Full Question & Answer Text (for Search Engines)
Question 1:
A new laboratory test trialled in 10 000 people showed a positive result in 11 people. Of the 10 000, 11 people have cystic fibrosis and ten of the 11 had a positive test result. What is the sensitivity of the test for cystic fibrosis?
Options:
Correct Answer: 0.9
Explanation:
Correct Answer: D-0.9 Explanation 0.9 This is a ‘know it or you don’t’ question. It is useful to know how both sensitivity and specificity are calculated. Sensitivity refers to the proportion of people with disease that have a positive test result. Specificity refers to the proportion of people without disease that have a negative
test result. SnNout is a mnemonic applied to the finding that when a sign, test or symptom has a high Sensitivity, a Negative result rules out the diagnosis. SpPin is a mnemonic applied to the finding that when a sign, test or symptom has a high Specificity, a Positive result rules in the diagnosis. How to calculate the sensitivity and specificity:
Target disorder Present Absent Diagnostic test reult +ve a b a + b -ve c d c + d a + c b + d a + b + c + d From this table, the sensitivity and specificity can be determined as follows:
• Sensitivity = a/(a + c) • Specificity = d/(b + d) 0.01 0.01 is incorrect. When correctly calculated the sensitivity here is 0.9. 0.09 0.09 is incorrect. When correctly calculated the sensitivity here is 0.9. 0.1 0.1 is incorrect. When correctly calculated the sensitivity here is 0.9. 1 1 is incorrect. When correctly calculated the sensitivity here is 0.9.
Question 2:
A 40-year-old man complains of increasing shortness of breath and his chest X-ray shows an elevated hemidiaphragm on the left side; no other abnormalities are seen. What is the most likely investigation to elucidate the mechanical reason for his shortness of breath?
Options:
- Computed tomography (CT) thorax scan
- Echocardiography
- Electrocardiogram (ECG)
- Fluoroscopy
- Magnetic resonance imaging (MRI) scan
Correct Answer: Fluoroscopy
Explanation:
Correct Answer: D- Fluoroscopy Explanation Fluoroscopy The diagnosis of unilateral paralysis, suggested by asymmetric elevation of the affected hemidiaphragm on X-ray, can be confirmed by fluoroscopy. During a forced inspiratory manoeuvre (the ‘sniff’ test), the unaffected hemidiaphragm descends forcefully, increasing intra- abdominal pressure and pushing the paralysed hemidiaphragm cephalad (paradoxical motion). Fluoroscopy is inaccurate for the diagnosis of bilateral paralysis. Computed tomography (CT) thorax scan Computed tomography (CT) thorax scan is incorrect. CT scan will demonstrate an elevated hemidiaphragm, but dynamic imaging is required to show diaphgragmatic paralysis which is the diagnosis here. Echocardiography Echocardiography is incorrect. The breathlessness here is not cardiac in origin, it is due to diaphragmatic paralysis, therefore cardiac investigations would not be helpful in making a diagnosis here. Electrocardiogram (ECG) Electrocardiogram (ECG) is incorrect. The breathlessness here is not cardiac in origin, it is due to diaphragmatic paralysis, therefore cardiac investigations would not be helpful in making a diagnosis here. Magnetic resonance imaging (MRI) scan Magnetic resonance imaging (MRI) scan is incorrect.
Although MRI may demonstrate a structural defect, it is not a dynamic investigation and would not be the most helpful here.
Question 3:
A 20-year-old woman complains of a sudden onset of dyspnoea associated with pleuritic chest pain. She takes the oral contraceptive pill, and has a BMI of 31. Her O2 saturation is 92% on air. Chest X- ray is reported as normal, pregnancy test is negative. Which of the following methods of assessment is the most appropriate to confirm your diagnosis of pulmonary embolism?
Options:
- CTPA
- d-Dimer
- Echocardiography
- Right heart catheterisation
- Ventilation perfusion scan
Correct Answer: CTPA
Explanation:
Correct Answer: A- CTPA Explanation CTPA CT pulmonary angiogram (CTPA), widely available in most Emergency units, is now seen as the diagnostic test of choice for for pulmonary embolus. d-Dimer d- Dimer is incorrect. A negative d-dimer test is useful for excluding pulmonary embolism (PE) in patients who are clinically thought to be at low risk, but a ‘positive’ result does not establish the diagnosis. We do not have full clinical information here to calculate this lady’s Well’s score, but it is likely she would be classed as high risk and therefore d-dimer testing would be inappropriate. Echocardiography Echocardiography is incorrect. Echocardiography might show right ventricular dilatation and evidence of pulmonary hypertension, which, in the proper clinical setting, might strengthen the clinical impression that a PE has occurred; however, a CTPA is the most likely test to give a definitive diagnosis here. Right heart catheterisation Right heart catheterisation is incorrect. Right heart catheterisation is not available in all hospitals and is an invasive investigation that should not be used to diagnose PE. If PE is present, this test will show elevated right heart pressures and pulmonary hypertension. In a small number of patients with massive PE, right heart catheterisation may be used to perform percutaneous thrombectomy to administer local thrombolysis to the site of the PE if there are contraindications to systemic thrombolysis. Ventilation perfusion scan Ventilation perfusion scan is incorrect. Ventilation/perfusion scans have been superceded by CTPA in the diagnostic work up of PE. Their use should now be restricted to individuals with contrast allergy or where the risk from radiation from CTPA is high.
