Full Question & Answer Text (for Search Engines)
Question 1:
A 19-year-old man is reviewed a few days after admission for a spontaneous, primary pneumothorax. He is a non-smoker who plays the trumpet for a local orchestra. He was treated with a chest drain and achieved full inflation of the lung. Which of the following should he strictly avoid for at least the next 6 months?
Options:
- Contact sports
- Flying in an aaeroplane
- Long-distance running
- Playing the trumpet
- Scuba diving
Correct Answer: Scuba diving
Explanation:
Correct Answer: E- Scuba diving Explanation Scuba diving Scuba diving is not recommended after spontaneous pneumothorax. Advice suggests that, in those who do not dive professionally, who have not undergone a definitive procedure (i.e. bilateral pleurodesis), it should be avoided permanently if possible. Contact sports Contact sports is incorrect. In the absence of a rib fracture, contact sports could re-commence after 2 months. Flying in an aaeroplane Flying in an aeroplane is incorrect. Air travel is not recommended for 1 week after full resolution of a pneumothorax. Long-distance running Long-distance running is incorrect. In the absence of a rib fracture, running could re-commence after 2 months. Playing the trumpet Playing the trumpet is incorrect. Opinions suggest that playing brass instruments can re-start approximately 2 months after the pneumothorax.
Question 2:
A 43-year-old woman is referred by her general practitioner with a productive cough and inspiratory crackles at the left base. Which one of the following is considered to be a core adverse prognostic factor under the CURB-65 criteria?
Options:
- Bilateral changes on chest X-ray
- Blood pressure 98/65 mmHg
- Oxygen saturation 92% on room air
- Respiratory rate of 28/min
- Serum urea 7.1 mmol/l
Correct Answer: Serum urea 7.1 mmol/l
Explanation:
Correct Answer: E- Serum urea 7.1 mmol/l Explanation Serum urea 7.1 mmol/l A urea >7 mmol/l is associated with an adverse prognosis and is a component of the CURB-65 scoring system. Core clinical adverse prognostic factors are summarised using the abbreviation CURB-65:
• Confusion (new onset) with a mini-mental test score of less than 8 •
Urea > 7.0 mmol/l • Respiratory rate > 30/min • Blood pressure – systolic < 90 mmHg or diastolic < 60 mmHg • 65 or older (age) If any of these core clinical features is present the patient is at increased risk of death and should not be sent home (British Thoracic Society Guidelines, December 2001) Bilateral changes on chest X-ray Bilateral changes on chest X-ray is incorrect. Although multilobar involvement can signify an adverse prognosis in pneumonia, it does not feature as part of the CURB-65 scoring system. Blood pressure 98/65 mmHg Blood pressure 98/65 mmHg is incorrect. Although and blood pressure is used as part of CURB-65 scoring, the value mentioned would not signify an adverse prognosis. Oxygen saturation 92% on room air Oxygen saturation 92% on room air is incorrect.
Although hypoxia can both signify an adverse prognosis in pneumonia, it does not feature as part of the CURB-65 scoring system. Respiratory rate of 28/min Respiratory rate of 28/min is incorrect. Although respiratory rate is used as part of CURB-65 scoring, the value mentioned would not signify an adverse prognosis.
Question 3:
What is the most common cause of haemoptysis in UK patients?
Options:
- Bronchial carcinoma
- Goodpastures syndrome
- Infective exacerbation of COPD
- Pulmonary infarction
- Tuberculosis
Correct Answer: Infective exacerbation of COPD
Explanation:
Correct Answer: C- Infective exacerbation of COPD Explanation Infective exacerbation of COPD The most common cause of haemoptysis is acute infection, in exacerbation of COPD in particular. But other causes should be excluded while investigating. Bronchial carcinoma, pulmonary infarction and tuberculosis are common causes. Pulmonary haemosiderosis, Goodpasture’s syndrome, microscopic polyangiitis, and trauma are some of the rarer causes worth remembering. The Question: asks for the commonest cause of haemoptysis in the UK therefore infective exacerbation of COPD is the correct answer. Bronchial carcinoma Bronchial carcinoma is incorrect. This is not the “most” common cause of those given. Goodpasture’s syndrome Goodpasture’s syndrome is incorrect. This is not the “most” common cause of those given. Pulmonary infarction Pulmonary infarction is incorrect. This is not the “most” common cause of those given. Tuberculosis Tuberculosis is incorrect. This is not the “most” common cause of those given.
Question 4:
A 42-year-old patient was diagnosed with mediastinal tuberculosis 3 weeks ago and commenced on treatment. He presents with worsening breathlessness and stridor. His chest X-ray shows mediastinal lymph nodes that are compressing the carina; although he is distressed, he is alert and orientated and maintaining his oxygenation. You give him an injection of hydrocortisone. What is the next step in the investigation and/or management?
