Full Question & Answer Text (for Search Engines)
Question 1:
An 82-year-old man living alone in a bungalow came to the clinic complaining of feeling generally unwell for about the last 3–4 months and of losing about 9.5 kg (21 lbs) in weight during this period. On further enquiry he said he had been having night sweats for the last month. He also has a past history of angina and arthritis and was on medication. On examination he did not look well. He was pyrexic but had no lymphadenopathy. Bibasal crepitus on the lower zone was heard on chest auscultation. He had hepatosplenomegaly and clubbing. Investigations showed: white cell count 12.3 × 109/l (neutrophils 52%, lymphocytes 39%), haemoglobin 9.1 g/dl, and all other routine investigations normal. A chest X-ray showed 1- to 2-mm- diameter miliary shadows all over the lung fields. The Mantoux test was negative. No bacteria grew in a sputum culture. What is the probable cause of the illness and the X-ray finding?
Options:
- Bacterial endocarditis
- Miliary tuberculosis
- Mycoplasma pneumonia
- Sarcoidosis
- Staphylococcal pneumonia
Correct Answer: Miliary tuberculosis
Explanation:
Correct Answer: B- Miliary tuberculosis Explanation Miliary tuberculosis This is a case of miliary tuberculosis, which is caused by a diffuse, widely disseminated spread of tubercle bacilli via the bloodstream. In older patients it is difficult to diagnose and is universally fatal if left untreated. Miliary tuberculosis presents with a gradual onset of vague ill health, loss of weight and then fever. It can also present as tubercular meningitis. Hepatosplenomegaly is seen in advanced disease. Choroidal tubercles can be seen in the eyes.
Investigations • Chest X-ray – initially this might be normal; later on, the chest X-ray reveals the presence of small, 1- to 2- mm lesions. • Computed tomography might show a lung parenchymal abnormality at an early stage. • Mantoux test – but this is negative in up to half of patients with severe disease. • Transbronchial biopsy – positive at an early stage. • Biopsy of liver and bone marrow might be required. Bacterial endocarditis Bacterial endocarditis is incorrect. Many of the symptoms described in this case could be attributed to infective endocarditis however the milliary pattern seen on the chest radiograph is most suggestive of milliary tuberculosis. Mycoplasma pneumonia Mycoplasma pneumonia is incorrect. Bacterial pneumonias would be associated with a shorter history of symptoms, weight loss would not be as severe, chest radiographs would show consolidation. Sarcoidosis Sarcoidosis is incorrect. Sarcoidosis would not be associated with fever and night sweats. Chest radiograph would show hilar lymphadenopathy +/- interstitial lung disease. Staphylococcal pneumonia Staphylococcal pneumonia is incorrect. Bacterial pneumonias would be associated with a shorter history of symptoms, weight loss would not be as severe, chest radiographs would show consolidation (perhaps with cavitation in Staphyococcal pneumonia).
Question 2:
A 36-year-old primary schoolteacher who works in a deprived area of London presents with increasing shortness of breath accompanied by sudden-onset, right- sided pleuritic chest pain. She gives a history of influenza for a few days before this acute presentation and also says she suffered a pulmonary embolus 2 years ago while taking the contraceptive pill (and describes her pain as identical to that she experienced on that occasion). On further questioning it transpires that her mother had suffered from recurrent deep vein thrombosis. Arterial blood gases reveal a pO2 of 7.2 kPa on a non re- breather mask, with a pCO2 of 3.2 kPa. Her chest X-ray reveals a wedge-shaped area of consolidation affecting her right middle and lower lobes. The white blood cell count is normal. Which diagnosis fits best with this clinical picture?
Options:
- Bronchial carcinoma
- Pneumothorax
- Recurrent pulmonary embolism
- Staphylococcal pneumonia
- Tuberculosis
Correct Answer: Recurrent pulmonary embolism
Explanation:
Correct Answer: C- Recurrent pulmonary embolism Explanation Recurrent pulmonary embolism The suspicion, given that this lady has had a previous pulmonary embolism while taking the oral contraceptive pill, is that she has an inherited disorder of clotting. It is crucial during the initial work- up to take extra samples for clotting studies before commencing heparin treatment. Predisposing factors for recurrent pulmonary embolism include:
• Antithrombin III deficiency • Protein C deficiency • Factor V Leiden mutation As she has suffered a further pulmonary embolism while off the contraceptive pill, lifelong warfarin treatment should be considered. Bronchial carcinoma Bronchial carcinoma is incorrect. There is no mention of smoking history, she is young and her symptoms are of sudden onset. Bronchial carcinoma is unlikely in view of these factors. Furthermore, no mass lesion is described on her chest radiograph and she has a presentation in keeping with recurrent pulmonary embolism. Pneumothorax Pneumothorax is incorrect. Pneumothorax often presents with sudden onset of shortness of breath and pleuritic chest pain. However, with this degree of hypoxia secondary to a pneumothorax in an individual with no history of chronic lung disease, a pneumothorax would be seen on the chest radiograph. Staphylococcal pneumonia Staphylococcal pneumonia is incorrect. Although a staphylococcal pneumonia might be a plausible
alternative, with the history of previous pulmonary embolism a second clot needs to be excluded. Tuberculosis Tuberculosis is incorrect. Her job and its location raise the possibility of tuberculosis, but this is not very likely given the sudden onset of symptoms, normal white cell count and the history suggestive of recurrent pulmonary embolism.
