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Question 1
Incorrect
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A 23-year-old male medical student presents to the A&E department with pleuritic chest pain. He does not have productive cough nor is he experiencing shortness of breath. He has no past medical history. A chest x-ray which was done shows a right-sided pneumothorax with a 1 cm rim of air and no mediastinal shift.
What is the most appropriate treatment option?Your Answer: Admit for 48 hours observation
Correct Answer: Discharge with outpatient chest x-ray
Explanation:Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Patients are typically aged 18-40 years, tall, thin, and, often, are smokers.
In small pneumothoraxes with minimal symptoms, no active treatment is required. These patients can be safely discharged with early outpatient review and should be given written advice to return if breathlessness worsens. Patients who have been discharged without intervention should be advised that air travel should be avoided until a radiograph has confirmed resolution of the pneumothorax.
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This question is part of the following fields:
- Respiratory System
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Question 2
Correct
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A 75-year-old man was admitted to the hospital with worsening dyspnoea. He was given a five day course of Amoxicillin.
On examination, his blood pressure was 89/59 mmHg with a respiratory rate of 35/min. A chest x-ray revealed left lower lobe consolidation.
Past medical history: Type 2 diabetes mellitus
Arterial blood gas on air:
pH 7.34
pCO2 5.4 kPa
pO2 9.0 kPa
Which antibiotic therapy is the most suitable?Your Answer: Intravenous co-amoxiclav + clarithromycin
Explanation:CURB Pneumonia Severity Score:
– Confusion (abbreviated Mental Test Score <=8) (1 point)
– Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
– Respiratory Rate > 30 per minute (1 point)
– Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) Based on the CURB Pneumonia Severity Score, the patient has severe pneumonia. According to the 2009 Centres for Medicare and Medicaid Services (CMS) and Joint Commission consensus guidelines, inpatient treatment of pneumonia should be given within four hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens, which are also in accordance with IDSA/ATS guidelines. For non-intensive care unit (ICU) patients:
Beta-lactam (intravenous [IV] or intramuscular [IM] administration) plus macrolide (IV or oral [PO])
Beta-lactam (IV or IM) plus doxycycline (IV or PO)
Antipneumococcal quinolone monotherapy (IV or IM)If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO)
For ICU patients:
IV beta-lactam plus IV macrolide
IV beta-lactam plus IV antipneumococcal quinoloneIf the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.
The most suitable antibiotic therapy for this patient is therefore Intravenous co-amoxiclav + clarithromycin.
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This question is part of the following fields:
- Respiratory System
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Question 3
Correct
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An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes seven cigarettes per day. Her exercise tolerance is only a few yards around the house now. Her FEV1 is 37% of predicted.
What is the most appropriate intervention for this patient?Your Answer: Give regular high-dose inhaled fluticasone and inhaled long-acting β-agonist
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 4
Correct
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A patient with a history of asthma presents with worsening of her symptoms and dyspnoea. She recently started taking a new medicine and she feels it might have aggravated her symptoms.
Which of the following is likely responsible for her symptoms?Your Answer: Timolol eye drops
Explanation:β-blockers are the class of drug most often chosen to treat glaucoma, although other medical therapies are available. Systemic absorption of timolol eye drops can cause unsuspected respiratory impairment and exacerbation of asthma. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with β-blockers. Leukotriene antagonists and salbutamol are used in asthma treatment. HRT and ferrous sulphate do not lead to the exacerbation of asthma.
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This question is part of the following fields:
- Respiratory System
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Question 5
Incorrect
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A 66-year-old man with newly-diagnosed small cell carcinoma discusses his further treatment options with the team of doctors.
Which statement is incorrect about small cell carcinoma?Your Answer: Brain metastases are uncommon in patients with small cell lung cancer
Correct Answer: Patients with small cell lung cancer always benefit from surgery
Explanation:Small cell lung cancer (SCLC) is characterized by rapid growth and early dissemination. Prompt initiation of treatment is important.