Options:
- Broad-spectrum antibiotics
- Ethambutol
- Heparin
- Tracheostomy
- Urgent computed tomography (CT) scan
Correct Answer: Urgent computed tomography (CT) scan
Explanation:
Correct Answer: E- Urgent computed tomography (CT) scan Explanation Urgent computed tomography (CT) scan The computed tomographic (CT) scan is the most appropriate investigation. On enhanced CT scans, nodes larger than 2 cm in diameter invariably show central areas of low attenuation and peripheral rim enhancement. Enhanced walls are usually irregular in thickness. CT scan is useful prior to commencing steroid therapy, first to confirm the degree of airway compression and second to assess the response to anti-tuberculous therapy. A number of commentators recommend rapid initiation of steroid therapy, and this would seem sensible prior to progression to CT scanning. Broad-spectrum antibiotics Broad-spectrum antibiotics is incorrect. This gentleman is already on antibiotic treatment for his tuberculosis and his current symptoms are a consequence of enlarged mediastinal nodes secondary to his tuberculosis. There is no need for additional antibiotics. Ethambutol Ethambutol is incorrect. As this gentleman started his antibiotic treatment for his tuberculosis 3 weeks ago he should already be taking ethambutol. Heparin Heparin is incorrect. Heparin would be an appropriate therapy for a pulmonary embolus. This gentleman’s dyspnoea has a clear explanation (extrinsic compression of carina) and so treatment for pulmonary embolus would be inappropriate. Tracheostomy Tracheostomy is incorrect. The gentleman is stated as being alert, orientated and maintaining his oxygenation, therefore there is time to proceed with further
investigation with CT scanning before deciding on definitive management.
Question 5:
Which of the following relates to an exacerbation of chronic bronchitis in patients with chronic obstructive pulmonary disease?
Options:
- An elevated white cell count indicates exacerbation
- Clinical symptoms are always severe
- Gram staining is inconclusive and blood cultures are necessary
- Moraxella catarrhalis is commonly a cause of COPD exacerbation
- Trimethoprim/sulfamethoxazole combinations are effective in the treatment of M. catarrhalis infection
Correct Answer: Moraxella catarrhalis is commonly a cause of COPD exacerbation
Explanation:
Correct Answer: D- Moraxella catarrhalis is commonly a cause of COPD exacerbation Explanation Moraxella catarrhalis is commonly a cause of COPD exacerbation Along with Haemophilus influenzae and Streptococcus pneumoniae, M. catarrhalis is a common cause of exacerbations of chronic bronchitis and pneumonia in patients with chronic obstructive pulmonary disease (COPD). Symptoms of moraxella infection tend to be mild to moderate in severity and it is quite common for the white cell count not to be raised. An elevated white cell count indicates exacerbation An elevated white cell count indicates exacerbation is incorrect. An elevated white cell count may be due to another cause, e.g. it may be secondary to oral steroid use. Additionally, white cell count may be normal in an exacerbation of COPD. Clinical symptoms are always severe Clinical symptoms are always severe is incorrect. Symptoms may be mild, moderate or severe. Gram staining is inconclusive and blood cultures are necessary Gram staining is inconclusive and blood cultures are necessary is incorrect. Blood cultures are not indicated unless the patient has a significant fever and/or is significantly unwell. Trimethoprim/sulfamethoxazole combinations are effective in the treatment of M. catarrhalis infection Trimethoprim/sulfamethoxazole combinations are effective in the treatment of M. catarrhalis infection is incorrect. Resistance to both trimethoprim/sulfamethoxazole combinations and tetracycline has been reported. The most appropriate choice would be a combination of ampicillin and clavulinic acid, which suppresses M. catarrhalis ß- lactamases.
Question 6:
A 41-year-old woman presents to the Emergency Department with sudden onset of pleuritic chest pain and breathlessness. A chest X-ray reveals a large right-sided pneumothorax. Pleural aspiration fails to result in adequate re-expansion of the lung and you therefore insert an intercostal tube connected to an underwater seal. After 24 hours of intercostal drainage the lung has not re- expanded despite the fact that the drain is still swinging with respiration. What would you do next?