Question 3:
A 62-year-old man with a heavy smoking history is referred to the Chest Clinic after a mass is seen on his chest X-ray. Which of the following clinical features might indicate a possibility of curative surgical resection for bronchial carcinoma?
Options:
- Forced vital capacity (FVC) < 1.5 pre-operatively
- Hypercalcaemia
- Invasive superior vena cava (SVC) obstruction
- Ipsilateral malignant pleural effusion
- Left recurrent laryngeal nerve palsy
Correct Answer: Hypercalcaemia
Explanation:
Correct Answer: B- Hypercalcaemia Explanation Hypercalcaemia Hypercalcaemia can be due to bony secondaries or to production of parathyroid hormone- (PTH)- like peptide by the tumour. If the hypercalcaemia is due to PTH-like peptide production, then the tumour might be operable. Forced vital capacity (FVC) < 1.5 pre-operatively Forced vital capacity (FVC) < 1.5 pre-operatively is incorrect. FVC of less than 1.5 essentially means there is unlikely to be sufficient reserve after pneumonectomy. Invasive superior vena cava (SVC) obstruction Invasive superior vena cava (SVC) obstruction is incorrect. The tumour is inoperable if there is invasive SVC obstruction, which occurs in 4% of cases, usually with small-cell carcinoma. Ipsilateral malignant pleural effusion Ipsilateral malignant pleural effusion is incorrect. The tumour is inoperable if there is malignant pleural involvement. Left recurrent laryngeal nerve palsy Left recurrent laryngeal nerve palsy is incorrect. The tumour is inoperable if there is left recurrent laryngeal nerve palsy (signifies mediastinal nodes).
Question 4:
A 60-year-old patient was referred with a 1-year history of persistent cough productive of mucopurulent sputum throughout the year. He has been treated by his GP for recurrent chest infections. What is the most likely diagnosis?
Options:
- Allergic asthma
- Bronchiectasis
- Carcinoma of the lung
- Interstitial lung disease
- Sarcoidosis
Correct Answer: Bronchiectasis
Explanation:
Correct Answer: B- Bronchiectasis Explanation Bronchiectasis Bronchiectasis should be suspected when there is a history of persistent cough productive of mucopurulent or purulent sputum throughout the year. Patients have frequently been treated for recurrent chest infections and labelled as ‘bronchitic’, often despite the absence of a history of smoking. Those presenting as adults often recall a ‘chesty cough’ or ‘wheezy bronchitis’ associated with upper respiratory tract infections in childhood, followed by complete resolution of symptoms in their teens and early adult life, before the symptoms return after a viral trigger. Patients might produce mucoid sputum early in their disease, developing purulent sputum when they suffer an exacerbation associated with a viral upper respiratory tract infection. • Productive cough • Postnasal drip – common (there is a history of chronic sinusitis in around 30%) • Tiredness – many patients find this more troublesome than the productive cough • Acute exacerbations, with:
o Purulent sputum o Pleuritic chest pain o Haemoptysis o Fever o Wheeze (less commonly) Allergic asthma Allergic asthma is incorrect. There are no symptoms to suggest a diagnosis of atopic asthma here. There is no mention of breathlessness, wheeze, allergic rhinitis or allergic conjunctivitis. Cough in asthma is usually dry unless there is intercurrent infection. Carcinoma of the lung Carcinoma of the lung is incorrect. The duration of symptoms makes lung malignancy an unlikely cause. Lung cancer can present with non-resolving respiratory infection with productive cough due to endobronchial obstruction by tumour, but there would be a much shorter duration of symptoms. Without treatment most patients would be dead within a year of the onset of lung cancer. Interstitial lung disease Interstitial lung disease is incorrect. Interstitial lung disease would initially present as exertional breathlessness with dry cough. In more advanced disease, traction bronchiectasis can occur and result in productive cough, but the history given here is more in keeping with bronchiectasis than interstitial lung disease. Sarcoidosis Sarcoidosis is incorrect. Interstitial lung disease due to sarcoidosis presents as exertional breathlessness and dry cough.
Question 5:
A 46-year-old cardiologist attended a local conference last weekend and fell ill with a fever of up to 40°C that lasted for 2 days. He had associated shortness of breath and a dry cough. In addition, he had loose motions for a day. His blood results showed deranged liver function tests and hyponatraemia. His white cell count was 10.2 × 109/l. Bibasal consolidation was seen on his X-ray. What would be the most effective treatment for his condition?
Options:
- Amoxicillin
- Cefuroxime
- Ciprofloxacin
- Clarithromycin
- Flucloxacillin
Correct Answer: Clarithromycin
Explanation:
Correct Answer: D- Clarithromycin Explanation Clarithromycin This is a case of Legionella pneumonia. Legionella outbreaks are seen in previously fit individuals staying in hotels or institutions where the shower facilities and/or the cooling system are contaminated with the organism. The incubation period is 2–10 days.Flu-like symptoms, fever, malaise and myalgia typically precede the development of a dry cough and dyspnoea. Extrapulmonary symptoms include anorexia, diarrhoea and vomiting, hepatitis, renal failure, confusion and coma. A chest X-ray shows bibasal consolidation, sometimes with a small pleural effusion. Blood results show an elevated white count, hyponatraemia and deranged liver function tests. Urinalysis might show haematuria. Diagnosis is by the urinary antigen test, which is highly specific. It is important to remember that the organism does not show up on Gram-staining.The preferred treatment is with the macrolide, clarithromycin. Ciprofloxacin can also be effective and rifampicin can be used. Amoxicillin Amoxicillin is incorrect. Amoxicillin monotherapy would be an appropriate treatment for a typical pneumonia of low severity. This case describes Legionella pneumonia which requires macrolide therapy. Cefuroxime Cefuroxime is incorrect. Cefuroxime is rarely prescribed now due to risk of Clostridium difficile infection. Ciprofloxacin Ciprofloxacin is incorrect. Ciprofloxacin is a 2nd line treatment for Legionella pneumonia e.g. if the patient cannot tolerate or is allergic to macrolides. The most effective treatment of the options given is clarithromycin. Flucloxacillin Flucloxacillin is incorrect. Flucloxacillin would be an appropriate treatment for a suspected Staphylococcal pneumonia.
