Respiratory MCQs Flashcards
A 62 year old patient is referred to the ED by her GP for progressive SOB, recent haemoptysis and weight loss. Her past medical history is significant for COPD and Type 2 diabetes, which is well controlled on metformin. She takes no other medications, takes occasional alcohol with her friends and stopped smoking 10 years ago, though smoked 40 a day for most of her adult life.
What is the most useful initial Investigation? D-Dimers CT chest CXR Transthoracic echocardiogram Bronchoscopy
CXR - would detect suspicious soft-tissue densities, especially given she has a long smoking history + sinister features (weight loss etc.)
What is a D-Dimer?
Breakdown product of cross-linked fibrin (produced during fibrinolysis)
D-dimer has high sensitivity but low specificity
A 52 year old abattoir worker presents to the ED with a week-long history of SOB, fevers and productive cough, which he describes as purulent with a rusty colour. He has recently returned from a week-long holiday from his friends in Spain, where he stayed in a large hotel. On examination he is pyrexial, with bronchial breathing at the right base.
Which ONE of the following is the most likely diagnosis? Coxiella burnetii Moraxella catarrhalis Legionella pneumophila Haemophilus influenzae Streptococcus pneumoniae
Strep is most common source of community-acquired infections
A 54 yr old accountant comes to see you because he has started coughing up blood. He is a life-long heavy smoker and today he looks pale and he tells you he has become increasingly breathless, tired and weak over the past few months. Blood tests show his Calcium to be elevated but he has no bony pain. Investigators reveal a malignancy with no metastatic disease evident. Which ONE of the following is the most likely diagnosis?
Squamous cell carcinoma Adenocarcinoma Carcinoid tumour Oat cell tumour Alveolar cell carcinoma
Squamous cell carcinoma secrete Parathyroid hormone which results in an increase in plasma Calcium (as this hormone causes bone resorption and kidneys to resorb Calcium as well as causing intestines to absorb more calcium). Net effect of these actions leads to increase plasma calcium levels.
- A 62 year old man presents to the ED with acute-onset SOB and haemoptysis. He had a hip replacement operation 2 weeks ago and has been finding the exercises to get him back on his feet very difficult. On examination he is tachypnoeic at rest, tachycardic with a pulse of 130/minute, has a pyrexia of 37.4’C (normal body temp: 36.1’C-37.1’C) and Oxygen saturations of 92% on room air.
Which one of the following is the most appropriate investigation in this patient?
Bronchoscopy D-Dimer ECG Lateral CXR Blood cultures
The most appropriate Investigation is ECG
The patient has a diagnosis of Pulmonary embolism, given the sudden onset of SOB (shortness of breath), haemoptysis and hypoxia, caused by a recent hip operation and prolonged immobility.
Given the high pre-test probability of a pulmonary embolism, a D-dimer test should not be performed because, regardless of the result, you will investigate with a CT pulmonary angiogram or a ventilation-perfusion scan to confirm your clinical suspicion. The place of a D-dimer testing is in those patients with a low pre-test probability of a pulmonary embolism and to help in it’s exclusion. D-dimers should not be used for diagnostic reasons because although the sensitivity of the test is high, the specificity is low.
A bronchoscopy is not useful as the haemoptysis does not reflect an underlying suspicion of malignancy or infection. A low-grade pyrexia is a common finding in patients with a PE (pulmonary embolism) and blood cultures are therefore not the most appropriate Investigation. In the acute setting, a PA or AP CXR is vital in assessement of patient w/ SOB, but a lateral CXR would not be reuired.
A patient involved in a road traffic accident is brought in with severe respiratory distress to the ED. On examination the trachea is deviated to the right side with a hyper-resonant percussion note on the left. What is the next most appropriate step?