Options:
- High-volume/low-pressure suction should be used
- Negative suction should be started at -1 to -2 cm H2O
- Refer for immediate surgical intervention
- Reposition the chest drain
- Wait another 24 hours
Correct Answer: Wait another 24 hours
Explanation:
Correct Answer: E- Wait another 24 hours Explanation Wait another 24 hours If pneumothorax fails to re-expand or if there is a persistent air leak (bubbling present) after 48 hours, then you should refer the patient to a respiratory specialist because negative suction might be required. The normal intrapleural pressure is -3.4 cm H2O during expiration, rising to -8 cm H2O during inspiration. High- volume/low-pressure suction should be considered if there is a persistent air leak and/or full lung re-expansion has not occurred approximately 48 hours following chest drain insertion. High-volume/low-pressure suction should be used High-volume/low-pressure suction should be used is incorrect. If high-volume/high-pressure suction is used, then high-airflow suction might be generated, which can lead to air stealing, hypoxaemia and/or the persistence of air leaks. Negative suction should be started at -1 to -2 cm H2O Negative suction should be started at -1 to -2 cm H2O is incorrect. Negative suction should be started at -10 to -20 cm H2O (-1 to -2 kPa = -7.5 to -15 mmHg) using a high- volume/low-pressure suction system. Refer for immediate surgical intervention Refer for immediate surgical intervention is incorrect. If appropriate suction fails to result in adequate re- expansion by 3–5 days then referral to a thoracic surgeon is indicated. Reposition the chest drain Reposition the chest drain is incorrect. The drain is still swinging with respiration, indicating it is still within the pleural cavity and therefore there is no need to reposition the drain at this stage.
Question 7:
A 62-year-old man who is a current smoker has been followed up for breathlessness with productive cough. Five years ago his FEV1/FVC was 80%, but this ratio is now only 50%. Which of the following treatments would have the biggest clinical impact?
Options:
- Inhaled anticholinergics
- Inhaled steroids
- Salbutamol
- Short course of prednisolone
- Smoking cessation
Correct Answer: Smoking cessation
Explanation:
Correct Answer: E- Smoking cessation Explanation Smoking cessation This man has severe chronic obstructive pulmonary disease (COPD) and has deteriorated significantly during the past 5 years. Currently the only interventions that have been proven to affect mortality are smoking cessation and long-term oxygen therapy (in patients who meet the prescription criteria). Inhaled anticholinergics Inhaled anticholinergics is incorrect. Inhaled long-acting anticholinergics and inhaled combination inhalers containing both a long-acting ß2-agonist and high-dose inhaled steroid have been shown to affect lung function positively. The TORCH study has also shown a positive effect on exacerbations with respect to the combination of LABA and inhaled corticosteroid. Inhaled steroids in isolation are not recommended to treat COPD. Inhaled steroids Inhaled steroids is incorrect. Inhaled long-acting anticholinergics and inhaled combination inhalers containing both a long-acting ß2-agonist and high-dose inhaled steroid have been shown to affect lung function positively. The TORCH study has also shown a positive effect on exacerbations with respect to the combination of LABA and inhaled corticosteroid. Inhaled steroids in isolation are not recommended to treat COPD. Salbutamol Salbutamol is incorrect. Salbutamol therapy may well help with symptomatic relief in COPD, but has no impact on survival. Short course of prednisolone Short course of prednisolone is incorrect. There is no evidence that this gentleman is experiencing an acute exacerbation of COPD that would benefit from oral steroids.
Question 8:
A 46-year-old man with a history of asthma, well controlled with regular low-dose Seretide, presents with a cough productive of purulent, blood-stained sputum. On examination his temperature is 38.6 °C, pulse is 90/min and regular; there is a cluster of cold sores on his upper lip. Auscultation reveals left-sided consolidation. Which of the following causes of lower respiratory tract infection is most likely to be associated with herpes labialis?
Options:
- Haemophilus influenzae
- Mycoplasma pneumoniae
- Staphylococcus aureus
- Streptococcus pneumoniae
- Streptococcus pyogenes
Correct Answer: Streptococcus pneumoniae
Explanation:
Correct Answer: D- Streptococcus pneumoniae Explanation Streptococcus pneumoniae Streptococcus pneumoniae is a common cause of community-acquired pneumonia and is characteristically associated with herpes labialis. In this case the majority of standard hospital protocols recommend dual therapy with a combination of co- amoxiclav and clarithromycin as the intervention of choice. Haemophilus influenzae Haemophilus influenzae is incorrect. Haemophilus influenzae is seen more frequently in patients with chronic obstructive pulmonary disease (COPD). Mycoplasma pneumoniae Mycoplasma pneumoniae is incorrect. Mycoplasma is a cause of atypical pneumonia. Staphylococcus aureus Staphylococcus aureus is incorrect. Staphylococcus aureus pneumonia is more likely to follow a viral respiratory tract infection such as influenza, and we are given no history of a prodromal viral illness here. Streptococcus pyogenes Streptococcus pyogenes is incorrect. Streptococcus pyogenes is most commonly associated with head and neck infections, eg pharyngitis, and skin and soft tissue infections, eg cellulitis.