Question 6:
A 56-year-old smoker is transferred to your hospital with increasing breathlessness and haemoptysis. On examination he is suspected of having early stridor. What is the most appropriate pulmonary function test in this case?
Options:
- FEF25%–75% (average expired flow over mid- expiratory range of forced vital capacity manoeuvre)
- FEV1 (forced expiratory volume in 1 s)
- Flow–volume loop
- TLC (total lung capacity)
- Vmax50 (maximal flow at 50% of vital capacity)
Correct Answer: Flow–volume loop
Explanation:
Correct Answer: C- Flow–volume loop Explanation Flow–volume loop Stridor in lung cancer is strongly suggestive of large- airway obstruction and is a medical emergency. Flow– volume loops show typical flattening caused by large- airways obstruction. Stridor complicating cancer requires urgent treatment and this can include steroids, radiotherapy, chemotherapy or endobronchial stenting. FEF25%–75% (average expired flow over mid- expiratory range of forced vital capacity manoeuvre) FEF 25%–75% (average expired flow over mid- expiratory range of forced vital capacity manoeuvre) is incorrect. This is a measure of flow in the small airways and would therefore not be helpful to determine a cause for the stridor.
FEV1 (forced expiratory volume in 1 s)
FEV1 (forced expiratory volume in 1 s) is incorrect. The
FEV1 reflects lower airway obstruction and therefore would not be as helpful as a flow–volume loop to determine a cause for the stridor.
TLC (total lung capacity)
TLC (total lung capacity) is incorrect. This is a measure of lung volume and would not be as helpful as a flow– volume loop to determine a cause for the stridor. Vmax50 (maximal flow at 50% of vital capacity) Vmax50 (maximal flow at 50% of vital capacity) is incorrect. This would not be as helpful as a flow– volume loop to determine a cause for the stridor.
Question 7:
A patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l. The patient is asymptomatic. What is the most appropriate therapy?
Options:
- Fluid restriction
- Glucocorticoids
- Hypertonic fluid infusion
- Start chemotherapy
- Start radiotherapy
Correct Answer: Fluid restriction
Explanation:
Correct Answer: A- Fluid restriction Explanation Fluid restriction This is a ‘know it or you don’t’ question. The continual secretion of antidiuretic hormone (ADH) in an amount in excess of the body’s needs leads to overhydration in both the intracellular and extracellular compartments. This is known as the ‘syndrome of inappropriate antidiuretic hormone secretion’ (SIADH). The cancer most commonly associated with this syndrome is small-cell lung cancer, where it is clinically obvious in 10% of cases, with subclinical involvement detectable by a water-loading test in more than 50%. The cerebral oedema resulting from water intoxication causes drowsiness, lethargy, irritability, mental confusion and disorientation, with seizures and coma being the most profound features. Peripheral oedema is remarkably rare. The patient is usually asymptomatic until the
sodium level falls below 120 mmol/l and the hyponatraemia is dilutional in type, with a low serum osmolality. Urine osmolality usually exceeds 300 mOsmol/kg. Restriction of fluid to a daily intake of 700–1000 ml redresses the hyponatraemia. In addition, desmethyl chlortetracycline (demeclocycline) 600–1200 mg daily is often effective. Glucocorticoids Glucocorticoids is incorrect. The most appropriate therapy here is fluid restriction to redress the hyponatraemia. Hypertonic fluid infusion Hypertonic fluid infusion is incorrect. Infusion of hypertonic saline is hazardous, often precipitating cardiac failure or more rarely too rapid correction of
sodium can lead to central pontine myelinolysis. It is therefore usually reserved for use in very severe/life- threatening hyponatraemia with altered consciousness or fits. Start chemotherapy Start chemotherapy is incorrect. The most appropriate therapy here is fluid restriction to redress the hyponatraemia. Start radiotherapy Start radiotherapy is incorrect. The most appropriate therapy here is fluid restriction to redress the hyponatraemia.
Question 8:
A 70-year-old man attends the clinic. He is an ex-smoker of 50 pack-years. He has chronic obstructive pulmonary disease, with an FEV1 of 40% predicted and minimal bronchodilator reversibility. He is breathless after walking 500 m and was keen to be referred to discuss the possibility of pulmonary rehabilitation. What do you tell him?