100% inspired Oxygen until senior help arrives
Chest drain insertion
Urgent CXR
Needle aspiration in 5th intercostal space, mid-axillary line
Needle aspiration in 2nd intercostal space, mid-clavicular line
Tension pneumothorax
Needle aspiration in 2nd intercostal space, mid-clavicular line
An 18 year old basketball player presents to the ED with SOB and pleuritic chest pain. A CXR shows a 1.5cm rim of air between the pleurae with absent lung markings at the apex. There is no significant respiratory distress and he is much more comfortable after the pain relief. Which ONE of the following should be the next step in his management?
Discharge Chest drain Aspiration Admit to ensure complete resolution Pleurodesis
Discharge
Patient has relatively small (<2cm) primary pneumothorax and current Rx guidelines recommend that patients such as this can be discharged from ED w/o active therapy. However he should be reviewed in 2 weeks time w/ a repeat CXR
- Which of the following statements about chronic type II respiratory failure is/are true?
PICK TWO ANSWERS!!!
The carbon dioxide level is characteristically reduced
The serum bicarbonate level is characteristically raised
It may be caused by asthma
It may be caused by COPD
It should be treated with high concentration of oxygen
The serum bicarbonate level is characteristically raised
It may be caused by COPD
Define Respiratory failure
There are 2 types:
There are 2 types:
- Type I where the carbon dioxide level is not increased - Type II where the carbon dioxide level is increased
In chronic type II respiratory failure, the oxygen level is reduced in the presence of carbon dioxide retention.
Carbon dioxide in blood is acidic.Therefore, in order to maintain the acid-base balance, the kindeys keep more bicarbonate (which is alkali).This is to ensure a normal pH, as over-acidification is a dangerous condition which weakens all our bodys systemsThe commonest cause for Type II respiratory failure is COPD. Asthma tends to cause hyperventilation, and hence leads to Type I respiratory failure.
Only controlled low Oxygen concentration should be used in Type II respiratory failure, as a high concentration may reduce respiratory drive even further and cause hypercapnia.
- Characteristic clinical features of a spontaneous pneumothorax are
1 ANS
Gradual onset of pain
Bilateral chest pain
Displacement of trachea to the affected side
Reduced or absent breath sounds on the affected side
Increased vocal resonance on the affected side
Reduced or absent breath sounds on the affected side
Signs of Pneumothorax:
Characteristic clinical features of a spontaneous pneumothorax are sudden onset of unilateral chest pain associated with breathlessness.
Cyanosis may be present if the pneumothorax is of the open or tension type.
Physical signs include deviation of the trachea to the unaffected side, and reduced movement of chest wall, hyperresonance, diminished or absent breath sounds, and reduced vocal resonance on the affected side.
10. Causes of a pleural effusion include 3 ANS Bacterial pneumonia Heart failure Pneumothorax Pulmonary embolism and infarction Fibrosing alveolitis
Bacterial pneumonia
Heart failure
Pulmonary embolism and infarction
Pleural effusions occur when fluid accumulates in the pleural space.
They may be EXUDATIVE or TRANSUDATIVE.
Exudative pleural effusions have a higher protein content. Therefore, they can be caused by infections, malignancy etc.
Transudative pleural effusions have a lower protein content. Therefore, they can be caused by anything which essentially increases the hydrostatic pressure in lung blood vessels, causes fluid from blood to transudate out into the pleural space
Transudative: Heart failure
Hyponatreinaemia
Exudative Bacterial pneumonia Tuberculosis Carcinoma Pulmonary infarction
11. Diseases associated with exposure to asbestos include 4 ANS Carcinoma of the bronchus Pleural thickening Progressive fibrosis Mesothelioma Sarcoidosis
Carcinoma of the bronchus
Pleural thickening
Progressive fibrosis
Mesothelioma
12. Causes of clubbing of the finger include: 3 ANS Idiopathic fibrosing alveolitis Chronic bronchitis and emphysema Subacute endocarditis Inflammatory bowel disease Carcinoma of the colon
Idiopathic fibrosing alveolitis
Subacute endocarditis
Inflammatory bowel disease
Causes of Clubbing: 4 Broad categories
Can be broadly catagorised into:
Respiratory
Cardiovascular
Congenital
Gastrointestinal