Question 4:
A 63-year-old woman who is a lifelong smoker is found to have non-small-cell lung cancer. Which of the symptoms below is most likely to be her presenting symptom?
Options:
- Breathlessness
- Chest wall pain
- Cough
- Haemoptysis
- Weight loss
Correct Answer: Cough
Explanation:
Correct Answer: C- Cough Explanation Cough Non-small-cell lung cancer can present in a number of different ways. The most common presentation is cough (45%) followed by breathlessness (37%). Chest pain and haemoptysis occur in about a third of patients; anorexia and weight loss affect about a fifth; and 3% experience dysphagia. About 15% of patients are asymptomatic, their lung cancer being detected on a routine chest X-ray being performed for another reason. Breathlessness Breathlessness is incorrect. Cough is the most common presentation affecting 45% of patients compared to 37% of patients for breathlessness. Chest wall pain Chest wall pain is incorrect. Cough is the most common presentation affecting 45% of patients compared to 33% of patients for chest pain. Haemoptysis Haemoptysis is incorrect. Cough is the most common presentation affecting 45% of patients compared to 33% of patients for haemoptysis. Weight loss Weight loss is incorrect. Cough is the most common presentation affecting 45% of patients compared to around 20% of patients for anorexia and weight loss.
Question 5:
A 32-year-old woman is admitted to the Emergency Department with a severe cough and shortness of breath. She has been unwell for a few days with a cough and sore throat and now says she is coughing purulent sputum which is rust-coloured and blood-stained. She has a history of asthma which is usually managed with a Seretide® inhaler. On examination, she is pyrexial (38.2 °C) and has a blood pressure of 110/82 mmHg. Her pulse is 95 bpm and regular. She has a respiratory rate of 30/min and coarse inspiratory crackles to the mid- zone on the right- hand side. There are marked cold sores affecting her upper lip. Investigation: Hb 12.1 g/dl WCC 14.3 x 109/l PLT 202 x 109/l Sodium 139 mmol/l Potassium 4.5 mmol/l Creatinine 179 µmol/l CRP 170 mg/l Po2 9.1 kPa Pco2 4.3 kPa Which of the following is the most likely cause of her underlying pneumonia?
Options:
- Chlamydia pneumoniae
- Klebsiella pneumoniae
- Mycoplasma pneumoniae
- Staphylococcus aureus
- Streptococcus pneumoniae
Correct Answer: Streptococcus pneumoniae
Explanation:
Correct Answer: E- Streptococcus pneumoniae Explanation Streptococcus pneumoniae The history is very typical of community-acquired pneumonia, the commonest cause of which is Streptococcus pneumoniae, and the clinical findings and investigations are also consistent with this. Herpes labialis is usually associated with Streptococcus pneumoniae infection. Management involves the combination of a penicillin such as amoxicillin with a macrolide such as clarithromycin. Chlamydia pneumoniae Chlamydia pneumoniae is incorrect. Chlamydia pneumoniae usually causes a mild pneumonia and many patients are asymptomatic. Klebsiella pneumoniae Klebsiella pneumoniae is incorrect. Klebsiella pneumoniae classically causes a cavitating pneumonia affecting the upper lobe(s). Mycoplasma pneumoniae Mycoplasma pneumoniae is incorrect. Mycoplasma pneumoniae causes an atypical pneumonia, classically with headaches, myalgia and a dry cough. It has an insidious onset, often over weeks. Staphylococcus aureus Staphylococcus aureus is incorrect. Staphylococcus aureus is not a common cause of community- acquired pneumonia unless an individual has immunosuppression. It may also occur after influenza infection. Pneumonia is classically cavitating.
Question 6:
A 26-year-old woman with previously well-controlled asthma on low-dose Seretide comes to the clinic for review. She has recently discontinued her inhaler and sticks only to PRN salbutamol as she is 4 months pregnant. On examination her BP is 100/60 mmHg, pulse is 79/min and regular. She has bilateral fine wheeze, and a peak flow of 350 l/min (510 predicted). Which of the following is the correct management for her?