Question 9:
A 49-year-old homosexual accountant came to the clinic with increased breathlessness. He had begun to become wheezy after a tooth extraction procedure 5 months ago and also had an associated troublesome cough. He used to smoke 15 cigarettes per day but gave up smoking about 2 months ago. Salbutamol and beclometasone inhalers only poorly controlled his symptoms. Recently he had been unwell: he had had a fever and had lost about 3.2 kg (7 lb.) in weight. There was no history of recent foreign travel and no significant past illness. On examination, he had a temperature of 37.2 °C and occasional rhonchi on both sides. Tests showed: haemoglobin 14.6 g/dl, white cell count 10.2 × 109/l (neutrophils 53%, lymphocytes 30%, raised esoinophils noted), ESR 110 mm in 1st hour; normal U&Es normal urine dipstick. A chest X-ray showed extensive symmetrical, homogenous shadowing affecting all the peripheral lung field. A skin test for inhaled antigens, including Aspergillus fumigatus, was negative. His serum IgE was normal. A serological screen for parasitic infection was negative. Pulmonary function was within normal limits. Oxygen saturations were 97% and there was no desaturation on exercise. What is the probable diagnosis?
Options:
- Asthma
- Cryptogenic pulmonary eosinophilia
- Granulomatosis with polyangiitis
- Loeffler syndrome
- Pneumocystis pneumonia
Correct Answer: Cryptogenic pulmonary eosinophilia
Explanation:
Correct Answer: B- Cryptogenic pulmonary eosinophilia Explanation Cryptogenic pulmonary eosinophilia This patient has eosinophilia and associated pulmonary signs, but no indications of drug involvement or malignancy. He has cryptogenic pulmonary eosinophilia. Systemic features can occur in this condition, including:
• malaise • weight loss • fever • raised ESR • asthma (in around 50%) The disease responds to steroid treatment, which needs to be continued for about 1 year. Asthma Asthma is incorrect. The lack of response to conventional therapies for asthma, normal total IgE, normal lung function together with the abnormal chest radiograph appearances make asthma unlikely. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Granulomatosis with polyangiitis is not associated with wheeze and eosinophila. Pulmonary involvement is seen on chest radiograph as nodules, often cavitating in nature. There is no indication of extrapulmonary involvement such as nasal disease or renal disease to suggest vasculitis. Loeffler syndrome Loeffler syndrome is incorrect. Loeffler syndrome (transient respiratory illness with blood eosinophilia and pulmonary infiltrates) is self-limiting and lasts less than 1 month. Pneumocystis pneumonia Pneumocystis pneumonia is incorrect. The diagnosis in this case has no relation to the patient’s sexual orientation and Pneumocystis jiroveci infection secondary to HIV is unlikely. Pneumocystis jiroveci pneumonia is associated with central pulmonary infiltrates not peripheral infiltrates and is not associated with eosinophilia.
Question 10:
You are asked to see a 32-year-old immigrant who complains of chronic cough and weight loss over the past few months. Examination of sputum reveals acid- and alcohol-fast bacilli (AAFB) and tuberculosis is confirmed. You elect to begin treatment with isoniazid, rifampicin, ethambutol and pyrazinamide as he is from an area where high levels of drug resistance are present. Which of the following blood tests is most desirable before starting therapy?
Options:
- Clotting screen
- Haemoglobin
- Liver function testing
- Platelet count
- Serum calcium
Correct Answer: Liver function testing
Explanation:
Correct Answer: C- Liver function testing Explanation Liver function testing This is a ‘know it or you don’t’ question. Both isoniazid and rifampicin can be associated with significant hepatic dysfunction. In particular, severe and sometimes fatal hepatitis has been seen with isoniazid. Particular problems occur in slow acetylators, who can have markedly elevated serum isoniazid levels. In patients with existing liver dysfunction, rifampicin and isoniazid should only be used in cases of absolute clinical necessity. Even then, dose reduction of rifampicin is recommended and initial weekly monitoring of liver function tests should be carried out. Clotting screen Clotting screen is incorrect. Clotting screen is not as important as liver function testing in this instance. Haemoglobin Haemoglobin is incorrect. Haemoglobin testing is not as important as liver function testing in this patient. Platelet count Platelet count is incorrect. Platelet count is not as important as liver function testing in this patient. Serum calcium Serum calcium is incorrect. Serum calcium is not as important as liver function testing in this patient.
Question 11:
A 35-year-old man presents with multiple small nodules on chest X-ray. Which of the following is the most likely diagnosis?
