign-body aspiration or luminal-airway tumor.Pulse Oximetry
Pulse oximetry is a useful tool for assessing the severity of respiratory or cardiac disease. However, it is not specific for any particular underlying pathology and is unlikely to help make a diagnosis. It is primarily used to guide clinical management.In conclusion, while there are several diagnostic tests available for bronchiectasis, each has its own uses and limitations. HRCT chest is the gold-standard test, while other tests may be used to support a diagnosis or identify potential underlying causes. Understanding the role of each test can help clinicians make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Respiratory
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Question 10
Correct
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A 50-year-old woman is admitted to hospital with fever, dyspnoea and consolidation at the left lower base. She is commenced on antibiotics. A few days later, she deteriorates and a chest X-ray reveals a large pleural effusion, with consolidation on the left side.
What is the most important investigation to perform next?Your Answer: Pleural aspiration
Explanation:Appropriate Investigations for a Unilateral Pleural Effusion
When a patient presents with a unilateral pleural effusion, the recommended first investigation is pleural aspiration. This procedure allows for the analysis of the fluid, including cytology, biochemical analysis, Gram staining, and culture and sensitivity. By classifying the effusion as a transudate or an exudate, further management can be guided.
While a blood culture may be helpful if the patient has a fever, pleural aspiration is still the more appropriate next investigation. A CT scan may be useful at some point to outline the extent of the consolidation and effusion, but it would not change management at this stage.
Bronchoscopy may be necessary if a tumour is suspected, but it is not required based on the information provided. Thoracoscopy may be used if pleural aspiration is inconclusive, but it is a more invasive procedure. Therefore, pleural aspiration should be performed first.
In summary, pleural aspiration is the recommended first investigation for a unilateral pleural effusion, as it provides valuable information for further management. Other investigations may be necessary depending on the specific case.
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This question is part of the following fields:
- Respiratory
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Question 11
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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Question 12
Correct
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As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed. You learn that he spent all his working life in a factory. The following results are available:
Measured Expected
FEV1 (L) 2.59 3.46
FVC (L) 3.16 4.21
Ratio (%) 82 81
Which of the following is the most likely cause?Your Answer: Asbestosis
Explanation:Possible Respiratory Diagnoses Based on Pulmonary Function Testing Results
Based on the patient’s age and history of factory work, along with a restrictive defect on pulmonary function testing, asbestosis is the most likely diagnosis. Other possible respiratory diagnoses include allergic bronchopulmonary aspergillosis (ABPA), asthma, emphysema, and bronchiectasis. ABPA and asthma are associated with an obstructive picture on pulmonary function tests, while emphysema and bronchiectasis are also possible differentials based on the history but are associated with an obstructive lung defect. However, it would be unusual for an individual to have their first presentation of asthma at 72 years old. Therefore, a thorough evaluation of the patient’s medical history, physical examination, and additional diagnostic tests may be necessary to confirm the diagnosis.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 75-year-old man with chronic obstructive pulmonary disease (COPD) comes in for a review of his home oxygen therapy. The results of his arterial blood gas (ABG) are as follows:
Investigation Result Normal range
pH 7.34 7.35–7.45
pa(O2) 8.0 kPa 10.5–13.5 kPa
pa(CO2) 7.6 kPa 4.6–6.0 kPa
HCO3- 36 mmol 24–30 mmol/l
Base excess +4 mmol −2 to +2 mmol
What is the best interpretation of this man's ABG results?Your Answer: Respiratory acidosis without metabolic compensation
Correct Answer: Respiratory acidosis with partial metabolic compensation
Explanation:Understanding Arterial Blood Gas (ABG) Results: A Five-Step Approach
Arterial Blood Gas (ABG) results provide valuable information about a patient’s acid-base balance and oxygenation status. Understanding ABG results requires a systematic approach. The Resuscitation Council (UK) recommends a five-step approach to assessing ABGs.
Step 1: Assess the patient and their oxygenation status. A pa(O2) level of >10 kPa is considered normal.
Step 2: Determine if the patient is acidotic (pH <7.35) or alkalotic (pH >7.45).