Options:
- Fluticasone only
- Give monteleukast
- Oral prednisolone
- Restart previous dose of Seretide
- Salmeterol only
Correct Answer: Restart previous dose of Seretide
Explanation:
Correct Answer: D- Restart previous dose of Seretide Explanation Restart previous dose of Seretide Several physiological changes occur in pregnancy, which are recognised to either improve or worsen the control of asthma, and it is well recognised that worsening or improvement of symptoms during the course of a pregnancy is difficult to predict. What is known, however, is that if asthma is well controlled during the pregnancy then there is little or no increased risk of maternal or fetal complications. With respect to use of long-acting β-agonists (LABA) and inhaled steroids, BTS/SIGN guidelines recommend continuing the normal dose as there is no evidence of increased risk to the mother or fetus from taking these medications. Fluticasone only Fluticasone only is incorrect. Although fluticasone can be taken in pregnancy if indicated, the most appropriate thing to do here is to restart the treatment which is known to provide effective control of this lady’s asthma. Give monteleukast Give monteleukast is incorrect. Although monteleukast can be taken in pregnancy if indicated, the most appropriate thing to do here is to restart the treatment which is known to provide effective control of this lady’s asthma. Monteleukast should not be started in an asthmatic prior to inhaled steroids. Oral prednisolone Oral prednisolone is incorrect. Oral prednisolone can be used in pregnancy but should be reserved for treating exacerbations or where patients have failed to gain control on inhaled medications. Salmeterol only Salmeterol only is incorrect. Although salmeterol can be taken in pregnancy if indicated, the most appropriate thing to do here is to restart the treatment which is known to provide effective control of this lady’s asthma. Salmeterol should not be started in an asthmatic prior to inhaled steroids.
Question 7:
A 17-year-old woman presents with a dry cough and pyrexia, some 3 weeks after induction therapy for acute lymphoblastic leukaemia. She has been treated with a macrolide and co-amoxiclav by her GP but there has been no response. On examination she is pyrexial 38.2 °C and short of breath at rest. There are scattered crackles throughout both lung fields on auscultation. Investigations: Hb 12.3 g/dl WCC 9.1 × 109/l PLT 155 × 109/l Na+ 138 mmol/l K+ 4.2 mmol/l Creatinine 102 μmol/l LDH 420 U/l CXR Diffuse bilateral infiltrates extending from the perihilar region pH 7.36 pO2 9.8 kPa pCO2 4.7 kPa Which of the following is the most likely diagnosis?
Options:
- CMV pneumonitis
- Fungal pneumonitis
- Klebsiella pneumoniae
- Leukaemic infiltration
- Pneumocystis jirovecii
Correct Answer: Pneumocystis jirovecii
Explanation:
Correct Answer: E- Pneumocystis jirovecii Explanation Pneumocystis jirovecii The pattern of diffuse pulmonary infiltrates coupled with mild hypoxia fits best with Pneumocystis jirovecii. Saturation falls rapidly on minimal exercise, and ambulatory oximetry is a useful further investigation. Co-trimoxazole is the effective antibiotic in treating the acute infection. CMV pneumonitis CMV pneumonitis is incorrect. Cytomegalovirus (CMV) is a reasonable differential diagnosis here but the chest radiograph appearances described are absolutely classical for Pneumocystis jirovecii pneumonia. Fungal pneumonitis Fungal pneumonitis is incorrect. Fungal pneumonitis is a reasonable differential diagnosis here but the chest radiograph appearances described are absolutely classical for Pneumocystis jirovecii pneumonia. Klebsiella pneumoniae Klebsiella pneumoniae is incorrect. Klebsiella pneumonia typically affects the upper lobes and is cavitating. Leukaemic infiltration Leukaemic infiltration is incorrect. Although raised LDH levels are seen in haematological malignancy, they would be expected to fall after induction chemotherapy, so the raised LDH seen here fits with Pneumocystis jirovecii infection.
Question 8:
You are asked to see a 57-year-old smoker, who complains of shortness of breath some 7 days after a total hip replacement. On examination, he is obese and has a swollen left leg. He is also visibly short of breath. There appears to be increased prominence of vascular markings at the right hilum on the chest X-ray. His calculated alveolar–arterial (a–a) gradient is 34 mmHg (10-24 normal range). Which of the following fits best with his diagnosis?
Options:
- Atelectasis
- Hyperventilation syndrome
- Pneumothorax
- Post-operative pneumonia
- Pulmonary embolus
Correct Answer: Pulmonary embolus
Explanation:
Correct Answer: E- Pulmonary embolus Explanation Pulmonary embolus The alveolar–arterial (A–a) gradient is affected primarily by ventilation/perfusion (V/Q) mismatch and shunting. This means that changes in alveolar–arterial gradient occur with ventilatory disorders, such as pneumonia, and disorders of the vasculature, such as a pulmonary embolus. Pulmonary embolus is the most likely diagnosis here. The alveolar–arterial (A–a) gradient is calculated using the following equation (where PAo2 is the alveolar oxygen, and Pao2 and Paco2 are the arterial O2 and CO2 levels, respectively):
PAo2 – (Pao2 + Paco2/0.8) The alveolar oxygen level in kPa is calculated by: (100 - 7)/100 × % inspired O2 eg for 21% O2, the PAo2 would be 20 mmHg. The gradient is then calculated by taking the arterial partial pressure of oxygen from the alveolar one. Because inspired oxygen can alter the ‘normal’ alveolar– arterial (A–a) gradient also varies according to level of inspired oxygen; if you are using a chart you must make sure that you are using the correct line on the chart corresponding to the correct inspired oxygen concentration. Atelectasis Atelectasis is incorrect. Atelectasis can certainly occur post-operatively. However, it is not noted on the chest radiograph and the presence of a unilaterally swollen leg is suggestive of venous thromboembolism. Hyperventilation syndrome Hyperventilation syndrome is incorrect. Hyperventilation is associated with a normal A–a gradient and in a 57- year-old patient this should typically be between 10 and 24 mmHg. This man has a reduced A–a gradient and a high clinical proabability of pulmonary embolus. Pneumothorax Pneumothorax is incorrect. The chest radiograph does not show a pneumothorax and this man has signs and symptoms more compatible with pulmonary embolism. Post-operative pneumonia Post-operative pneumonia is incorrect. The lack of consolidation on chest radiograph or infective symptoms, such as fever or productive cough, makes respiratory infection an unlikely diagnosis here.