Patients with clinical stage Ia (T1N0) after standard staging evaluation may be considered for surgical resection, but combined treatment with chemotherapy and radiation therapy is the standard of care. Radiation therapy is often added at the second cycle of chemotherapy.
Historically, patients undergoing surgery for small cell lung cancer (SCLC) had a dismal prognosis. However, more recent data suggest that patients with true stage I SCLC may benefit from surgical resection.
Common sites of hematogenous metastases include the brain, bones, liver, adrenal glands, and bone marrow. The symptoms depend upon the site of spread.
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This question is part of the following fields:
- Respiratory System
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Question 6
Correct
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A 23-year-old female presents to the hospital with worsening shortness of breath, increased volume of purulent sputum and left-sided chest pain. She has a history of cystic fibrosis. Medical notes state that she is under consideration for the transplant list and for some years has been colonised with pseudomonas.
On examination she has a temperature of 38.4°C and FEV1 falling below 75% of the previous value that was recorded. She looks unwell and is tachycardic and hypotensive with a respiratory rate of 21/min. Burkholderia cepacia is confirmed as the pathogen in this case.
What would be the most appropriate antibiotic regime?Your Answer: Ceftazidime and aminoglycoside
Explanation:Burkholderia cepacia is an aerobic gram-negative bacillus found in various aquatic environments. B cepacia is an organism of low virulence and is a frequent colonizer of fluids used in the hospital (e.g., irrigation solutions, intravenous fluids).
B cepacia, as a non-aeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillin, and antipseudomonal third-generation cephalosporins and polymyxin B.
B cepacia is often susceptible to trimethoprim plus sulfamethoxazole (TMP-SMX), cefepime, meropenem, minocycline, and tigecycline and has varying susceptibility to fluoroquinolones.
Based on the options available, ceftazidime and aminoglycoside would be the best option. -
This question is part of the following fields:
- Respiratory System
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Question 7
Correct
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How should DVT during pregnancy be managed?
Your Answer: Dalteparin
Explanation:Deep vein thrombosis (DVT) is a serious condition in which a blood clot forms in a deep vein, usually in the leg.
Subcutaneous low molecular weight heparin (LMWH) is the preferred treatment for most patients with acute DVT, including in pregnancy. A large meta-analyses comparing LMWH to unfractionated heparin (UFH) showed that LMWH decreased the risk of mortality, recurrent veno-thrombo embolism (VTE), and haemorrhage compared with heparin. Other advantages of LMWH may include more predictable therapeutic response, ease of administration and monitoring, and less heparin-induced thrombocytopenia. Disadvantages of LMWH include cost and longer half-life compared with heparin.
Warfarin, which is administered orally, is used if long-term anticoagulation is needed. The international normalized ratio (INR) is followed, with a target range of 2-3. Warfarin crosses the placenta and is teratogenic, causing a constellation of anomalies known as warfarin embryopathy, with greatest risk between the sixth and twelfth week of gestation.
Other options are not indicated for use. -
This question is part of the following fields:
- Respiratory System
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Question 8
Incorrect
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A 52-year-old female, known case of rheumatoid arthritis presents to the clinic with dyspnoea, cough, and intermittent pleuritic chest pain. She was previously taking second line agents Salazopyrin and gold previously and has now started Methotrexate with folic acid replacement a few months back. Pulmonary function tests reveal restrictive lung pattern and CXR reveals pulmonary infiltrates.
Which of the following treatments is most suitable in this case?Your Answer: Stop methotrexate and begin oral corticosteroids
Correct Answer: Stop methotrexate
Explanation:Methotrexate lung disease (pneumonitis and fibrosis) is the specific etiological type of drug-induced lung disease. It can occur due to the administration of methotrexate which is an antimetabolite, which is given as disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxemia and tachypnoea are always present and crackles are frequently audible. Symptoms typically manifest within months of starting therapy. Methotrexate withdrawal is indicated in such cases.