Options:
- His exercise tolerance is too poor to be considered for the rehabilitation programme
- His lung function should improve after the rehabilitation programme
- His walking distance should improve after the rehabilitation programme
- If his exercise tolerance did improve following pulmonary rehabilitation, this would be a long-lasting improvement
- Rehabilitation will make little difference to the length of any future hospital stays
Correct Answer: His walking distance should improve after the rehabilitation programme
Explanation:
Correct Answer: C- His walking distance should improve after the rehabilitation programme Explanation His walking distance should improve after the rehabilitation programme Pulmonary rehabilitation has been found to lead to significant improvements in functional exercise capacity. His exercise tolerance is too poor to be considered for the rehabilitation programme His exercise tolerance is too poor to be considered for the rehabilitation programme is incorrect. Patients with very limited exercise tolerances may benefit from pulmonary rehabilitation and in the most severely limited patients chair-based exercises can be taught. His lung function should improve after the rehabilitation programme His lung function should improve after the rehabilitation programme is incorrect. Pulmonary rehabilitation does not improve lung function. If his exercise tolerance did improve following pulmonary rehabilitation, this would be a long-lasting improvement If his exercise tolerance did improve following pulmonary rehabilitation, this would be a long-lasting improvement is incorrect. Decline in exercise tolerance and heath status tends to occur 6–12 months after the completion of a course. The effect of sustained improvement with ongoing rehabilitation has yet to be evaluated. Rehabilitation will make little difference to the length of any future hospital stays Rehabilitation will make little difference to the length of any future hospital stays is incorrect. Patients who have completed pulmonary rehabilitation experience no fewer hospital admissions because of chest problems, but their hospital stays are likely to be shorter.
Question 9:
A 60-year-old man who has a 30 pack-year smoking history comes to clinic with worsening shortness of breath over the last 6 months. He works as a baker and keeps racing pigeons. On examination, he is clubbed, has saturations of 91% on air and has widespread fine inspiratory crepitations. His chest X- ray shows reticulonodular shadowing and computed tomography (CT) confirms reticulation, mainly subpleural, and some honeycombing. What is the diagnosis?
Options:
- Hypersensitivity pneumonitis
- Langerhans cell histiocytosis
- Occupational asthma
- Pulmonary sarcoidosis
- Usual interstitial pneumonitis
Correct Answer: Usual interstitial pneumonitis
Explanation:
Correct Answer: E- Usual interstitial pneumonitis Explanation Usual interstitial pneumonitis Dyspnoea, clubbing and inspiratory crepitations are the classic features of usual interstitial pneumonitis. A chest X-ray will show reticulation, which is classically subpleural in distribution and on computed tomography (CT) and honeycombing. Hypersensitivity pneumonitis Hypersensitivity pneumonitis is incorrect. With hypersensitivity pneumonitis the expected findings would be ground-glass shadowing, with reticular and nodular patterns. Langerhans cell histiocytosis Langerhans cell histiocytosis is incorrect. In Langerhans cell histiocytosis nodules and cystic lesions would classically be seen on CT. Occupational asthma Occupational asthma is incorrect. Wheeze rather than crackles would be heard in occupational asthma and clubbing would not be present. CT might show non- specific features of air trapping. Pulmonary sarcoidosis Pulmonary sarcoidosis is incorrect. Pulmonary sarcoidosis does not cause clubbing and crepitations would be associated with end-stage fibrotic disease. Typically lungs are clear to auscultation in pulmonary sarcoidosis. CT thorax will show nodularity, including fissural nodularity in a bronchovascular and subpleural distribution.
Question 10:
You are asked to review a patient with known asthma on the haematology ward. He is neutropenic from chemotherapy for Hodgkin lymphoma. He has a cough and a low-grade fever, sparse crepitations on chest examination and his chest X-ray shows diffuse pulmonary shadowing. He has been on broad-spectrum antibiotics for 1 week with no improvement. His sputum has shown a few hyphae, but is culture-negative. Blood cultures have been negative. Aspergillus precipitins are negative, as is an Aspergillus skinprick test. What is the diagnosis?
Options:
- Allergic bronchopulmonary aspergillosis
- Aspergilloma
- Invasive aspergillosis
- Pneumocystis pneumonia
- Systemic candidosis
Correct Answer: Invasive aspergillosis
Explanation:
Correct Answer: C- Invasive aspergillosis Explanation Invasive aspergillosis This man has invasive aspergillosis, due to his immunosuppression. He has fungal hyphae in his sputum and a corresponding clinical and radiological picture. He is unable to mount an immune response and so precipitin and skinprick tests are negative. Allergic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis (ABPA) is incorrect. ABPA is an IgE-mediated hypersensitivity reaction associated with exposure to Aspergillus. It presents with wheeze and cough often productive of thick mucus plugs. Chest radiograph shows transient pulmonary infiltrates (which are not widespread, as is described in this case). Blood tests show high IgE levels and antibodies to Aspergillus, so the skinprick is positive and precipitins are high if there is no immunosuppression. By virtue of the fact that this patient is heavily immunosuppressed it would be very unlikely for him to develop ABPA. Aspergilloma Aspergilloma is incorrect. Aspergilloma is a fungal ball in an area of previously damaged lung tissue, such as old tuberculosis. It does not cause diffuse pulmonary infiltrates as are described in this case. It usually causes high levels of Aspergillus antibody, so precipitins are high, although the skinprick test is negative as there is no IgE-mediated allergy to Aspergillus. Pneumocystis pneumonia Pneumocystis pneumonia is incorrect. Pneumocystis pneumonia does not cause hyphae in the sputum. Systemic candidosis Systemic candidosis is incorrect. Candida can be identified and cultured from the sputum. It rarely causes objective evidence of lung invasion and is not recognised as having specific radiological features.