Question 9:
A 26-year-old male smoker presents to the Emergency Department with sudden onset of left-sided pleuritic chest pain and breathlessness. He takes no regular medication and has not received a diagnosis of significant chest disease. A chest X-ray confirms the clinical suspicion of a left sided pneumothorax with a 2.5cm rim of air. What should the initial management of his pneumothorax be?
Options:
- 100% inspired oxygen
- Aspiration
- Conservative treatment
- Intercostal tube drainage
- Surgical referral for pleurodesis
Correct Answer: Aspiration
Explanation:
Correct Answer: B- Aspiration Explanation Aspiration The immediate management of a spontaneous primary pneumothorax >2cm is air aspiration. 100% inspired oxygen 100% inspired oxygen is incorrect. High-flow oxygen is helpful regardless of a patient’s oxygen saturations in pneumothorax as it aids resolution of the pneumothorax; however, 100% oxygen is not required. The correct initial management is aspiration. Conservative treatment Conservative treatment is incorrect. In a young, stable patient conservative management can be considered if the pneumothorax is small (rim of air is < 2 cm at level of hilum). Intercostal tube drainage Intercostal tube drainage is incorrect. Intercostal tube drainage should be reserved for patients who fail to respond to aspiration or who have a tension pneumothorax. Surgical referral for pleurodesis Surgical referral for pleurodesis is incorrect. Surgical referral is considered in patients who develop complications of their pneumothorax (ie bronchopleural fistula) or who have had more than one pneumothorax.
Question 10:
A 75-year-old woman visits your chronic obstructive pulmonary disease (COPD) clinic for review. Her blood gases were checked at her last visit 2 months ago when she was relatively well, and you check them again today. Her PaO2 on air on both occasions was 6.8 kPa. There is no CO2 retention on 28% O2. To her credit, she did succeed in stopping smoking 6 months ago. She is maintained on combination inhaled steroid and long- acting ß2-agonist therapy. What is the next management step most likely to improve her prognosis?
Options:
- Add in an anticholinergic to her therapy
- Continue her current treatment and review in 4 months’ time
- Give her rotational antibiotics to prevent an exacerbation
- Offer her oxygen cylinders for use as required
- Suggest she uses an oxygen concentrator for at least 15 hours a day
Correct Answer: Suggest she uses an oxygen concentrator for at least 15 hours a day
Explanation:
Correct Answer: E- Suggest she uses an oxygen concentrator for at least 15 hours a day Explanation Suggest she uses an oxygen concentrator for at least 15 hours a day Studies have shown that at least 15 hours of oxygen therapy per day is required to reduce the pulmonary hypertension associated with COPD, to treat the underlying pathology of incipient right heart failure and to improve survival. This cannot be realistically achieved using cylinders, and patients should be given a concentrator and a venturi mask to deliver the oxygen at an FiO2 that corrects the hypoxaemia without inducing hypercapnoea. Add in an anticholinergic to her therapy Add in an anticholinergic to her therapy is incorrect. This would be an appropriate adjunctive therapy to her current regimen, but would not improve her prognosis. Only smoking cessation and long-term oxygen therapy (in patients who meet prescription criteria) improve survival in COPD. Continue her current treatment and review in 4 months’ time Continue her current treatment and review in 4 months’ time is incorrect. Continuing her current therapy will not
alter her prognosis. Give her rotational antibiotics to prevent an exacerbation Give her rotational antibiotics to prevent an exacerbation is incorrect. There is no evidence for routine prophylactic rotational antibiotics in COPD. Offer her oxygen cylinders for use as required Offer her oxygen cylinders for use as required is incorrect. This lady’s gases indicate that long-term oxygen therapy will confer a survival benefit. Short-burst oxygen therapy may provide symptom relief but will not improve her survival.
Question 11:
A 58-year-old smoker with chronic bronchitis was treated with antibiotics for a right upper-lobe bronchopneumonia by his GP. After 6 weeks he was readmitted to hospital. The chest X-ray shows signs of a pneumonia in the same place. What is the most likely reason?