Options:
- Bronchopulmonary aspergillosis
- Granulomatosis with polyangiitis
- Metastasis of renal carcinoma
- Polyarteritis nodosa
- Sarcoidosis
Correct Answer: Sarcoidosis
Explanation:
Correct Answer: E- Sarcoidosis Explanation Sarcoidosis Sarcoidosis is graded on the appearance of bilateral hilar lymphadenopathy and/or pulmonary infiltrates, with the infiltrates referred to as ‘miliary reticulonodular’. There may be calcification of the hilar lymph nodes or lung parenchyma in chronic sarcoidosis. Bronchopulmonary aspergillosis Bronchopulmonary aspergillosis is incorrect. In bronchopulmonary aspergillosis, a cystic space containing a rounded opacity is seen on chest X-ray. An air space is seen between the fungus and the cavity wall (the ‘halo sign’) in aspergilloma. Granulomatosis with polyangitis Granulomatosis with polyangitis is incorrect. Granulomatosis with polyangitis might be seen as pulmonary infiltrates or multiple pulmonary nodules on chest X-ray, which tend to cavitate. Metastasis of renal carcinoma Metastasis of renal carcinoma is incorrect. Lung metastases from renal carcinoma are seen as solid masses; there may be several, but they are masses rather than nodules. Polyarteritis nodosa Polyarteritis nodosa is incorrect. Polyarteritis nodosua is a vasculitis affecting muscular arteries. It does not affect the lungs, although a related vasculitic disease, eosinophilic granulomatosis with polyangitis, does affect the lungs in the form of pulmonary infiltrates and asthma.
Question 12:
A 36-year-old lorry driver who smokes heavily presents with a 2-day history of cough associated with fever. He also complains of right-sided chest pain on inspiration. On examination he is slightly cyanosed. His temperature is 38°C, respiratory rate 38/min, BP 100/70 mmHg and pulse 130 bpm. He has basal crepitations and dullness to percussion at the right lung base. What is the most important next step in confirming the diagnosis?
Options:
- Blood cultures
- Chest X-ray
- d-Dimer
- ESR (erythrocyte sedimentation rate)
- Sputum sample
Correct Answer: Chest X-ray
Explanation:
Correct Answer: B- Chest X-ray Explanation Chest X-ray The classic presentation of pneumonia is with cough and fever, with or without sputum production, dyspnoea and pleurisy. Most patients have constitutional symptoms such as malaise, fatigue and asthenia, and many also have gastrointestinal symptoms. Examination of the lung might reveal decreased vesicular breath sounds, localised foci of crepitations, dullness to percussion and sometimes a bronchial wheeze. The chest X-ray is a pivotal test for the confirmation of pneumonia. Blood cultures Blood cultures is incorrect. Blood cultures will identify infection within the blood stream and may be suggestive of pneumonia if pneumococcus is cultured. However, blood cultures are not a diagnostic test for pneumonia. d-Dimer d- Dimer is incorrect. d-Dimer would be an inappropriate test here as the history is suggestive of pneumonia, not of pulmonary embolus.
ESR (erythrocyte sedimentation rate)
ESR (erythrocyte sedimentation rate) is incorrect. ESR is raised in a wide variety of inflammatory and infective conditions and is not a diagnostic test in itself. It is now rarely performed, other than when a diagnosis of temporal arteritis is suspected. Sputum sample Sputum sample is incorrect. A sputum sample will undoubtedly be helpful here but a sputum sample in isolation does not confirm a diagnosis of pneumonia, furthermore it may take several days before a result is available. Chest radiograph will give a more immediate result and reveal the diagnosis of pneumonia and is therefore the most appropriate answer here.
Question 13:
A 45-year-old man who races pigeons becomes breathless. Which of the following features is suggestive of extrinsic allergic alveolitis (EAA)?
Options:
- Almost immediate onset of symptoms after exposure
- Eosinophilia of sputum
- Circulating IgG precipitins
- Positive skinprick testing
- Type I hypersensitivity reaction
Correct Answer: Circulating IgG precipitins
Explanation:
Correct Answer: C- Circulating IgG precipitins Explanation Circulating IgG precipitins Circulating IgG precipitins are suggestive of EAA. Almost immediate onset of symptoms after exposure Almost immediate onset of symptoms after exposure is incorrect. EAA can be classified according to how acutely it presents. • In the acute form, fever, cough and marked shortness of breath occur 4–6 h after exposure • In the subacute form there is weight loss and fatigue • In the chronic form there is exertional shortness of breath and pulmonary fibrosis (typically upper lobe) The chest X-ray shows fine reticular or nodular shadowing, progressing eventually to a fibrotic pattern, with shrunken lungs. Eosinophilia of sputum Eosinophilia of sputum is incorrect. Despite its name, EAA is not allergic and therefore features associated with allergy and type I reactions do not tend to occur in EAA (ie wheeze, immediate symptoms, raised IgE, positive skinprick test, eosinophilia of blood or sputum). Positive skinprick testing Positive skinprick testing is incorrect. Despite its name, EAA is not allergic and therefore features associated with allergy and type I reactions do not tend to occur in EAA (ie wheeze, immediate symptoms, raised IgE, positive skinprick test, eosinophilia of blood or sputum). Type I hypersensitivity reaction Type I hypersensitivity reaction is incorrect. EAA is characterised by type III (immune-complex) and type IV (cell-mediated) hypersensitivity reactions to inhaled antigen(s).
