Respiratory 123doc

8/11/2019 Respiratory 123doc

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Respiratory 123

A 40-year-old man is undergoing investigation for acromegaly. MRI of thepituitary fossa is normal, but a routine chest X-ray reveals a large centrally basedmass. he patient is a non-smo!er. he most li!ely type of lung tumour is"

Options

A.#$uamous cell

B.#mall cell

C.%arcinoid

D.&arge cell

E.Adenocarcinoma

Teaching Notes for Question 1Theme: Lung Tumours

A central based mass in a non-smo!er sho'ing clinical evidence of neuroendocrine cell origin is consistent'ith a carcinoid. It represents the 'ell differentiated spectrum of small cell lung cancer and surgery in non-metastatic disease confers (0) survival at * years.

Question 2

A patient is diagnosed 'ith primary adenocarcinoma of the left upper lobe of the lung. he + is ./ 10)predicted2 and the staging % scan sho's only ipsilateral hilar lymphadenopathy. he ne3t step for thepatient is"

Options

A.%hemotherapy

B.Radiotherapy and chemotherapy

C.&obectomy

D.Mediastinoscopy and lobectomy

E.est supportive care

Teaching Notes for Question 2Theme: Lung Tumours

he best chance of cure for someone 'ith primary non-small cell lung cancer is surgery. % is not al'aysable to e3clude mediastinal node involvement and mediastinoscopy is al'ays re$uired before surgery.

Question 3

A 5/-year-old builder is admitted 'ith sudden onset high fever, left-sidedpleuritic chest pain and confusion. his presentation is most suggestive ofpneumonia caused by"

Options

A.6aemophilus influen7ae

B.Mycoplasma pneumoniae

C.#treptococcus pneumoniae

D.Influen7a type A

E.&egionella pneumophila


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Teaching Notes for Question 3Theme: Communit Ac!uire" #neumonia

#treptococcus pneumoniae typically presents 'ith acute onset, high fever and pleuritic chest pain. lderlyand patients 'ith co-morbidity are at increased ris!. +emale se3, diabetes mellitus, %89: and alcoholism are

associated 'ith bacteraemia

Question $

A 54-year-old man is referred for investigation of the cause of chronic sputumproduction and haemoptysis. 6e is a non-smo!er. he most appropriate ne3tinvestigation is"

Options

A.Ig; subclass measurement

B.lectron microscopy M2 of a nasal biopsy

C.#'eat test

D.Aspergillus Ig; and Ig levels

E.6igh resolution computer tomography 6R%2 of the lungs

Teaching Notes for Question $Theme: Chronic %uppurati&e Lung Disease

%hronic production of sputum and haemoptysis is very consistent 'ith underlying bronchiectasis. 6R% isdiagnostic of the disease. 8nce the diagnosis is established the cause must be found.

Question '

A *5-year-old man 'ith history of smo!ing presents 'ith breathlessness.#pirometry sho's an obstructive pattern. he most appropriate first line oftreatment is"

Options

A.Inhaled steroid

B.6igh dose inhaled steroid to prevent disease progression

C.#albutamol

D.Ipratropium bromide

E.#almeterol

Teaching Notes for Question 'Theme: Chronic O(structi&e Air)as Disease

Anticholinergics are more effective than b5 agonists in %89: and are thus thetreatment of choice during the initiation of therapy. #teroids do not alter theprogression of the disease unli!e asthma2 and are reserved for patients 'hodemonstrate steroid responsiveness or very severe disease.

Question *


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A.8bstructive spirometry 'ith lo' >%8 and MM genotype

B.8bstructive spirometry, mar!edly decreased >%8 and basal emphysema

C.8bstructive spirometry, mar!edly decreased >%8 and upper lobe emphysema

D.8bstructive spirometry, normal >%8 and basal emphysema

E.&o' >%8 and normal residual volume

Teaching Notes for Question *Theme: Chronic O(structi&e Air)as Disease

Although %89: due to alpha- antitrypsin can present in any of the described 'ays the classic presentationis of predominantly basal emphysema and is pan-acinar obstructive spirometry and lo' >%82. he 9i??genotype leads to the 'orst form of the disease.