Question 11:
A 32-year-old alcoholic man is brought to the Emergency Department having been found collapsed on a street corner. He is a frequent attender at the hospital with intoxication, is known to have chronic liver disease with hepatitis C, and has one previous episode of haematemesis due to oesophageal varices. On examination he is drowsy and confused, his BP is 100/70 mmHg, pulse is 90/min and regular, and his temperature is 38.2 °C. Auscultation of the chest reveals coarse right- sided crackles, with decreased breath sounds at the right base. Investigations: Hb 10.5 g/dl WCC 13.1 × 109/l Neutrophils 11.2 × 109/l PLT 100 × 109/l Na+ 131 mmol/l K+ 4.5 mmol/l Creatinine 95 μmol/l CRP 171 mg/l CXR Right lower lobe consolidation with evidence of cavitation Which of the following is the most likely diagnosis?
Options:
- Aspiration pneumonia
- Klebsiella pneumonia
- Legionnaire’s disease
- Staphylococcal pneumonia
- Tuberculosis
Correct Answer: Klebsiella pneumonia
Explanation:
Correct Answer: B- Klebsiella pneumonia Explanation Klebsiella pneumonia Klebsiella pneumonia occurs with increased frequency in debilitated patients, particularly those with a history of alcoholism. It leads to cavitation, as seen here. Aspiration pneumonia Aspiration pneumonia is incorrect. Aspiration pneumonia is predominantly associated with changes in the right upper and middle lobes. Legionnaire’s disease Legionnaire's disease is incorrect. Legionnaire’s is a much more rare cause of community-acquired pneumonia, and is often associated with diarrhoea. Staphylococcal pneumonia Staphylococcal pneumonia is incorrect. The other common cause of cavitating pneumonia is staphylococcal infection, although that occurs most frequently post influenza, of which there is no mention here. Tuberculosis Tuberculosis is incorrect. Tuberculosis typically affects the upper lobes or apical lower lobes.
Question 12:
Which of the following is the best agent for treating chlamydial pneumonia in a woman who is 25-weeks pregnant?
Options:
- Ampicillin
- Clindamycin
- Erythromycin
- Imipenem
- Piperacillin
Correct Answer: Erythromycin
Explanation:
Correct Answer: C- Erythromycin Explanation Erythromycin Macrolide antibiotics (eg erythromycin) are the treatment of choice for Chlamydia pneumonia and other atypical pneumonias. The most frequent side-effects are nausea, vomiting and diarrhoea. Treatment is likely to be most effective when it is given over a longer time, when suboptimal doses are avoided and if compliance is strict. In this case macrolides would have the best evidence of safety in pregnancy and efficacy, although most evidence to support safe use is in the third trimester. The other choices are incorrect – All of these antibiotics are less effective than macrolides in treating Chlamydial pneumonia therefore erythromycin is the most appropriate treatment of the options given. Piperacillin, clindamycin and ampicillin can be safely used in pregnancy. Imipenem should be avoided in pregnancy given evidence of toxicity in animal studies. Ampicillin Ampicillin is incorrect. As described this would be less effective than erythromycin. Clindamycin Clindamycin is incorrect. As described this would be less effective than erythromycin. Imipenem Imipenem is incorrect. Imipenem should be avoided in pregnancy. Piperacillin Piperacillin is incorrect. As described this would be less effective than erythromycin.
Question 13:
A 64-year-old demolition worker presents to his GP with a severe, dull, right-sided chest pain. He first noticed it some months ago and he is now having particular problems with shortness of breath. Apparently he was given an asthma inhaler for shortness of breath around 2 years earlier. On examination he appears to have a right- sided pleural effusion and has finger clubbing. He admits to having been exposed to asbestos. On further questioning he says that his brother, who worked with him, died of ‘some sort of lung cancer’ around 2 years ago. X-ray confirms a right pleural effusion with evidence of pleural plaques elsewhere. What diagnosis would fit best with this clinical picture?
Options:
- Asthma
- Bronchial carcinoma
- Mesothelioma
- Rheumatoid arthritis
- Tuberculosis
Correct Answer: Mesothelioma
Explanation:
Correct Answer: C- Mesothelioma Explanation Mesothelioma The clue to the answer here is the occupation, and the fact that a co-worker has already died of a cancer related to the chest. A restrictive lung defect, evidence of asbestosis, and now a painful pleural effusion would fit best with a diagnosis of mesothelioma. Diagnosis is confirmed by pleural biopsy. The median survival after diagnosis ranges from 12 to 21 months depending on staging. The cancer is poorly responsive to any form of intervention, however, and it is notable that a significant number of patients survive far less than 2 years. Asthma Asthma is incorrect. Asthma is not associated with pleural effusions or finger clubbing. Additionally, the presence of pleural plaques, chest pain and previous asbestos exposure make mesothelioma the most likely diagnosis. Bronchial carcinoma Bronchial carcinoma is incorrect. Although bronchial carcinoma can present with dyspnoea and a pleural effusion, the presence of finger clubbing, pleural plaques and previous asbestos exposure makes mesothelioma the most likely diagnosis. Rheumatoid arthritis Rheumatoid arthritis is incorrect. Rheumatoid arthritis can be associated with pleural effusions but there is no mention of any joint symptoms, and the presence of finger clubbing, pleural plaques and previous asbestos exposure makes mesothelioma the most likely diagnosis. Tuberculosis Tuberculosis is incorrect. Tuberculosis can present with a pleural effusion. However, there is no mention of contact with tuberculosis and there is no history of fevers or sweats. Furthermore, the presence of finger clubbing, pleural plaques and previous asbestos exposure makes mesothelioma the most likely diagnosis.