Question 14:
A 28-year-old Afro-Caribbean nurse develops painful nodules on the shins of her legs. She has a low-grade fever and has lost 5 kg in weight over the past 2 months. Her chest X-ray shows bilateral hilar lymphadenopathy. The most likely outcome of this patient’s illness is?
Options:
- Complete initial remission but soon interrupted by increasingly frequent relapses
- Complete remission after appropriate course of steroid and cytotoxic drugs
- Complete remission without any specific treatment
- Diffuse reticulonodular changes in the lung and progressive shortness of breath
- Generalised lymphadenopathy and progressive wasting in 5–10 years
Correct Answer: Complete remission after appropriate course of steroid and cytotoxic drugs
Explanation:
Correct Answer: B- Complete remission without any specific treatment Explanation Complete remission without any specific treatment This lady has acute sarcoidosis. Spontaneous remission occurs in nearly two-thirds of patients with acute sarcoidosis. Complete initial remission but soon interrupted by increasingly frequent relapses Complete initial remission but soon interrupted by increasingly frequent relapses is incorrect. Stage 1 sarcoidosis (ie bilateral hilar lymphadenopathy on chest radiograph) is not usually associated with frequent relapses. At 5 years following initial diagnosis, 95% of patients previously diagnosed with stage 1 sarcoidosis will be asymptomatic. Complete remission after appropriate course of steroid and cytotoxic drugs Complete remission after appropriate course of steroid and cytotoxic drugs is incorrect. Spontaneous remission of acute sarcoidosis occurs in nearly two-thirds of patients. Diffuse reticulonodular changes in the lung and progressive shortness of breath Diffuse reticulonodular changes in the lung and progressive shortness of breath is incorrect. Acute sarcoidosis is characterised by erythema nodosum with X-ray findings of bilateral hilar adenopathy, often accompanied by joint symptoms, including arthritis at the ankles, knees, wrists or elbows. Diffuse reticulonodular changes in the lung and progressive shortness of breath would be expected in chronic sarcoidosis, which affects 10–30% of patients. Generalised lymphadenopathy and progressive wasting in 5–10 years Generalised lymphadenopathy and progressive wasting in 5–10 years is incorrect. These are not features of sarcoidosis.
Question 15:
A 38-year-old woman is brought to the Emergency Department by her husband as she has taken to her bed over the past 48 h with a worsening cough productive of purulent, blood-stained sputum, fevers and shortness of breath, such that she is unable even to walk a few paces. She has no past medical history of note and her only medication is the oral contraceptive pill. Apparently she has been suffering from influenza for a few days before she took to her bed. On examination she is pyrexial 38.9 °C, her BP is 95/50 mmHg and she is tachycardic with a pulse of 105 bpm. There are signs of bilateral lower lobe consolidation. Investigations: Hb 13.4 g/dl WCC 17.2 × 109/l PLT 203 × 109/l Na+ 136 mmol/l K+ 4.4 mmol/l Creatinine 110 μmol/l CXR Bilateral lower lobe consolidation with evidence of cavitation Which of the following is the most likely diagnosis?
Options:
- Haemophilus influenzae
- Klebsiella pneumoniae
- Mycoplasma pneumoniae
- Staphylococcus aureus
- Streptococcus pneumoniae
Correct Answer: Staphylococcus aureus
Explanation:
Correct Answer: D- Staphylococcus aureus Explanation Staphylococcus aureus Staphylococcus aureus leads to pneumonia with cavitation and is recognised to occur after initial influenza infection. In this case IV flucloxacillin would be an appropriate initial therapeutic option, with clarithromycin an alternative in patients who are penicillin allergic. There is increased risk of empyema formation after Staphylococcus aureus pneumonia, if it occurs then thoracic ultrasound with guided drainage may be required. Haemophilus influenzae Haemophilus influenzae is incorrect. The influenza mentioned in this case relates to the influenza virus, not the bacteria Haemophilus influenza. Haemophilus influenzae is a cause of community- acquired pneumonia, but it does not usually cause cavitation. The key clue to the infecting organism here is the history of influenza which is associated with Staphylococcus aureus pneumonia. Klebsiella pneumoniae Klebsiella pneumoniae is incorrect. Klebsiella pneumoniae can cause caviating pneumonia but usually affects the upper lobes and occurs in immunosuppressed individuals or, classically, alcoholics. Mycoplasma pneumoniae Mycoplasma pneumoniae is incorrect. Mycoplasma pneumoniae causes an atypical pneumonia, often with predominant symptoms being dry cough, headache and malaise. It does not cause cavitatory pneumonia. Streptococcus pneumoniae Streptococcus pneumoniae is incorrect. Streptococcus pneumonia is the most common cause of community- acquired pneumonia. It does not usually cause cavitation. It is not associated with preceding influenza infection. A history of a recent/current cold sore would be suggestive of S. pneumoniae pneumonia.