Question +

he most important investigation to confirm the adult respiratory distress

syndrome in an adult 'ith refractory hypo3aemia is"

Options

A.%hest X-ray

B.chocardiogram

C.% thora3

D.9ulmonary artery catheter 'ith 'edge pressure measurement

E.roncho-alveolar lavage

Teaching Notes for Question +Theme: A"u,t -espirator Distress %n"rome

he radiological investigations mimic heart failure in the adult respiratory distress syndrome AR:#2 and it isimportant to confirm that the pulmonary capillary 'edge pressure 9%


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Question /

A 4-year-old man is rescued from a burning building and brought to hospital. 6e has nausea, vomiting,diarrhoea and abdominal pain. 6e is confused. he carbo3y-haemoglobin %86b2 level is 5*).


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C.%admium

D.#ilica

E.eryllium

Teaching Notes for Question 11

Theme: ranu,omatous Lung Disease

#ilica is to3ic to macrophages and impairs their function. hus there is an increased ris! of Mycobacteriumtuberculosis in slate 'or!ers, stone masons, fettlers and miners drilling through $uart7 strata2.

Question 12

A 40-year-old 'indo' cleaner 'ants to $uit smo!ing. 6e is on aspirin, a steroidinhaler and phenytoin. he best treatment for this man is"

Options

A.%ounselling

B.upropion ?ybanD2

C.Eicotine patches

D.%ounselling and nicotine patches

E.+luo3etine

Teaching Notes for Question 12Theme: Therapeutics an" the Lung

upropion ?ybanD2 is far more effective than nicotine patches in smo!ing cessation. 6o'ever it is contra-indicated in patients 'ith eating disorder and those 'ith a history of sei7ures. here is no advantage incombining nicotine patches 'ith bupropion.

Question 13

A */-year-old, obese, heavy smo!er presents 'ith impotence, nocturia anddepression. 6e is hypo3ic at rest on air and has an!le oedema. he mostappropriate investigation to determine the aetiology is"

Options

A.Arterial blood gas

B.%hest X-ray

C.entilation-perfusion scan

D.hyroid function test

E.#leep study

Teaching Notes for Question 13Theme: -espirator ai,ure

%or pulmonale secondary to diurnal respiratory failure occurs in patients 'ith severe obstructive sleep apnoea8#A2. Most patients 'ho develop this complication have lo'er air'ay obstruction from smo!ing2, grossobesity or respiratory muscle 'ea!ness. 6ypercapnia out of proportion to the degree of lung disease shouldsuggest 8#A as a possible diagnosis.

Question 1$

A 4*-year-old 'oman is breathless. he &%8 is very lo' but the >%8 is (0) predicted. he most li!ely


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diagnosis is"

Options

A.Eeuromuscular chest 'all disorder

B.9rimary pulmonary hypertension 9962

C.A patient 'ith the ?? genotype for alpha- antitrypsin

D.#cleroderma

E.6ereditary haemorrhagic telangiectasia

Teaching Notes for Question 1$Theme: #hsio,og

9atients 'ith e3tra-pulmonary restriction e.g. neuromuscular chest 'all disorders2 the lungs cannot fullyinflate. hus the surface area available for gaseous e3change is decreased lo' &%82. 6o'ever, the cardiacoutput is unchanged so that a higher density of blood per unit volume is obtained resulting in a raised >%8.

Question 1'

A /-year-old 6I-positive man presents 'ith life threatening haemoptysis.