Question 14:
A patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l. Which of the following is the most likely cause?
Options:
- Bone metastases
- Liver metastases
- Sodium-reduced water drinking
- Sodium-restricted diet
- Syndrome of inappropriate antidiuretic hormone secretion
Correct Answer: Syndrome of inappropriate antidiuretic hormone secretion
Explanation:
Correct Answer: E- Syndrome of inappropriate antidiuretic hormone secretion Explanation Syndrome of inappropriate antidiuretic hormone secretion Continual secretion of vasopressin (antidiuretic hormone, ADH) in amounts in excess of the body’s needs leads to overhydration in both the intracellular and extracellular compartments – the so-called ‘syndrome of inappropriate antidiuretic hormone secretion’ or SIADH. The commonest cancer to cause this syndrome is small-cell cancer of the lung and it is clinically obvious in 10% of people with this tumour, with subclinical involvement detectable by a water-loading test in more than 50%. Clinical and biochemical features:
• The cerebral oedema resulting from water intoxication causes drowsiness, lethargy, irritability, mental confusion and disorientation, with seizures and coma being the most profound features. Peripheral oedema is remarkably rare. The patient is usually asymptomatic until the sodium concentration falls below 120 mmol/l. • The hyponatraemia is dilutional in type, with a low serum osmolality. Urine osmolality usually exceeds 300 mOsmol/kg. Restriction of fluid to a daily intake of 700– 1000 ml might be sufficient to redress the hyponatraemia. • Demethylchlortetracycline (demeclocycline) 600– 1200 mg daily induces nephrogenic diabetes insipidus, making water restriction unnecessary. However, it has an unpredictable onset, only works in approximately 60% patinets and can be associated with renal dysfunction. • Tolvaptan, an arginine vasopressin (AVP) antagonist, promotes aquaresis and can lead to a contolled increase in serum sodium. • Infusion of hypertonic saline is hazardous, often precipitating cardiac failure or cerebral oedema but may be required in severe hyponatraemia in the presence of seizures, impaired mental status or coma. Treatment with hypertonic saline should be stopped once symptoms resolve, a safe serum sodium concentration is achieved, or the maximum sodium correction limits are approached (<12mEq/L increase in serum sodium in 24 hours). Bone metastases Bone metastases is incorrect. Bone metastases are not a cause of hyponatraemia. Liver metastases Liver metastases is incorrect. Liver metastases are not a cause of hyponatraemia. Sodium-reduced water drinking
Sodium-reduced water drinking is incorrect. Psychogenic polydipsia is a cause of hyponatraemia but given this lady has small cell lung cancer SIADH is more likely
Sodium-restricted diet
Sodium-restricted diet is incorrect. This is unlikely to cause significant hyponatraemia
Question 15:
Which one of the following features is most characteristic of small-cell bronchial carcinoma?
Options:
- A history of prior asbestos exposure
- Cancer cell origin from small lymphocytes
- Has a relatively better prognosis than other bronchial cancers
- Hyponatraemia
- Surgery is often the only possible treatment
Correct Answer: Hyponatraemia
Explanation:
Correct Answer: D- Hyponatraemia Explanation Hyponatraemia Syndrome of inappropriate antidiuretic hormone secretion (SIADH) resulting in hyponatraemia occurs in approximately 15% of patients with small-cell lung cancer. A history of prior asbestos exposure A history of prior asbestos exposure is incorrect. Asbestos exposure increases the risk of lung cancer but is most associated with pleural malignancy (malignant mesothelioma). Cancer cell origin from small lymphocytes Cancer cell origin from small lymphocytes is incorrect. Small-cell lung cancer is of neuroendocrine cell origin. Has a relatively better prognosis than other bronchial cancers Has a relatively better prognosis than other bronchial cancers is incorrect. The prognosis is very poor and survival beyond two 2 years is exceptional. Surgery is often the only possible treatment Surgery is often the only possible treatment is incorrect. By the time the diagnosis has been made the tumour is usually disseminated, so that surgery is seldom considered.
Question 16:
A 37-year-old patient with haemophilia A has been complaining of fever and dry cough. An interstitial pneumonia was diagnosed. He only makes intermittent contact with medical services. After 7 days' treatment with doxycycline 200 mg/day his temperature was still 39 °C and a chest X- ray showed increased interstitial infiltrates. Which is the most likely diagnosis?
