MCQ Flashcards
A 32-year-old female presents to the emergency department with a 1-day history of increasing shortness of breath and wheeze. She is a known asthmatic. She denies any cough, sputum production or fever. On examination, there is marked accessory muscle use, she is struggling to complete sentences and there is diffuse wheeze on auscultation of the posterior chest wall. Nebulised salbutamol has been administered and she is starting to respond but remains wheezy. What is the next most appropriate step in the management of this patient?
IV aminophylline
IV salbutamol
IV co-amoxiclav
IV hydrocortisone
IV magnesium sulphate
Answer: D – IV hydrocortisone
Rationale:
This is an acute exacerbation of asthma, based on the symptoms and signs.
The inability to complete sentences indicates a severe attack, and there is some evidence that she is responding to treatment. There are no suggestions of a life threatening asthma attack e.g. silent chest, abnormal ABG (e.g. rising CO2 or normal CO2 when low would be expected, bradycardia, hypotension, cyanosis).
It’s usual to follow a treatment algorithm for an acute asthma exacerbation. Some of the agents mentioned here e.g. aminophylline, magnesium sulphate, IV salbutamol can be used but usually in more severe cases or if initial management steps have failed
A 65-year-old man attends the respiratory outpatient clinic. He describes worsening breathlessness on exertion over the last year, and a dry cough. On examination, there is no evidence of finger clubbing, and there are fine crackles in the upper zones bilaterally. His chest X-ray reveals bilateral upper lobe scarring and spirometry demonstrates a restrictive pattern. What is the most likely underlying diagnosis for of his chronic shortness of breath?
Asbestosis
Cryptogenic fibrosing alveolitis
Coal workers pneumoconiosis
Amiodarone pulmonary toxicity
Systemic sclerosis
Answer: C – coal workers’ pneumoconiosis
The symptoms and test results are suspicious for a diagnosis of interstitial lung disease – progressively worsening dyspnoea, dry cough. Clubbing is not present – this can be seen in ILD, commonly in IPF. Upper lobe crackles and upper lobe scarring and restrictive defect on PFT also support this diagnosis
Of the 5 options, CWP is most likely to affect the upper lobes, the others are all usually associated with lower zone fibrosis.
A 68 year old woman is referred to the respiratory outpatient clinic. She reports a progressively worsening cough which is productive of whitish sputum daily, and dyspnoea on exertion. She has been treated for three chest infections by her GP in the last 18 months. Examination shows tar staining on her fingers, increased AP diameter and a prolonged expiratory phase and wheeze with scattered crepitations on auscultation. What investigation should be performed to confirm the most likely diagnosis?
Spirometry
Chest X-ray
Sputum culture
CT thorax
Echocardiogram
Answer: A – Spirometry
This patient has multiple symptoms and signs that point to COPD – dyspnoea, wheeze, sputum, infections are very common symptoms. Tar staining suggests the underlying aetiology (smoking) and there are signs of air trapping (↑ AP diameter and PEP) mucous hypersecretion (crepitations) and airflow obstruction (wheeze)
Spirometry will be most likely to confirm the diagnosis – obstructive defect (FEV1/FVC <0.7, reduced FEV1
A 35-year-old woman is brought into the emergency department with dyspnoea, dizziness and confusion. She is one week post-partum with no other background history. Her blood pressure is 70/30 mmHg and her heart rate is 130 beats per minute. A bedside echocardiogram demonstrates right ventricular dilation with a clot seen in the right ventricle. A clot is also seen in the common femoral vein on ultrasound. What is the most important step in her immediate management?
Thrombolysis
Anticoagulation
Fluids
Inotropes
Diuretics
Answer: A – Thrombolysis
Although the patient does not have a confirmed PE, this history is highly suggestive of this – dyspnoea risk factor of recent pregnancy and delivery, evidence of DVT. The key issue here is that this patient is unstable, with evidence of right ventricular strain and haemodynamic instability (tachy, hypotension. For this reason, thrombolysis is the most appropriate management.
A 53-year-old man presents to the emergency department. He has a 3-week history of a cough productive of green sputum with occasional bloodstaining, chills and sweats. His GP prescribed two courses of oral antibiotics with no improvement. On review he is cachectic, pale and clammy. Chest X-ray shows loss of the right costophrenic angle and a positive meniscus sign. Sputum culture is positive for Staph aureus. Pleural fluid is aspirated. Initial results showed a pH of 6.5, and gram positive cocci were seen on initial microscopy. What is the most likely diagnosis?
Aspiration pneumonia
Lung abscess
Mesothelioma
Empyema
Bronchial carcinoma
Answer: D – Empyema
This patient has a history in keeping with pulmonary infection, not responding to treatment.
His X-ray findings suggest a pleural effusion, and the results of this are unlikely to be anything else other than empyema, in light of the low pH (<7.2) and supported by the presence of organisms in the fluid.
A 55 year old woman presents to the emergency department. She has a known diagnosis of longstanding COPD and reports a 3 day history of fevers, worsened cough with greenish sputum and dyspnoea. On review she appears a little drowsy but is rousable and able to give a history. ABG shows pH 7.21 (7.35-7.45), pO2 7.2 (10-14) pCO2 8.5 (4.5-6.0) and HCO3 29 (22-26). What is the most appropriate management of this patient?
100% oxygen via non-rebreather
High flow oxygen
2L oxygen via nasal cannulae
Intubation and ventilation
Non-invasive ventilation
Answer: E – non invasive ventilation
This patient has COPD, a presenation with infective exacerbation and type 2 respiratory failure (acidosis, hypercapnoea, hypoxia)
The treatment for this, given the presentation is NIV – specifically this would be bilevel positive pressure ventilation, or BiPAP – provides positive air pressure when breathing in and breathing, usually higher during inspiration (IPAP) to lower CO2 (increased ventilation and tidal volume), and maintaining patency of the airways during expiration (EPAP) to increase oxygen levels.