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Question 2

A 4-year-old 'oman presents 'ith a prolonged history of epista3is and rapidly progressive, shortness ofbreath. he >%8 and eosinophil count are raised. he most li!ely diagnosis is"

Options

A.;oodpasture@s syndrome

B.Microscopic polyangiitis

C.%hurg-#trauss syndrome

D.


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Multi-drug resistant M:R2- is of concern in anyone 'ho is from a part of the 'orld 'here M:R- isprevalent and also in those 'ho have had previous partially treated disease. hus a 4 drug regime untilsensitivity is available is usual practice.

Question '

A F-year-old hairdresser 'ho has been 6I-positive for 0 years presents 'ithprogressive shortness of breath on e3ercise. he chest X-ray is normal e3cept forprominent pulmonary arteries. 9ulse o3imetry sho's he desaturates on e3ercise.he most li!ely diagnosis is"

Options

A.9neumocystis carinii pneumonia

B.9rimary pulmonary hypertension

C.Intracardiac shunt across an atrial septal defect

D.9ulmonary embolic disease

E.Anaemia

Teaching Notes for Question 'Theme: Circu,ation of the Lung

nlarged pulmonary central vasculature but other'ise normal chest X-ray suggests pulmonary arterialhypertension, a primary form of 'hich is associated 'ith chronic 6I infection. 9ulmonary arterialhypertension should be suggested by enlargement of the central elastic arteries and pruning of the peripheralarteries. he pulmonary artery systemic pressure is usually .0mm6g. 9ulmonary oligaemia the pulmonarytrun! is small or inapparent 'ith small peripheral vessels2 usually indicates right ventricular outflo'obstruction 'ith a right to left shunt. Bneven vascularity on the %XR is e3pected 'ith embolic disease.

Question *

An airline pilot presents 'ith cough, 'hee7e and bloody sputum. he %XR sho's upper lobe infiltrates andthe eosinophil count is .5. he most important diagnostic step is"

Options

A.#putum for acid-fast-bacilli

B.#tool for ova, cysts and parasites

C.Aspergillus Ig and Ig;

D.ronchoscopy

E.6I testing

Teaching Notes for Question *Theme: Eosinophi,ia an" the Lung

A9A is associated 'ith eosinophilia, high aspergillus Ig leads to positive s!in pric! tests2, fre$uentlypositive aspergillus Ig; precipitins2 and eosinophilic consolidation of the lung that is characteristically flittingin nature. Asthma and pro3imal bronchiectasis are clinical complications.

Question +

A 54-year-old patient presents 'ith cough, 'hee7e and lo'-grade fever. heeosinophil count is raised.


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C.ropical pulmonary eosinophilia

D.%hurg-#trauss syndrome

E.Allergic bronchopulmonary mycosis

Teaching Notes for Question +

Theme: Eosinophi,ia an" the Lung

3trinsic Gallergic@ alveolitis is not associated 'ith 'hee7ing but 'ith fever, coughing and dyspnoea. Inaddition, eosinophilia is not a feature. All the rest cause eosinophilia.

Question

A 4-year-old man presents un'ell. 6e is noted to have a microcytic anaemiaand pulse o3imetry sho's saturations of /() on air. 4/h later he suffers a denseleft hemiplegia. here is a strong family history of stro!e and several othermembers of his immediate family have been anaemic. he most li!ely diagnosisis"

OptionsA.6ereditary haemorrhagic telangiectasia

B.asculitis

C.9ulmonary arterio-venous malformation

D.9atent foramen ovale

E.entricular septal defect

Teaching Notes for Question Theme: Circu,ation of the Lung

6ypo3ia and a history of stro!e should suggest a right to left shunt. he history of anaemia and family history'ould be consistent 'ith hereditary haemorrhagic telangiectasia 662 as they bleed from both cerebral and

gut arterio-venous malformations.