Options:
- Candida pneumonia
- Extrinsic allergic alveolitis
- Mycoplasma pneumonia
- Ornithosis
- Pneumocystis jirovecii pneumonia
Correct Answer: Pneumocystis jirovecii pneumonia
Explanation:
Correct Answer: E- Pneumocystis jirovecii pneumonia Explanation Pneumocystis jirovecii pneumonia Pneumocystis jirovecii pneumonia (formerly called Pneumocystis carinii) typically presents with gradually increasing dyspnoea and cough over weeks, but sometimes as an acute illness with rapid deterioration over a few days. Patients with haemophilia A were more susceptible to HIV due to frequent blood transfusions that were not screened in the past. The chest X-ray usually reveals diffuse ground-glass opacities, which strongly suggests the diagnosis, but it sometimes shows nodular opacities, lobar consolidation, or even a normal film. Cystic abnormalities and spontaneous pneumothoraces in patients with known or suspected HIV infection are usually caused by Pneumocystis jirovecii pneumonia. Pneumocystis jiroveciipneumonia is unlikely in a patient who has had a CD4+ cell count above 200 cells/µl in the preceding 2 months in the absence of other HIV- associated symptoms. Approximately 90% of patients with Pneumocystis jirovecii pneumonia have an elevated serum lactic dehydrogenase, but this may also occur with other pulmonary diseases. Candida pneumonia Candida pneumonia is incorrect. This is a reasonable differential diagnosis here, but the dry cough is classical of Pneumocystis jirovecii pneumonia and one might expect a history of oral candidiasis if candida pneumonia was suspected in an immunocompromised patient. Extrinsic allergic alveolitis Extrinsic allergic alveolitis is incorrect. There is no mention of a potential allergen/precipitin to cause extrinsic allergic alveolitis; the history is more suggestive of respiratory infection and the diagnosis of haemophilia A is supposed to trigger the candidate to suspect HIV infection from blood transfusion and a subsequent opportunistic respiratory infection. Mycoplasma pneumonia Mycoplasma pneumonia is incorrect. Mycoplasmal pneumonia is likely to be adequately treated by doxycycline, making other diagnoses more likely. Ornithosis Ornithosis is incorrect. There is no mention of avian exposure to suggest Chlamydia psittaci pneumonia (ornithosis). In addition, doxycycline is an appropriate treatment for this infection, so improvement rather than deterioration after treatment would be more likely.
Question 17:
You review a 72-year-old man with severe chronic obstructive pulmonary disease (COPD), who asks about the provision of oxygen therapy at home. In which of the following settings have randomised controlled trials shown that long-term oxygen therapy (LTOT) reduces mortality?
Options:
- Asthma
- Cor pulmonale caused by chronic airflow obstruction
- Cystic fibrosis
- Idiopathic pulmonary fibrosis
- Pulmonary sarcoidosis
Correct Answer: Cor pulmonale caused by chronic airflow obstruction
Explanation:
Correct Answer: B- Cor pulmonale caused by chronic airflow obstruction Explanation Cor pulmonale caused by chronic airflow obstruction Two controlled studies (in a mostly male population) indicated that life can be prolonged by the continuous delivery of 2 l/min of oxygen via nasal prongs to achieve saturations of greater than 90% for a large proportion of the day and night. Improvements in pulmonary artery hypertension were obtained in patients who used oxygen for more than 15 h/day, but mortality was only improved in patients who used oxygen for more than 18 h/day. Long-term oxygen therapy (LTOT) should therefore be considered in patients with chronic obstructive pulmonary disease (COPD) and a forced expiratory volume in 1 s (FEV1) of less than 1.5 l, an arterial partial pressure of oxygen (Pao2) of less than 7.3 kPa and carboxyhaemoglobin of less than 3%. Although oxygen cylinders can be provided for intermittent use by patients for the relief of symptoms of breathlessness, they have no effect on prognosis. Asthma Asthma is incorrect. Although oxygen cylinders can be provided for intermittent use by patients for the relief of symptoms of breathlessness, they have no effect on prognosis. Cystic fibrosis Cystic fibrosis is incorrect. Although oxygen cylinders can be provided for intermittent use by patients for the relief of symptoms of breathlessness, they have no effect on prognosis. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Although oxygen cylinders can be provided for intermittent use by patients for the relief of symptoms of breathlessness, they have no effect on prognosis. Pulmonary sarcoidosis Pulmonary sarcoidosis is incorrect. Although oxygen cylinders can be provided for intermittent use by patients for the relief of symptoms of breathlessness, they have no effect on prognosis.
Question 18:
A 28-year-old man presents with sudden left-sided pleuritic chest pain while working on a house clearance. He is usually fit and well, has no significant medical problems and takes no medication. On examination his respiratory rate is 20 bpm, his BP is 125/82 mmHg, and pulse is 85 bpm and regular. He is in pain, although breath sounds are normal on auscultation. Investigations: Hb 13.4 g/dl WCC 8.1 × 109/l PLT 201 × 109/l Na+ 137 mmol/l K+ 4.3 mmol/l Creatinine 100 μmol/l CXR 1 cm left-sided pneumothorax O2 saturation 98% on air Which of the following is the correct way to manage him?
Options:
- Admit for overnight observation
- Attempt percutaneous aspiration
- Discharge with review after 12 h
- Discharge with review in clinic in approximately 2 weeks
- Insert chest drain
Correct Answer: Discharge with review after 12 h
Explanation:
Correct Answer: C- Discharge with review in clinic in approximately 2 weeks Explanation Discharge with review in clinic in approximately 2 weeks This patient has a minimal pneumothorax and his pain should settle with adequate analgesia. As such it is appropriate to discharge him with review in clinic in approximately 2 weeks. Of course he should be warned to return as soon as possible if shortness of breath or pain worsens. Admit for overnight observation Admit for overnight observation is incorrect. This patient has a minimal pneumothorax and his pain should settle with adequate analgesia. As such it is appropriate to discharge him with review in clinic in approximately 2 weeks. Of course he should be warned to return as soon as possible if shortness of breath or pain worsens. Attempt percutaneous aspiration Attempt percutaneous aspiration is incorrect. In the event the pneumothorax was > 2 cm in size, aspiration would be the initial management of choice. Discharge with review after 12 h Discharge with review after 12 h is incorrect. This patient has a minimal pneumothorax and his pain should settle with adequate analgesia. As such it is appropriate to discharge him with review in clinic in approximately 2 weeks. Of course he should be warned to return as soon as possible if shortness of breath or pain worsens. Insert chest drain Insert chest drain is incorrect. In the event the pneumothorax was > 2 cm in size, chest drain insertion may be considered following a failed aspiration.