Step 3: Evaluate the respiratory component of the acid-base balance. A high pa(CO2) level (>6.0) suggests respiratory acidosis or compensation for metabolic alkalosis, while a low pa(CO2) level (<4.5) suggests respiratory alkalosis or compensation for metabolic acidosis. Step 4: Evaluate the metabolic component of the acid-base balance. A high bicarbonate (HCO3) level (>26 mmol) suggests metabolic alkalosis or renal compensation for respiratory acidosis, while a low bicarbonate level (<22 mmol) suggests metabolic acidosis or renal compensation for respiratory alkalosis. Step 5: Interpret the results in the context of the patient’s clinical history and presentation. It is important to note that ABG results should not be interpreted in isolation. A thorough clinical assessment is necessary to fully understand a patient’s acid-base balance and oxygenation status.
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This question is part of the following fields:
- Respiratory
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Question 14
Correct
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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: 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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This question is part of the following fields:
- Respiratory
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Question 15
Correct
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A 28-year-old Afro-Caribbean lady undergoes a routine chest X-ray during a career-associated medical examination. The chest X-ray report reveals bilateral hilar lymphadenopathy. On closer questioning the patient admits to symptoms of fatigue and weight loss and painful blue-red nodules on her shins.
What is the most likely diagnosis in this case?Your Answer: Sarcoidosis
Explanation:Differential Diagnosis for a Patient with Hilar Lymphadenopathy and Erythema Nodosum
Sarcoidosis is a condition characterized by granulomas affecting multiple systems, with lung involvement being the most common. It typically affects young adults, especially females and Afro-Caribbean populations. While the cause is unknown, infections and environmental factors have been suggested. Symptoms include weight loss, fatigue, and fever, as well as erythema nodosum and anterior uveitis. Acute sarcoidosis usually resolves without treatment, while chronic sarcoidosis requires steroids and monitoring of lung function, ESR, CRP, and serum ACE levels.
Tuberculosis is a potential differential diagnosis, as it can also present with erythema nodosum and hilar lymphadenopathy. However, the absence of a fever and risk factors make it less likely.
Lung cancer is rare in young adults and typically presents as a mass or pleural effusion on X-ray.
Pneumonia is an infection of the lung parenchyma, but the absence of infective symptoms and consolidation on X-ray make it less likely.
Mesothelioma is a cancer associated with asbestos exposure and typically presents in older individuals. The absence of exposure and the patient’s age make it less likely.
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This question is part of the following fields:
- Respiratory
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Question 16
Correct
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A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath, unable to speak in complete sentences, tachypnoeic and with a tachycardia of 122 bpm. Severe inspiratory wheeze is noted on examination. The patient is given nebulised salbutamol and ipratropium bromide, and IV hydrocortisone is administered. After 45 minutes of IV salbutamol infusion, there is no improvement in tachypnea and oxygen saturation has dropped to 80% at high flow oxygen. An ABG is taken, showing a pH of 7.50, pO2 of 10.3 kPa, pCO2 of 5.6 kPa, and HCO3− of 28.4 mmol/l. What is the next most appropriate course of action?
Your Answer: Request an anaesthetic assessment for the Intensive Care Unit (ICU)
Explanation:Why an Anaesthetic Assessment is Needed for a Severe Asthma Attack in ICU
When a patient is experiencing a severe asthma attack, it is important to take the appropriate steps to provide the best care possible. In this scenario, the patient has already received nebulisers, an iv salbutamol infusion, and hydrocortisone, but their condition has not improved. The next best step is to request an anaesthetic assessment for ICU, as rapid intubation may be required and the patient may need ventilation support.
While there are other options such as CPAP and NIPPV, these should only be used in a controlled environment with anaesthetic backup. Administering oral magnesium is also not recommended, and iv aminophylline should only be considered after an anaesthetic review. By requesting an anaesthetic assessment for ICU, the patient can receive the best possible care for their severe asthma attack.
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This question is part of the following fields:
- Respiratory
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Question 17
Incorrect
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A previously fit 36-year-old man presents to his general practitioner (GP) with a 4-day history of shortness of breath, a productive cough and flu-like symptoms. There is no past medical history of note. He is a non-smoker and exercises regularly. On examination, he appears unwell. There is reduced chest expansion on the left-hand side of the chest and a dull percussion note over the lower lobe of the left lung. The GP suspects a lobar pneumonia.