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This question is part of the following fields:
- Respiratory System
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Question 9
Correct
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A 50-year-old farmer presented with fever, malaise, cough, and shortness of breath. He also reports a history of severe weight loss. Examination revealed tachypnoea, coarse end-inspiratory crackles and wheeze. His chest X-ray showed fluffy nodular shadowing and lab results showed polymorphonuclear leukocytosis. Which of the following is the most appropriate diagnosis?
Your Answer: Extrinsic allergic alveolitis
Explanation:Extrinsic allergic alveolitis, also known as hypersensitivity pneumonitis, is an allergic response of the lungs to an environmental allergen. Nodular shadowing in the chest X-ray is characteristic of extrinsic allergic alveolitis.
Churg-Strauss syndrome is an auto-immune disorder that is known to cause vasculitis mostly in patients having a pre-existing airway disease.
Cryptogenic organizing pneumonia is an inflammatory condition of the alveoli. The CXR of which shows ground-glass opacifications.
The CXR of progressive massive fibrosis also shows opacifications normally in the upper lung lobes. -
This question is part of the following fields:
- Respiratory System
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Question 10
Correct
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A 70-year-old thyroid cancer patient is admitted due to dyspnoea. Which investigation should be done to assess for possible compression of the upper airways?
Your Answer: Flow volume loop
Explanation:Flow-volume loop is an easy, non-invasive diagnostic tool that can be used even in severely-ill patients. It can provide information about the location of the obstruction and can differentiate between obstructive pulmonary disease and upper-airway obstruction. Therefore, it is recommended to obtain a flow-volume loop during the assessment of patients with upper airway obstruction.
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This question is part of the following fields:
- Respiratory System
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Question 11
Correct
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A 56-year-old woman presents with persistent cough, pyrexia, crackles and left sided chest pain which worsens upon deep inspiration. She has a history of smoking. What is the most likely diagnosis?
Your Answer: Pneumonia
Explanation:The clinical picture is very suggestive of pneumonia. Pneumonia presents with chest pain exacerbated by deep breathing, fever and localized crackles or consolidation.
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This question is part of the following fields:
- Respiratory System
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Question 12
Correct
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Which of the following is not a known cause of occupational asthma?
Your Answer: Cadmium
Explanation:Occupational asthma (OA) could be divided into a nonimmunological, irritant-induced asthma and an immunological, allergy-induced asthma. In addition, allergy-induced asthma can be caused by two different groups of agents: high molecular weight proteins (>5,000 Da) or low molecular weight agents (<5,000 Da), generally chemicals like the isocyanates.
Isocyanates are very reactive chemicals characterized by one or more isocyanate groups (-N=C=O). The main reactions of this chemical group are addition reactions with ethanol, resulting in urethanes, with amines (resulting in urea derivates) and with water. Here, the product is carbamic acid which is not stable and reacts further to amines, releasing free carbon dioxide.Diisocyanates and polyisocyanates are, together with the largely nontoxic polyol group, the basic building blocks of the polyurethane (PU) chemical industry, where they are used solely or in combination with solvents or additives in the production of adhesives, foams, elastomers, paintings, coatings and other materials.
The complex salts of platinum are one of the most potent respiratory sensitising agents having caused occupational asthma in more than 50% of exposed workers. Substitution of ammonium hexachlor platinate with platinum tetra amine dichloride in the manufacture of catalyst has controlled the problem in the catalyst industry. Ammonium hexachlorplatinate exposure still occurs in the refining process.
Rosin based solder flux fume is produced when soldering. This fume is a top cause of occupational asthma.
Bakeries, flour mills and kitchens where flour dust and additives in the flour are a common cause of occupational asthma.
Cadmium was not found to cause occupational asthma.
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This question is part of the following fields:
- Respiratory System
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Question 13
Incorrect
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Which of the statements is most accurate regarding the lung?