Question /

&ong term o3ygen therapy for an e3-smo!er 'ith ype II respiratory failure 'ould best"

Options

A.Improve lung function of the patient

B.Improve the $uality of life of the patient

C.9rolong survival of the patient

D.6ave no effect on the patient@s haemoglobin level

E.6ave the most benefit if used for episodes of shortness of breath only

Teaching Notes for Question /Theme: -espirator ai,ure

&ong term o3ygen therapy &82 in %89: leads to"H Improved survivalH Improved polycythaemiaH #lo'ing of any further increases in pulmonary artery pressureH Eo improvement in lung function occursH uality of life remains unchangedhe benefit of &8 is proportional to the number of hours per day the o3ygen is 'orn by the patient.

Question 10


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he most important finding to confirm the diagnosis of asthma is"

Options

A.6igh total blood Ig level

B.:emonstration of air'ay reversibility

C.6igh levels of interleu!in-* and granulocyte macrophage colony stimulatingfactor ;M-%#+2 in blood

D.+amily history of asthma

E.A high &%8 and >%8

Teaching Notes for Question 10Theme: Asthma

Asthma by definition must demonstrate variability in airflo' limitation. he other investigations 'ouldsuggest asthma but can also occur 'ith other respiratory diseases.

Question 11


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mouth and dry eyes is a classic symptom of this condition, and patients are AEA positive 'ith a nucleolarpattern.

Question 13

A *0-year-old patient 'ith asthma is prescribed a leu!otriene inhibitor. 6e presents 'ith severe abdominalpain and a pleural effusion. he most li!ely cause of the effusion is"

Options

A.%arcinoma

B.9ancreatitis

C.9neumonia

D.6eart failure

E.%hurg-#trauss syndrome

Teaching Notes for Question 13Theme: %stemic Disease an" the Lung

%hurg-#trauss syndrome has a predilection for serosal surfaces and therefore can cause both pleural andpericardial effusions and peritonitis. %ytological analysis of this fluid 'ould confirm an eosinophilia.&eu!otriene inhibitor use is associated 'ith an increased incidence of the disease.

Question 1$

A patient 'ith pneumocystis carinii pneumonia 9%92 has the follo'ing bloodgases" 9a85 1.(!9a and 9a%85 .*!9a. he most important prognostic step is"

Options

A.Easal ventilation

B.9hysiotherapy

C.Intravenous steroids

D.Brgent commencement of retroviral therapy

E.%ontrolled o3ygen therapy

Teaching Notes for Question 1$Theme: 45 an" the Lung

In pneumocystis carinii pneumonia, steroids decrease the ris! of respiratory failure by *0), and the ris! ofdeath by ). #teroids are indicated if the arterial o3ygen tension is less than or e$ual to (.!9a on air.

Question 1'

A 4-year-old plumber has Just started treatment for a community ac$uired pneumonia but is noticed to havedeveloped anaemia 'ith a fall in haemoglobin of gLdl over F days. he M% is 05fl. he most usefulinvestigation is"

Options

A.Mycoplasma serology

B.Reticulocyte count

C.6aematinic measurements


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D.&iver function tests

E.ndoscopy

Cardiology

Question 1

he follo'ing drugs are matched correctly 'ith their action"

Options

A.:igo3in stimulates EaL> A9ase

B.#imvastatin inhibits 6M;%oA reductase

C.#otalol has class I and class III properties

D.Amiodarone shortens the action potential

E.#trepto!inase increases fibrinogen levels

Teaching Notes for Question 1Theme: Car"io&ascu,ar #harmaco,og

#otalol has class II b-bloc!er2 and class III Amiodarone2 li!e actions. Amiodarone prolongs the actionpotential and the interval. oth #otalol and Amiodarone carry the ris! of precipitating ventriculararrhythmias. After thrombolysis, fibrinogen levels are lo', due to consumption during thrombosis.

Question 2

A 41-year-old man 'ith a history of high alcohol inta!e presents 'ithbreathlessness and peripheral oedema.