Which organism is likely to be responsible for this patient’s symptoms?Your Answer: Mycoplasma pneumoniae
Correct Answer: Streptococcus pneumoniae
Explanation:Common Causes of Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) is a lower respiratory tract infection that can be acquired outside of a hospital setting. The most common cause of CAP is Streptococcus pneumoniae, which can result in lobar or bronchopneumonia. Mycoplasma pneumoniae is another cause of CAP, often presenting with flu-like symptoms and a dry cough. Haemophilus influenzae can also cause CAP, as well as other infections such as otitis media and acute epiglottitis. Legionella pneumophila can cause outbreaks of Legionnaires disease and present with flu-like symptoms and bibasal consolidation on a chest X-ray. While Staphylococcus aureus is not a common cause of respiratory infections, it can cause severe pneumonia following influenzae or in certain populations such as the young, elderly, or intravenous drug users. Proper classification of the type of pneumonia can help predict the responsible organism and guide treatment.
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This question is part of the following fields:
- Respiratory
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Question 18
Correct
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A 61-year-old man presents to the Respiratory Clinic with a history of two episodes of right-sided bronchial pneumonia in the past 2 months, which have not completely resolved. He has been a heavy smoker, consuming 30 cigarettes per day since he was 16 years old. On examination, he has signs consistent with COPD and right-sided consolidation on respiratory examination. His BMI is 18. Further investigations reveal a right hilar mass measuring 4 x 2 cm in size on chest X-ray, along with abnormal laboratory values including low haemoglobin, elevated WCC, and corrected calcium levels. What is the most likely diagnosis?
Your Answer: Squamous cell carcinoma of the bronchus
Explanation:Types of Bronchial Carcinomas
Bronchial carcinomas are a type of lung cancer that originates in the bronchial tubes. There are several types of bronchial carcinomas, each with their own characteristics and treatment options.
Squamous cell carcinoma of the bronchus is the most common type of bronchial carcinoma, accounting for 42% of cases. It typically occurs in the central part of the lung and is strongly associated with smoking. Patients with squamous cell carcinoma may also present with hypercalcemia.
Bronchial carcinoids are rare and slow-growing tumors that arise from the bronchial mucosa. They are typically benign but can become malignant in some cases.
Large cell bronchial carcinoma is a heterogeneous group of tumors that lack the organized features of other lung cancers. They tend to grow quickly and are often found in the periphery of the lung.
Small cell bronchial carcinoma is a highly aggressive type of lung cancer that grows rapidly and spreads early. It is strongly associated with smoking and is often found in the central part of the lung.
Adenocarcinoma of the bronchus is the least associated with smoking and typically presents with lesions in the lung peripheries rather than near the bronchus.
In summary, the type of bronchial carcinoma a patient has can vary greatly and can impact treatment options and prognosis. It is important for healthcare providers to accurately diagnose and classify the type of bronchial carcinoma to provide the best possible care for their patients.
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This question is part of the following fields:
- Respiratory
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Question 19
Correct
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What is the most effective tool for assessing a patient who is suspected of having occupational asthma?
Your Answer: Serial measurements of ventilatory function performed before, during, and after work
Explanation:Occupational Asthma
Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable airflow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases. To diagnose occupational asthma, several investigations are conducted, including serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. A consistent fall in peak flow values and increased intraday variability on working days, along with improvement on days away from work, confirms the diagnosis of occupational asthma. It is important to understand the causes and symptoms of occupational asthma to prevent and manage this condition effectively.
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This question is part of the following fields:
- Respiratory
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Question 20
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A 70-year old man is being evaluated by the respiratory team for progressive cough and shortness of breath over the last 10 months. He has no history of smoking and is typically healthy. The only notable change in his lifestyle is that he recently started breeding pigeons after retiring. Upon examination, the patient is diagnosed with interstitial pneumonia.
What is the most frequently linked organism with interstitial pneumonia?Your Answer: Mycoplasma
Explanation:Types of Bacterial Pneumonia and Their Patterns in the Lung
Bacterial pneumonia can be caused by various organisms, each with their own unique patterns in the lung. Mycoplasma, viruses like RSV and CMV, and fungal infections like histoplasmosis typically cause interstitial patterns in the lung. Haemophilus influenzae, Staphylococcus, Pneumococcus, Escherichia coli, and Klebsiella all typically have the same alveolar pattern, with Klebsiella often causing an aggressive, necrotizing lobar pneumonia. Streptococcus pneumoniae is the most common cause of typical bacterial pneumonia, while Staphylococcus aureus pneumonia is typically of the alveolar type and seen in intravenous drug users or patients with underlying debilitating conditions. Mycoplasma pneumonia may also have extra-pulmonary manifestations. These conditions are sometimes referred to as atypical pneumonia.
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This question is part of the following fields:
- Respiratory
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