Options:
- Bronchial carcinoma with post-stenotic pneumonia
- Candida pneumonia
- Immunodeficiency
- Sarcoidosis
- Tuberculosis
Correct Answer: Bronchial carcinoma with post-stenotic pneumonia
Explanation:
Correct Answer: A- Bronchial carcinoma with post- stenotic pneumonia Explanation Bronchial carcinoma with post-stenotic pneumonia Non-resolving pneumonia is an indication of bronchogenic carcinoma. An ill-defined homogeneous or patchy consolidation in a segmental or non-segmental distribution might be an indication of bronchogenic carcinoma. Patients with these findings are often initially treated for pneumonia; the lack of response to antibiotic therapy suggests the diagnosis of a malignancy. Radiological signs:
• An endobronchial lesion commonly leads to partial or complete atelectasis and this is the most common sign of bronchogenic carcinoma • Bronchial stenosis and post-stenotic changes are commonly seen because most non-small- cell carcinomas demonstrate intraluminal growth. Narrowing of the main bronchi or a complete cut-off can be identified on chest X-rays • Complete endobronchial obstruction can sometimes produce distal mucoid impaction, which can be visible on plain chest X-rays as a tubular or branching opacity • The opacity can contain air bronchograms and air alveolograms. This presentation is often seen with adenocarcinoma and bronchoalveolar carcinoma Candida pneumonia Candida pneumonia is incorrect. Candida pneumonia would be very unusual in a patient who is not immunosuppressed. Given there is nothing in the history to suggest immunosuppression, this diagnosis is unlikely. Immunodeficiency Immunodeficiency is incorrect. Given this gentleman’s age, one would expect more history of recurrent infections +/- bronchiectasis if primary immunodeficiency was the correct diagnosis. There is no history given to suggest a secondary immunodeficiency such as HIV, immunosuppressive medications or haematological malignancy. Sarcoidosis Sarcoidosis is incorrect. Sarcoidosis does not present as pneumonia clinically or on a chest radiograph. It is likely the chest radiograph would show bilateral hilar lymphadenopathy +/- interstitial infiltrates, but not focal consolidation. Tuberculosis Tuberculosis is incorrect. In a non-resolving right upper lobe pneumonia, tuberculosis is a reasonable differential diagnosis, but given the lack of history suggesting this patient is at risk of tuberculosis (eg ethnicity, known contact with TB, alcoholism, malnutrition, immunosuppression) and the fact that this patient is a smoker, the most likely underlying diagnosis is bronchial carcinoma.
Question 12:
A 67-year-old man consults his doctor complaining of a painful mouth and increasing difficulty eating. He has a past history of smoking and has chronic obstructive pulmonary disease (COPD). His medication history includes use of a fluticasone/salmeterol combination inhaler and omeprazole for indigestion. On examination he has a body mass index (BMI) of 29 kg/m2 and looks well. There is extensive stomatitis and pharyngitis on examination of the oropharynx, with white plaques on examination of the tongue. Full blood count, U&Es, liver function tests (LFTs) and viscosity are all normal. Which of the following would be the most appropriate management in this case?
Options:
- Advise him to rinse his mouth each time he uses his inhaler and use a spacer device and review him in a month
- Arrange urgent barium swallow
- Arrange an urgent upper gastrointestinal endoscopy
- Increase his dose of omeprazole
- Stop his inhaled steroids
Correct Answer: Advise him to rinse his mouth each time he uses his inhaler and use a spacer device and review him in a month
Explanation:
Correct Answer: A- Advise him to rinse his mouth each time he uses his inhaler and use a spacer device and review him in a month Explanation Advise him to rinse his mouth each time he uses his inhaler and use a spacer device and review him in a month This man almost certainly has oropharyngeal and oesophageal candidiasis from inadequate hygiene after using his inhaler. He should be taught adequate inhaler technique and urged to rinse his mouth after each use. Resistant symptoms can be managed with oral nystatin or a course of fluconazole. Arrange urgent barium swallow Arrange urgent barium swallow is incorrect. The lack of weight loss and the normal investigation results makes underlying malignancy unlikely, although a symptom check in 1 month is still advisable. If symptoms had not resolved or had worsened then further investigation with a barium study may be warranted. Arrange an urgent upper gastrointestinal endoscopy Arrange an urgent upper gastrointestinal endoscopy is incorrect. The lack of weight loss and the normal
investigation results makes underlying malignancy unlikely, although a symptom check in 1 month is still advisable. If symptoms had not resolved or had worsened then further investigation with an endoscopy may be warranted. Increase his dose of omeprazole Increase his dose of omeprazole is incorrect. The history is not suggestive of poorly controlled reflux. Stop his inhaled steroids Stop his inhaled steroids is incorrect. It would be more appropriate to try mouth rinsing post dose and the use of a spacer first, and if this does not lead to resolution of his symptoms then consider stopping his current inhaled steroid.
Question 13:
A 58-year-old man is referred by his GP with probable obstructive sleep apnoea (OSA). Which of the following features is most strongly associated with OSA?