Your Answer: On the right side the transverse fissure separates the upper lobe from the lower lobe
Correct Answer: The medial basal segment is absent in the left lower lobe
Explanation:The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes: right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). The left lung consists of two lobes: right upper lobe (RUL) and right lower lobe (RLL). The right lobe is divided by an oblique and horizontal fissure, where the horizontal fissure divides the upper and middle lobe, and the oblique fissure divides the middle and lower lobes. In the left lobe there is only an oblique fissure that separates the upper and lower lobe.
The lobes further divide into segments which are associated with specific segmental bronchi. Segmental bronchi are the third-order branches off the second-order branches (lobar bronchi) that come off the main bronchus.
The right lung consists of ten segments. There are three segments in the RUL (apical, anterior and posterior), two in the RML (medial and lateral), and five in the RLL (superior, medial, anterior, lateral, and posterior). The oblique fissure separates the RUL from the RML, and the horizontal fissure separates the RLL from the RML and RUL.
There are eight to nine segments on the left depending on the division of the lobe. In general, there are four segments in the left upper lobe (anterior, apicoposterior, inferior and superior lingula) and four or five in the left lower lobe (lateral, anteromedial, superior and posterior). The medium sized airways offer the maximum airway resistance, not smaller ones.
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This question is part of the following fields:
- Respiratory System
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Question 14
Correct
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A young man presents to the clinic with recurrent episodes of breathlessness. Past medical history reveals recurrent episodes of colicky abdominal pain for the past three years.
On examination, he has a productive cough with foul smelling sputum.
Investigations show: Sputum culture with Heavy growth of Pseudomonas aeruginosa and Haemophilus influenzae.
Chest x-ray: Tramline and ring shadows.
What is his diagnosis?Your Answer: Cystic fibrosis
Explanation:Cystic fibrosis (CF) is a multisystemic, autosomal recessive disorder that predominantly affects infants, children, and young adults. CF is the most common life-limiting genetic disorder in whites, with an incidence of 1 case per 3200-3300 new-borns in the United States.
People with CF can have a variety of symptoms, including:
Very salty-tasting skin
Persistent coughing, at times with phlegm
Frequent lung infections including pneumonia or bronchitis
Wheezing or shortness of breath
Poor growth or weight gain in spite of a good appetite
Frequent greasy, bulky stools or difficulty with bowel movements
Male infertilitySigns of bronchiectasis include the tubular shadows; tram tracks, or horizontally oriented bronchi; and the signet-ring sign, which is a vertically oriented bronchus with a luminal airway diameter that is 1.5 times the diameter of the adjacent pulmonary arterial branch.
Bronchiectasis is characterized by parallel, thick, line markings radiating from hila (line tracks) in cylindrical bronchiectasis. Ring shadows represent dilated thick-wall bronchi seen in longitudinal section or on-end or dilated bronchi in varicose bronchiectasis.
Pseudomonas aeruginosa is the key bacterial agent of cystic fibrosis (CF) lung infections, and the most important pathogen in progressive and severe CF lung disease. This opportunistic pathogen can grow and proliferate in patients, and exposure can occur in hospitals and other healthcare settings.
Haemophilus influenzae is regularly involved in chronic lung infections and acute exacerbations of CF patients
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This question is part of the following fields:
- Respiratory System
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Question 15
Incorrect
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A 45-year-old known asthmatic was admitted with acute severe asthma and was treated with nebulised salbutamol, ipratropium and bromide, along with 100% oxygen therapy. He was also given IV hydrocortisone, however there was no significant improvement. What would be the next step in management of this patient?
Your Answer: IV Magnesium Sulphate
Correct Answer: IV Aminophylline
Explanation:Aminophylline is a very effective bronchodilator. It is short acting and therefore very effective in acute scenarios.
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This question is part of the following fields:
- Respiratory System
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Question 16
Correct
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A 23-year-old female presents with a five month history of worsening breathlessness and daily productive cough. As a young child, she had occasional wheezing with viral illnesses and she currently works in a shipyard and also smokes one pack of cigarettes daily for the past three years. Which of the following is the likely diagnosis?