Question 16:
A 52-year-old woman with chronic obstructive pulmonary disease is assessed for long-term oxygen therapy (LTOT). She is found to be suitable for LTOT. What is the minimum number of hours per day that she should be using the oxygen?
Options:
Correct Answer: 15
Explanation:
Correct Answer: E-15 Explanation 15 In the early 1980s two large studies (MRC and NOTT) concluded that the minimum duration of long- term oxygen therapy (LTOT) should be 15 hours/day at a flow rate that keeps the arterial Po2 above 8.0 kPa (60 mmHg), and preferably up to 18 hours/day. At 3 years, survival was shown to be 50% better in the LTOT group compared with conventional treatment alone. Indications for LTOT:
Two arterial blood gas measurements should be made at least 3 weeks apart. Indications for LTOT in patients with chronic obstructive pulmonary disease are:
•
Pao2 on air < 7.3 kPa with a normal/elevated Paco2 and an FEV1< 1.5 l •
Pao2 7.3–8.0 kPa with evidence of cor pulmonale, peripheral oedema or nocturnal hypoxaemia 3 3 hours is incorrect. This does not reflect current recommendations. 55 hours is incorrect. This does not reflect current recommendations. 10hours is incorrect. This does not reflect current recommendations. 12 hours is incorrect. This does not reflect current recommendations.
Question 17:
Which one of the following statements about sarcoidosis is true?
Options:
- A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis
- Clubbing of the fingers is an early feature
- Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis
- Parenchymal lung disease is often accompanied by pleural effusion
- When hypercalcaemia manifests, it is usually resistant to steroid therapy
Correct Answer: A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis
Explanation:
Correct Answer: A- A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis Explanation A positive tuberculin test in a patient with chronic sarcoidosis is suggestive of active tuberculosis Sarcoidosis is a systemic disorder of unknown cause. Its pathological hallmark is the non-caseating granuloma, which primarily affects the respiratory tract, skin, eye, heart, kidneys and liver. A tuberculin test is usually negative in chronic sarcoidosis, but most patients with sarcoidosis who develop tuberculosis become tuberculin- positive. This is suggestive but not an absolute indicator of active infection. Clubbing of the fingers is an early feature Clubbing of the fingers is an early feature is incorrect. Clubbing of the fingers is not a recognised feature of sarcoidosis. Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis is incorrect. Although liver biopsy reveals granulomatous involvement in 40– 70% of patients, clinically significant hepatic disease is rare. Parenchymal lung disease is often accompanied by pleural effusion Parenchymal lung disease is often accompanied by pleural effusion is incorrect. Pleural disease is relatively infrequent, with effusions occurring in fewer than 5% of patients. When hypercalcaemia manifests, it is usually resistant to steroid therapy When hypercalcaemia manifests, it is usually resistant to steroid therapy is incorrect. Hypercalcaemia, a potentially important complication of sarcoidosis, occurs in fewer than 10% of patients and is thought to be owing to elevated levels of 1,25-dihydroxyvitamin D (calcitriol), which is produced by macrophages within the granulomas. High-dose glucocorticoids are very helpful in vitamin D intoxication, granulomatous diseases such as sarcoidosis, and haematological malignancies known to be or likely to be glucocorticoid- responsive.
Question 18:
A thin 24-year-old man complains of constant daytime sleepiness. He mentions involuntary naps, often in the middle of activity, which occur suddenly and without warning. He also caused an accident when he fell asleep while driving home from work. The patient works as an office manager and has no history of exposure to chemicals. Which of the following treatments would be indicated?