Question 19:
You are asked to review a 28-year-old man who is thought to originate from Afghanistan who has presented to an immigration centre claiming asylum. He has been diagnosed with HIV for which HAART has been commenced. There is a past history of tuberculosis as a child for which he was successfully treated with triple anti-bacterial therapy. Over the past few days he has developed a severe cough, productive of bloody sputum. On examination he is pyrexial 37.8 °C, his BP is 105/70 mmHg, and pulse is 80 bpm and regular. There are scattered coarse crackles on auscultation of the chest. Investigations: Hb 11.0 g/dl WCC 7.9 × 109/l PLT 194 × 109/l Na+ 137 mmol/l K+ 4.2 mmol/l Creatinine 115 μmol/l CXR Bilateral pleural effusions, widespread nodular consolidation Which of the following is the most likely diagnosis?
Options:
- Invasive aspergillosis
- Pneumocystis jirovecii
- Pseudomonal pneumonia
- Staphylococcal pneumonia
- Tuberculosis
Correct Answer: Tuberculosis
Explanation:
Correct Answer: E- Tuberculosis Explanation Tuberculosis Given this patient has a history of tuberculosis that was previously treated and a recent diagnosis of HIV, the most likely diagnosis is immune reconstitution syndrome that has led to reactivation of the latent tuberculosis infection. In a patient like this with a past history of infection, additional prophylaxis against tuberculosis can be considered at the same time as starting HAART. The chest X- ray appearance fits with disseminated pulmonary tuberculosis. Invasive aspergillosis Invasive aspergillosis is incorrect. Immunosuppressed individuals are at increased risk of developing invasive aspergillosis. However, untreated, this condition is rapidly fatal and thus the diagnosis is unlikely in the history described. Pneumocystis jirovecii Pneumocystis jirovecii is incorrect. Immunosuppressed individuals are at increased risk of developing Pneumocystis jirovecii infection. However, the history of a severe cough with bloody sputum is not classical and pleural effusions are also not usually found in this type of pneumonia. Pseudomonal pneumonia Pseudomonal pneumonia is incorrect. Immunosuppressed individuals are at increased risk of developing pseudomonal infection. However, one would expect a leukocytosis and, with the history of previous tuberculosis and the presence of nodular consolidation and pleural effusions, a diagnosis of tuberculosis is more likely. Staphylococcal pneumonia Staphylococcal pneumonia is incorrect. Immunosuppressed individuals are at increased risk of developing staphylococcal pneumonia. Classically this causes a cavitating pneumonia rather than nodular consolidation and, with the history of previous tuberculosis and the presence of nodular consolidation and pleural effusions, a diagnosis of tuberculosis is more likely.
Question 20:
A 65-year-old woman has been diagnosed with lung cancer. Which of the following statements is true?
Options:
- Hypercalcaemia associated with bone metastases is best treated with intravenous steroids
- Hypercalcaemia can occur without bone metastasis
- Hypertrophic pulmonary osteoarthropathy (HPOA) is commonly seen patients with small-cell carcinoma
- Inappropriate secretion of antidiuretic hormone (SIADH) is commonly seen in patients with squamous- cell carcinoma
- Paraneoplastic syndromes occur more commonly with squamous-cell carcinomas
Correct Answer: Hypercalcaemia can occur without bone metastasis
Explanation:
Correct Answer: B- Hypercalcaemia can occur without bone metastasis Explanation Hypercalcaemia can occur without bone metastasis Hypercalcaemia can occur as a paraneoplastic syndrome with squamous-cell carcinoma. This is caused by the production of a parathyroid hormone-related peptide by the tumour, which increases bone resorption, and renal tubular reabsorption of calcium. Hypercalcaemia associated with bone metastases is best treated with intravenous steroids Hypercalcaemia secondary to bone metastases is best treated with intravenous fluids and bisphosphonates. (Steroids are mainly used for treating hypercalcaemia associated with sarcoidosis). Hypertrophic pulmonary osteoarthropathy (HPOA) is commonly seen patients with small-cell carcinoma Hypertrophic pulmonary osteoarthropathy (HPOA) is characterised by a painful symmetrical arthropathy involving the wrist, ankle and knee joints. It is most commonly seen in patients with non- small cell cancer. Inappropriate secretion of antidiuretic hormone (SIADH) is commonly seen in patients with squamous-cell carcinoma SIADH is most common in patients with small-cell carcinoma. Paraneoplastic syndromes occur more commonly with squamous-cell carcinomas Paraneoplastic syndromes comprise a variety of non-metastatic, metabolic or neuromuscular manifestations of lung cancer. They are commonly associated with small-cell carcinoma, apart from hypercalcaemia which is seen in association with squamous cell cancer.