Options:
- Body mass index of 26 kg/m2
- Daytime somnolence
- Epworth sleepiness score of 6
- Normal blood pressure
- Normal oxygen saturations at night
Correct Answer: Daytime somnolence
Explanation:
Correct Answer: B- Daytime somnolence Explanation Daytime somnolence Daytime somnolence is the predominant symptom of OSA. Body mass index of 26 kg/m2 Body mass index of 26 kg/m2 is incorrect. Obstructive sleep apnoea is associated with obesity (of which hypothyroidism is a cause) and sedatives such as alcohol. Epworth sleepiness score of 6 Epworth sleepiness score of 6 is incorrect. The Epworth sleepiness score can be between 0 and 24 (the higher the score, the more sleepy the patient is) and 6/24 is low. A score of 11 or more is suggestive of OSA. Normal blood pressure Normal blood pressure is incorrect. OSA is associated with hypertension. Normal oxygen saturations at night Normal oxygen saturations at night is incorrect. OSA results in repeated oxygen desaturations overnight. The disorder is most marked during rapid eye movement (REM) sleep.
Question 14:
A 55-year-old man presents with increasing shortness of breath. He has been working in the sand- blasting industry and exposed to quartz particles. What is the most likely diagnosis?
Options:
- Asbestosis
- Asthma
- Eosinophilic pneumonitis
- Sarcoidosis
- Silicosis
Correct Answer: Silicosis
Explanation:
Correct Answer: E- Silicosis Explanation Silicosis Silicosis is a fibrotic disease of the lungs caused by inhalation of crystalline silicon dioxide, usually in the form of quartz. Silicosis can affect anyone involved in quarrying, carving, mining, tunnelling, grinding or sand- blasting, if the dust generated contains quartz. Between 50 and 60 cases are diagnosed in the UK each year, generally in people involved in the production of slate or granite, among miners cutting through rock and in fettlers in foundries. Crystalline silica is present in the earth’s crust usually as quartz, although other forms such as crystobalite and tridymite occur occasionally. They are all extremely toxic to macrophages. Quartz seems to be most toxic when freshly fractured, suggesting that its surface properties are important in toxicity. Silicosis presents a spectrum of clinical appearances, depending on the circumstances in which it is contracted. The most severe form is acute silicosis, which can be acquired after very heavy exposure over just a few months, such as during a sand-blasting job without respiratory protection. These patients become intensely breathless and die within months. The X-ray shows appearances resembling pulmonary oedema. Less heavy exposure causes progressively less dramatic symptoms, ranging from a progressive upper lobe fibrosis with slowly increasing exertional dyspnoea over several years (accelerated silicosis) to a condition with radiographic nodular changes similar to coal-worker’s pneumoconiosis (simple nodular silicosis) that is unassociated with any symptoms or physical signs. This last type of silicosis is the most common, and is usually associated with exposure to dust containing 10–30% silica over a prolonged period. Simple nodular silicosis differs from coal-worker’s pneumoconiosis in that the lesions tend to be larger (3–5 mm) and in that it is progressive even after dust exposure ceases. Lesions increase in size and become more profuse. Moreover, extensive simple silicosis can be associated with some restriction of lung volumes. Accelerated silicosis and progressive massive fibrosis cause lung restriction and lead to cor pulmonale and cardiorespiratory failure. Asbestosis Asbestosis is incorrect. Asbestosis can develop following exposure to asbestos fibres. Typical occupations associated with possible exposure include plumbers, electricians, engineers and ship dockyard workers. Asthma Asthma is incorrect. The short history given alludes to an occupation-related cause of breathlessness. The specific mentioning of quartz particles suggests a diagnosis of silicosis. Asthma is not an occupation-related lung disease. Eosinophilic pneumonitis Eosinophilic pneumonitis is incorrect. The short history given alludes to an occupation-related cause of breathlessness. The specific mentioning of quartz particles suggests a diagnosis of silicosis. Eosinophilic pneumonitis is not an occupation-related lung disease. Sarcoidosis Sarcoidosis is incorrect. The short history given alludes to an occupation-related cause of breathlessness. The specific mentioning of quartz particles suggests a diagnosis of silicosis. Sarcoidosis is not an occupation- related lung disease.
Question 15:
A 33-year-old woman with cystic fibrosis dies while awaiting a lung transplant. She undergoes a post-mortem examination including a biopsy of the respiratory epithelium. Which of the following cells is likely to be found on the surface of the respiratory epithelium?
Options:
- Basophils
- Eosinophils
- Lymphocytes
- Monocytes
- Neutrophils
Correct Answer: Neutrophils
Explanation:
Correct Answer: E- Neutrophils Explanation Neutrophil infiltration is well recognised as a determinant of progression in cystic fibrosis. Infiltration occurs early in the course of the disease, and neutrophil derived factors such as elastase lead to accelerated damage to the respiratory epithelium. Basophils Basophils (Option A) is incorrect. Basophilic infiltration is associated with fatal asthma. Eosinophils Eosinophils (Option B) is incorrect. Eosinophils are associated with allergic lung diseases. Lymphocytes Lymphocytes (Option C) is incorrect. Lymphocytic infiltration is associated with lymphocytic interstitial pneumonia. Monocytes Monocytes (Option D) is incorrect. Monocyte infiltration may be involved in the development of idiopathic pulmonary fibrosis.