Options:
- Continuous positive airway pressure breathing device
- Diazepam
- Fluoxetine
- Modafinil
- Nortriptyline
Correct Answer: Modafinil
Explanation:
Correct Answer: D- Modafinil Explanation Modafinil This patient has narcolepsy, which is a sleep disorder that causes hypersomnia and which usually starts in adolescence or young adulthood. Treatment involves the use of central nervous system stimulants such as modafinil to allow daytime functioning. Continuous positive airway pressure breathing device Continuous positive airway pressure (CPAP) breathing device is incorrect. CPAP breathing devices are used in the treatment of sleep apnoea. A typical patient with sleep apnoea is usually older and obese and there will be a long history of gradually worsening snoring with apnoeas, possibly witnessed by a partner (who will probably have moved out of the bedroom because of the noise). There is usually a history of fairly high alcohol intake and smoking. Diazepam Diazepam is incorrect. Diazepam, a benzodiazepine has a sedative effect and would exacerbate this patient’s symptoms. Fluoxetine Fluoxetine is incorrect. The selective serotonin reuptake inhibiting antidepressant fluoxetine is a potential cause of sleep disturbance (typically insomnia). It is not used in the treatment of sleep disorders. Nortriptyline Nortriptyline is incorrect. Nortiptyline is a treatment for insomnia. This patient has hypersomnia due to narcolepsy.
Question 19:
A 64-year-old man is brought to the Emergency Department by his wife with drowsiness and confusion. He has a history of chronic obstructive pulmonary disease (COPD) and attends the Chest Clinic. He had been commenced on antibiotics by his GP 2 days earlier for an exacerbation of his COPD. Which of the following blood gases (on 2 l O2/min) fit best with this man’s condition?
Options:
- pH 7.14, Paco2 7.3 kPa, Pao2 9.1 kPa, bicarbonate 14 mmol/l
- pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/l
- pH 7.38, Paco2 5.3 kPa, Pao2 8.1 kPa, bicarbonate 30 mmol/l
- pH 7.38, Paco2 8.3 kPa, Pao2 8.1 kPa, bicarbonate 38 mmol/l
- pH 7.54, Paco2 3.3 kPa, Pao2 9.1 kPa, bicarbonate 24 mmol/l
Correct Answer: pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/l
Explanation:
Correct Answer: B- pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/ Explanation
pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/l This is a ‘know it or you don’t’ question. This patient has acute on chronic respiratory acidosis. In respiratory acidosis there will be raised PaCO2 and hydrogen ion concentration. The elevation of the bicarbonate reflects renal buffering from his chronic respiratory failure. In acute respiratory acidosis every 1-kPa rise in CO2 produces 6 nmol/l of hydrogen ion and a 1-mmol/l increase in bicarbonate. In contrast, in chronic respiratory acidosis, the increase in hydrogen ions per kPa rise in carbon dioxide falls to about 2.5 nmol/l.
pH 7.14, Paco2 7.3 kPa, Pao2 9.1 kPa, bicarbonate 14 mmol/l
pH 7.14, Paco2 7.3 kPa, Pao2 9.1 kPa, bicarbonate 14 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.
pH 7.38, Paco2 5.3 kPa, Pao2 8.1 kPa, bicarbonate 30 mmol/l
pH 7.38, Paco2 5.3 kPa, Pao2 8.1 kPa, bicarbonate 30 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.
pH 7.38, Paco2 8.3 kPa, Pao2 8.1 kPa, bicarbonate 38 mmol/l
pH 7.38, Paco2 8.3 kPa, Pao2 8.1 kPa, bicarbonate 38 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.
pH 7.54, Paco2 3.3 kPa, Pao2 9.1 kPa, bicarbonate 24 mmol/l
pH 7.54, Paco2 3.3 kPa, Pao2 9.1 kPa, bicarbonate 24 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.
Question 20:
A 64-year-old woman is referred to the medical team from the orthopaedic ward. She underwent a right total hip replacement 6 days ago. She is known to suffer from mild chronic obstructive pulmonary disease and is on regular inhaled steroids and a short-acting β2-agonist. She now complains of left-sided chest pain and is also dyspnoeic. Your clinical diagnosis is pulmonary embolism. Which one of the following would not be a feature of pulmonary embolism in this patient?
Options:
- Bradycardia
- Dyspnoea
- Fever
- New-onset atrial fibrillation
- Tachypnoea
Correct Answer: Bradycardia
Explanation:
Correct Answer: A- Bradycardia Explanation Bradycardia The clinical features of pulmonary embolism are:
• Dyspnoea • Tachypnoea (respiratory rate > 20/min) – the commonest feature, occurring in 85% of patients • Tachycardia – occurs in 30% of patients • Atrial flutter, atrial fibrillation and premature beats can also occur • Fever – a frequent finding, occurs in 34–50% of patients Dyspnoea Dyspnoea is incorrect. Dyspnoea is a feature of pulmonary embolism. Fever Fever is incorrect. Fever is a feature of pulmonary embolism. New-onset atrial fibrillation New-onset atrial fibrillation is incorrect. New-onset atrial fibrillation is a feature of pulmonary embolism. Tachypnoea Tachypnoea is incorrect. Tachypnoea is a feature of pulmonary embolism.