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Options

A.Right bundle branch bloc! R2

B.&eft bundle branch bloc! &2

C.Right atrial pacing

D.Mild aortic stenosis

E.entricular septal defect

Teaching Notes for Question 3Theme: 75#8 #u,se8 an" eart %oun"s

#5 is reversed split if at rest 95 occurs before A5. hen 'ith inspiration, as 95 is delayed, the gap bet'eenthe t'o components of #5 gets smaller. his may occur 'ith delay in A5, as 'ith severe aortic stenosis notmild2, left bundle branch bloc! and right ventricular pacing.

Question $

A F5-year-old 'oman is admitted to hospital 'ith sudden onset right arm and leg 'ea!ness. #he 'aspreviously 'ell and independent ta!ing only bendroflua7ide for hypertension diagnosed 5 years previously.3amination reveals a right hemiparesis 'ith bris! refle3es and an e3tensor plantar on the right. #he has asoft mid systolic clic! on auscultation of her chest. here are * splinter haemorrhages on her left hand, andshe has a cold 'hite left middle finger. %XR sho's cardiomegaly and is suggestive of left atrial enlargement.Bs, +% and clotting are normal but the #R is F0mmLhr. An urgent %68 reveals a mass in the leftatrium.


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9ravastatin does not interact 'ith 'arfarin, 'hereas simvastatin can theoretically raise the IER slightly byinhibiting the metabolism of 'arfarin. %imetidine, being a 94*0 en7yme inhibitor potentiates 'arfarin greatly.9henytoin, rifampicin and carbama7epine are en7yme inducers and so reduce the effects of 'arfarin.

Question *

%oarctation of the aorta"

Options

A.Is more common in 'omen

B.Is associated 'ith rib notching all 5 ribs on the left

C.Is commonly associated 'ith pulmonary stenosis

D.Rarely causes problems in paediatric life

E.Is associated 'ith berry aneurysms

Teaching Notes for Question *Theme: B,oo" 5esse, Disease

%oarctation can cause heart failure in the neonate and hypertension in the adult. It is associated 'ith urner@ssyndrome, neurofibromatosis, bicuspid aortic valve, and more 'ea!ly 'ith #: and A#:. #tro!e may resultfrom hypertension or from associated berry aneurysms. As 'ith all left heart obstructions, it is more commonin males. Eotching of ribs C/ is seen. Eotching or ribs and 5 suggests inferior vena cava obstruction, alaloc! shunt or hypertrophied nerves.

Question +

A 5-year-old man is noted to have a systolic murmur at an insurance medical. lood pressure is normal. An

echocardiogram sho's a bicuspid aortic valve.


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B.#he should be advised to see! antibiotic prophyla3is for dental procedures

C.he murmur is produced by associated pulmonary stenosis

D.#he has a lo' ris! of developing pulmonary hypertension no' she is an adult

E.R 'ith a normal a3is is the usual %; finding

Teaching Notes for Question Theme: Congenita, eart Disease

A#:s are the second commonest congenital heart disease seen in adults. hey are not benign, 'ith *0)death rate at age *0. %omplications rarely occur in childhood, but prolonged shunting leads to pulmonaryhypertension, atrial arrhythmias, but not the ris! of endocarditis. A 9rimum defect causes R and &A:,'hilst #ecundum causes R and RA: on the %;. he only murmur heard is a pulmonary flo' murmur,'hich is not as pronounced as the murmur of pulmonary stenosis. #ecundum A#: is associated 'ith 6olt-8ram syndrome, 'ith tri-phalangeal thumb and radial abnormalities.