Question 16:
A 50-year-old smoker was diagnosed with a non-small- cell carcinoma. Investigations revealed a 4 cm × 3 cm × 2 cm tumour in the lower lobe of his left lung that has invaded the visceral pleura. The ipsilateral hilar lymph node is also involved, but there is no metastatic involvement of any distal organ. What is the stage of disease in this patient?
Options:
- T2 N0 M0
- T2 N1 M0
- T3 N1 M0
- T4 N0 M0
- T4 N1 M0
Correct Answer: T2 N1 M0
Explanation:
Correct Answer: B- T2 N1 M0 Explanation T2 N1 M0 This is a 'know it or you don't' answer. It is important to remember the criteria for staging carcinoma of the lung. As the tumour is more than 3 cm in its greatest dimension and has only invaded the visceral pleura, it is designated T2. Metastasis to the ipsilateral peribronchial and/or ipsilateral hilar lymph nodes makes the nodal stage N1. Absence of distal metastasis is called M0. TNM staging takes into account:
• The size and position of the tumour (T) • Whether the cancer cells have spread into the lymph nodes (N) • Whether the tumour has spread anywhere else in the body - secondary cancer or metastases (M) It would be useful to go through the staging in detail for other possible combinations. See external link for full TNM staging criteria:
T2 N0 M0 T2 N0 M0 is incorrect. The correct disease staging for this patient is T2 N1 M0. T3 N1 M0 T3 N1 M0 is incorrect. The correct disease staging for this patient is T2 N1 M0. T4 N0 M0 T4 N0 M0 is incorrect. The correct disease staging for this patient is T2 N1 M0. T4 N1 M0 T4 N1 M0 is incorrect. The correct disease staging for this patient is T2 N1 M0.
Question 17:
A 48-year-old woman presents with a pleural effusion. You perform a diagnostic pleural aspiration. Which of the following is true regarding the results that you might receive from the laboratory?
Options:
- An eosinophilia makes malignancy less likely
- Heavy bloodstaining effectively excludes pulmonary embolic disease
- High glucose levels occur in rheumatoid arthritis
- Low levels of salivary amylase suggest oesophageal rupture
- The presence of antinuclear factor is virtually diagnostic of scleroderma
Correct Answer: An eosinophilia makes malignancy less likely
Explanation:
Correct Answer: A- An eosinophilia makes malignancy less likely Explanation An eosinophilia makes malignancy less likely Pleural fluid eosinophilia (> 10%) makes malignancy and tuberculosis (TB) less likely, and suggests air in the pleural cavity. Heavy bloodstaining effectively excludes pulmonary embolic disease Heavy bloodstaining effectively excludes pulmonary embolic disease is incorrect. Heavily bloodstained fluid in the absence of trauma suggests pulmonary infarction or malignancy. High glucose levels occur in rheumatoid arthritis High glucose levels occur in rheumatoid arthritis is incorrect. Low glucose levels occur in rheumatoid arthritis, TB, empyema and malignancy. Low levels of salivary amylase suggest oesophageal rupture Low levels of salivary amylase suggest oesophageal rupture is incorrect. High levels of salivary amylase suggest oesophageal rupture. The presence of antinuclear factor is virtually diagnostic of scleroderma The presence of antinuclear factor is virtually diagnostic of scleroderma is incorrect. The presence of antinuclear factor is virtually diagnostic of systemic lupus erythematosus (SLE), not scleroderma.
Question 18:
A 50-year-old patient presents with blood eosinophilia in association with a radiographic pulmonary infiltrate. A bronchoscopy shows an excess of eosinophils in bronchoalveolar lavage fluid in the absence of pathogenic micro-organisms. The diagnosis of eosinophilic pneumonia is made. What is the best treatment apart from removing the causal factors?