Your Answer: Bronchiectasis
Explanation:Bronchiectasis is a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection. The most common symptoms of bronchiectasis include:
– a persistent productive cough
– breathlessness.The 3 most common causes in the UK are:
– a lung infection in the past, such as pneumonia or whooping cough, that damages the bronchi
– underlying problems with the immune system (the body’s defence against infection) that make the bronchi more vulnerable to damage from an infection
– allergic bronchopulmonary aspergillosis (ABPA) – an allergy to a certain type of fungi that can cause the bronchi to become inflamed if spores from the fungi are inhaled -
This question is part of the following fields:
- Respiratory System
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Question 17
Incorrect
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Which one of the following paraneoplastic features is less likely to be seen in patients with squamous cell lung cancer?
Your Answer: Hyperthyroidism
Correct Answer: Lambert-Eaton syndrome
Explanation:Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission in which release of acetylcholine (ACh) is impaired, causing a unique set of clinical characteristics, which include proximal muscle weakness, depressed tendon reflexes, post-tetanic potentiation, and autonomic changes.
In 40% of patients with LEMS, cancer is present when the weakness begins or is found later. This is usually a small cell lung cancer (SCLC). However, LEMS has also been associated with non-SCLC, lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.
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This question is part of the following fields:
- Respiratory System
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Question 18
Incorrect
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A 73-year-old woman presents with severe emphysema. She is on maximal therapy including high dose Seretide and tiotropium. She tells you that she is so unwell that she can barely manage the walk the 160 metres to the bus stop.
On examination she looks short of breath at rest. Her BP is 158/74 mmHg, pulse is 76 and regular. There are quiet breath sounds, occasional coarse crackles and wheeze on auscultation of the chest.
Investigations show:
Haemoglobin 14.2 g/dl (13.5-17.7)
White cell count 8.4 x 109/l (4-11)
Platelets 300 x 109/l (150-400)
Sodium 137 mmol/l (135-146)
Potassium 4.1 mmol/l (3.5-5)
Creatinine 127 micromol/l (79-118)
pH 7.4 (7.35-7.45)
pCO2 7.5 kPa (4.8-6.1)
pO2 9.7 kPa (10-13.3)
Chest x-ray - Prominent upper lobe emphysema.
FEV1 - 30% of predicted.
Which of the features of her history, examination or investigations would preclude referral for lung reduction surgery?Your Answer: Severe limitation of exercise capacity
Correct Answer: pCO2 7.4
Explanation:Nice guidelines for lung reduction surgery:
FEV1 > 20% predicted
PaCO2 < 7.3 kPa
TLco > 20% predicted
Upper lobe predominant emphysemaThis patient has pCO2 of 7.4 so she is unsuitable for referral for lung reduction surgery.
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This question is part of the following fields:
- Respiratory System
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Question 19
Incorrect
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Which type of lung cancer is most commonly linked to cavitating lesions?
Your Answer: Carcinoid
Correct Answer: Squamous cell
Explanation:Squamous-cell carcinoma is the most common histological type of lung cancer to cavitate (82% of cavitary primary lung cancer), followed by adenocarcinoma and large cell carcinoma. Multiple cavitary lesions in primary lung cancer are rare, however, multifocal bronchoalveolar cell carcinoma can occasionally have multiple cavitary lesions. Small cell carcinoma is not known to cavitate.
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This question is part of the following fields:
- Respiratory System
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Question 20
Correct
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A 35-year-old male complains of a headache that gets worse when he moves his head forward. From the list of options, which is the most likely diagnosis?
Your Answer: Chronic Sinusitis
Explanation:Symptoms such as pain worsening when bending forward, are consistent with chronic sinusitis. Sinusitis also does not present with nausea or vomiting, which is worsened by loud noises or bright lights.
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This question is part of the following fields:
- Respiratory System
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