Question /

he follo'ing are of aetiological significance in defining the cause of a cardiomyopathy"

Options

A.-'ave flattening in the inferior %; leads in a 10-year-old man

B.he presence of a soft pan-systolic murmur in the mitral area

C.A# of *0IBLl 'ith a bilirubin of 5mmolLl in a *0-year-old lady

D.he presence of sinus tachycardia, 'ith 9 40L/0

E.he presence of diabetes mellitus in a tanned patient

Teaching Notes for Question /Theme: 6ocar"ia, Disease

he commonest form of cardiomyopathy is dilated cardiomyopathy, 'ith dilatation of the left ventricle, andreduction in the eJection fraction. Eo cause is often found, although rarely, it can be familial. A cause shouldbe loo!ed for in most cases. he commonest causes are ischaemic heart disease -'aves on the %;,history of MI2, and hypertension. Eon-specific %; changes and atrial fibrillation are common and do notpoint to a specific cause. Minor abnormalities of liver function result from liver congestion. More mar!edabnormalities and diabetes in a pigmented patient 'ould suggest haemochromatosis. Mitral regurgitation andarrhythmias are common in dilated cardiomyopathy of any cause.

Question 10

Aortic regurgitation may be found in all the follo'ing e3cept"

Options

A.icuspid aortic valve

B.9rimary syphilis

C.An!ylosing spondylitis

D.%oarctation of the aorta

E.


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aortitis2. Acute syphilis does not cause an aortitis and is not associated 'ith AR.

Question 11

In hyperlipidaemia"

Options

A.riglycerides ;2 .mmolLl give a ris! of pancreatitis

B.9olygenic disorders are more common than monogenic

C.#tatins are the agent of choice in secondary hyperlipidaemia

D.&ipoprotein lipase &9&2 deficiency elevated &:& more than ;

E.he liver function tests need to be measured monthly on statin therapy


Theme: Other Car"io,og

A triglyceride level .*mmolLl increases the ris! of pancreatitis. &o'er levels probably increase coronary ris!in association 'ith lo' 6:& levels. #econdary hyperlipidaemias need treatment of their cause e.g. nephroticsyndrome2 as 'ell as treatment of the lipid abnormality. or &+@s are notcalled for. &9& deficiency is a cause of elevated triglycerides more than of cholesterol, but polygenic disordersare much more common than monogenic ones.

Question 12

In patients 'ith ischaemic heart disease I6:2 all the follo'ing are true e3cept"

Options

A.A fall in blood pressure on e3ercise testing suggests severe coronary disease

B.he only finding on e3amination may be a fourth heart sound during an acuteattac!

C.:yspnoea after an attac! of angina is the hallmar! of poor left ventricular &2function

D.Angiotensin converting en7yme inhibitor A%-I2 therapy reduces myocardialinfarction rates

E.A positive troponin- 'ithout creatinine !inase %>2 rise diagnoses non-'ave myocardial infarction


Theme: E&i"ence Base" Car"io,og

Ischaemic heart disease is often manifesting only 'ith the symptoms of angina. 3amination may findpredisposing factors e.g. hypertension2, or complications e.g. heart failure2, but in the absence of these, afourth heart sound during an attac! of angina may be the only finding. ven before systolic & dysfunctionoccurs, cardiac ischaemia produces diastolic dysfunction, causing impaired rela3ation and a stiff ventricle,creating the conditions for an #4 'ith atrial systole. he myocardium can become Gstunned@ 'ith ischaemia,so causing temporary & systolic impairment and dyspnoea despite good resting & function. he use of A%-I is associated 'ith reduced future MI rates as sho'n in the 689 trial. he definition of non- 'avemyocardial infarction has e3panded to include those patients 'ith unstable angina 'ho have had a rise introponin- only. heir prognosis is as bad 'hether or not %> is also elevated.

Question 13

A 10-year-old diabetic man undergoes an elective coronary angioplasty to relieve a 10) stenosis in his right


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coronary artery. A mm by *mm stent is inserted to produce an optimal angiographic result.


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#:s are the commonest adult congenital heart disease. hey may close spontaneously, and if small causeloud systolic murmurs. his murmur disappears 'ith the onset of isenmenger@s syndrome as pressurese$ualise.

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Respiratory 123doc