Options:
- Clarithromycin
- Inhaled ß2-agonists
- Leukotriene-receptor antagonists
- Nebulised ß2-agonists
- Systemic steroids
Correct Answer: Systemic steroids
Explanation:
Correct Answer: E- Systemic steroids Explanation Systemic steroids Eosinophilic pneumonia often responds well to corticosteroid medication, although treatment might need to be prolonged (6 months or more) in patients with the chronic forms of the disorder. The importance of identifying whether it is associated with the causal factors listed below lies in the need to manage these. Otherwise, eosinophilic pneumonia may not respond adequately to steroid therapy; the associated diseases can also produce other manifestations. Ask yourself whether there are any causal factors:
• Is there parasitic infestation? • Have any drugs been administered? • Is there asthma? • Is there evidence of allergy to parasites or drugs? • Is there evidence of allergic bronchopulmonary mycosis (particularly aspergillosis)? • Is there evidence of vasculitis? • Is there evidence of the hypereosinophilic syndrome? • Is there evidence of other disorders known to be associated with eosinophilic pneumonia? Clarithromycin Clarithromycin is incorrect. Eosinophilic pneumonia is not an infective pneumonia and antibiotics will not improve it. Inhaled ß2-agonists Inhaled ß2-agonists is incorrect. This is a treatment used in asthma. They have no role in the treatment of pure eosinophilic pneumonia, although ß2-agonists may be trialled if there is associated bronchospasm. Leukotriene-receptor antagonists Leukotriene-receptor antagonists is incorrect. This is a treatment used in asthma. They have no role in the treatment of pure eosinophilic pneumonia. Nebulised ß2-agonists Nebulised ß2-agonists is incorrect. This is a treatment used in asthma. They have no role in the treatment of pure eosinophilic pneumonia, although ß2-agonists may be trialled if there is associated bronchospasm.
Question 19:
What would the optimal management be for a 70-year- old man with moderate chronic obstructive pulmonary disease (COPD) who has attended the Emergency Department with increasing dyspnoea and who has been found to have a 3 cm pneumothorax?
Options:
- Chest drain insertion if needle aspiration fails
- Chest drain insertion initially
- Conservative management, with observation and repeat chest X-ray after 4 hours
- Conservative management, with observation and repeat chest X-ray after 12 hours
- Needle aspiration
Correct Answer: Chest drain insertion initially
Explanation:
Correct Answer: B- Chest drain insertion initially Explanation Chest drain insertion initially This is a man with a pneumothorax secondary to his COPD. He is symptomatic and the British Thoracic Society (BTS) Guidelines suggest he should not undergo needle aspiration but proceed to chest drain insertion initially, given the rim of the pneumothorax is > 2 cm and he is breathless. Chest drain insertion if needle aspiration fails Chest drain insertion if needle aspiration fails is incorrect. This is appropriate management of a primary pneumothorax > 2 cm. Conservative management, with observation and repeat chest X-ray after 4 hours Conservative management, with observation and repeat chest X-ray after 4 hours is incorrect. Pneumothoraces with a > 2 cm rim should be actively treated with either aspiration (in primary pneumothoraces) or chest drain insertion (secondary pneumothoraces). Conservative management, with observation and repeat chest X-ray after 12 hours Conservative management, with observation and repeat chest X-ray after 12 hours is incorrect. Conservative management is appropriate for primary pneumothoraces if the rim is < 2 cm and the patient is not breathless. For secondary pneumothoraces, conservative management with admission for high-flow oxygen and observation for 24 hours is appropriate if the rim is < 1 cm and the patient is not breathless. Needle aspiration Needle aspiration is incorrect. Needle aspiration is considered as first-line management in secondary pneumothoraces of 1–2 cm in a patient who is not breathless. In primary pneumothoraces, needle aspiration is appropriate first-line management if the patient is breathless or the rim is > 2 cm.
Question 20:
In which of the following emergency medical presentations is non-invasive ventilation an established first choice therapy in the presence of respiratory acidosis?
Options:
- Acute asthma
- Acute exacerbation of chronic obstructive pulmonary disease with respiratory acidosis
- Adult respiratory distress syndrome (ARDS)
- Pulmonary oedema with hypertension
- Tension pneumothorax
Correct Answer: Acute exacerbation of chronic obstructive pulmonary disease with respiratory acidosis
Explanation:
Correct Answer: B- Acute exacerbation of chronic obstructive pulmonary disease with respiratory acidosis Explanation Acute exacerbation of chronic obstructive pulmonary disease with respiratory acidosis Non-invasive ventilation (NIV) is currently being evaluated in a number of emergency situations. The best evidence relates to exacerbations of chronic obstructive pulmonary disease. In particular, this type of therapy is effective in patients with decompensated type II respiratory failure. Physiological responses (heart rate, respiratory rate and arterial blood gases) improve more quickly with NIV in these patients compared with standard treatment. Intubation is also less frequently required. Acute asthma Acute asthma is incorrect. The correct management for acute asthma with respiratory acidosis is oxygen, steroids, nebulised bronchodilators, intravenous magnesium alongside urgent critical care/anaesthetic for consideration of intubation and invasive ventilation. Adult respiratory distress syndrome (ARDS) Adult respiratory distress syndrome (ARDS) is incorrect. ARDS with respiratory acidosis is best managed with invasive ventilation using low tidal volumes (6 mL/kg based upon ideal body weight). Pulmonary oedema with hypertension Pulmonary oedema with hypertension is incorrect. NIV is part of a range of therapies for pulmonary oedema, but more usually where pulmonary oedema co-exists with hypertension, diuretics and measures to control blood pressure are normally attempted first. Tension pneumothorax Tension pneumothorax is incorrect. The correct first choice treatment for tension pneumothorax is immediate needle decompression followed by intercostal drain insertion.
