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1. General Principles & Basic Science MCQs

Practice Set 41 of 789

This practice set contains high-yield board review questions covering key concepts in 1. General Principles & Basic Science. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 801

Topic: 1. General Principles & Basic Science

A 58-year-old man comes to the Emergency Department. He has been treated at home with nebulisers and oral steroids for a chronic obstructive pulmonary disease (COPD) exacerbation but continues to deteriorate. When you see him he has been in the department for 30 min and is on his third salbutamol nebuliser. On examination he looks tired and cyanosed. He has poor air entry and wheeze on auscultation of his chest. Arterial blood gasses on 24% O2 (turned down from 28% 15 min earlier) pO2 8.0 kPa

PCO2 9.2 kPa

pH 7.2 15 min earlier

pO2 8.2 kPa

pCO2 8.5 kPa

pH 7.31 Which of the following is the next appropriate management step?

. Doxapram
. Further nebulisers
. Intubation and ventilation
. Non-invasive positive pressure ventilation
. Sodium bicarbonate

Correct Answer & Explanation

. Non-invasive positive pressure ventilation

Explanation

Correct Answer: D- Non-invasive positive pressure ventilation Explanation Non-invasive positive pressure ventilation This patient has CO2 retention, hypoxia and respiratory acidosis, which has worsened over the past 15 min, despite reducing his inspired O2. As such the next logical option is NIPPV as he is not responding to medical therapy. Doxapram Doxapram is incorrect. Although doxapram is a respiratory stimulant it is inferior to NIPPV in terms of outcomes. Further nebulisers Further nebulisers is incorrect. The patient has already deteriorated despite 3 nebulisers. He requires help with his ventilator requirements via NIPPV as the next most appropriate step. Intubation and ventilation Intubation and ventilation is incorrect. Intubation and ventilation may be considered if the patient fails to respond to NIPPV.Sodium bicarbonateSodium bicarbonate is incorrect. Sodium bicarbonate will not affect his CO2 retention and may exacerbate fluid retention.

Question 802

Topic: Infection, Pharmacology & VTE
A 65-year-old man complains of lethargy, fever, dry cough, headache, chest pain and increasing shortness of breath. He returned from a cruise 2 days ago. His chest X-ray shows bilateral consolidation and his Po2 is 8.35 kPa. What is the most likely diagnosis?
. Legionella pneumonia
. Pulmonary embolism
. Sarcoidosis
. Small-cell carcinoma of the lung
. Tuberculosis

Correct Answer & Explanation

. Legionella pneumonia

Explanation

Legionella infection is the cause of around 2–5% of cases of community-acquired pneumonia admitted to hospital. The incubation period is usually 2–10 days. Typically, the illness starts fairly abruptly with high fever, shivers, severe headache and muscle pains. A history of a recent hotel holiday or cruise can alert the clinician to the possible diagnosis.

Question 803

Topic: 1. General Principles & Basic Science

A 72-year-old former coal-miner visits you for review. He reports having frequently worked at the coal face in cramped conditions, with exposure to a large volume of coal dust. He says he has had increasing symptoms of cough and shortness of breath over the past few years, but continues to smoke 10–15 cigarettes per day. His chest X-ray reveals a large number of small, round opacities within the lung fields, with almost complete obscuration of normal lung markings. Which diagnosis fits best with this clinical picture?

. Asthma
. Category 1 pneumoconiosis
. Category 2 pneumoconiosis
. Category 3 pneumoconiosis
. Chronic obstructive pulmonary disease

Correct Answer & Explanation

. Category 3 pneumoconiosis

Explanation

Correct Answer: D- Category 3 pneumoconiosis Explanation Category 3 pneumoconiosis The severity of X-ray changes described here suggests category 3 (the most severe) form of pneumoconiosis. The 0–3 classification is defined by the international labour organisation and reflects an increasing density of small opacities on the chest radiograph. Asthma Asthma is incorrect. The abnormal chest X-ray appearances and occupational history given make pneumoconiosis more likely than asthma. Category 1 pneumoconiosis Category 1 pneumoconiosis is incorrect. Category 1 pneumoconiosis is the least severe, with fewer opacities and normal lung markings clearly visible. Category 2 pneumoconiosis Category 2 pneumoconiosis is incorrect. Category 2 pneumoconiosis is less severe, with a number of opacities but normal lung markings still visible. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is incorrect. Although he could have some smoking- related COPD, his chest X-ray is diagnostic in the presence of his occupational history of category 3 pneumoconiosis.

Question 804

Topic: 1. General Principles & Basic Science

A 42-year-old salesman was admitted with a diagnosis of pneumonia. His chest X-ray showed a hazy opacity in the right lower lobe and mid-zone. He is allergic to erythromycin. Blood investigations showed hyponatraemia and a slight rise in the level of liver aminotransferases. On the 5th day after starting medication he became acutely jaundiced and his liver aminotransferase levels became very high. He also complained of discoloration of his urine, though dipstick testing did not show haematuria. Which one of the following drugs probably caused the jaundice?

. Amoxicillin
. Ciprofloxacin
. Clarithromycin
. Flucloxacillin
. Rifampicin

Correct Answer & Explanation

. Rifampicin

Explanation

Correct Answer: E- Rifampicin Explanation Rifampicin This patient has Legionella pneumonia and so rifampicin was prescribed. However, rifampicin is a hepatic-enzyme inducer and its use can lead to acute jaundice, with a rise in liver aminotransferases. It also causes red or orange discoloration of the urine and other body fluids and patients should be warned about this side- effect.Monotherapy with rifampicin is associated with the development of resistance and is not generally used to treat Legionella pneumonia. As this patient is allergic to the macrolides, ciprofloxacin would be the other drug of choice. Amoxicillin Amoxicillin is incorrect. Amoxicillin is not an effective treatment for Legionella pneumonia and should not be prescribed in a case such as this. Regardless, hepatotoxicity from amoxicillin is ucommon. Ciprofloxacin Ciprofloxacin is incorrect. Ciprofloxacin may be used to treat Legionella pneumonia in macrolide allergic patients but it is not usually associated with hepatotoxicity. Furthermore, the discolouration of urine is suggestive of rifampicin which is more likely to be associated with hepatotoxicity and is therefore the correct answer. Clarithromycin Clarithromycin is incorrect. He is allergic to macrolides so would not have been prescribed clarithromycin. Flucloxacillin Flucloxacillin is incorrect. Flucloxacillin can be associated with hepatotoxicity but this is rare. The risk of hepatotoxicity is increased with use over 2 weeks and with increased patient age. Furthermore, flucloxacillin is not an effective treatment for Legionella pneumonia and should not be prescribed in a case such as this.

Question 805

Topic: 1. General Principles & Basic Science
You are reviewing a 67-year-old man with a history of chronic obstructive pulmonary disease (COPD) who comes to the clinic. He feels increasingly short of breath despite maximal therapy with home nebulisers, high-dose Seretide and tiotropium. Which of the following features would drive you towards a prescription for long-term oxygen therapy (LTOT) with respect to two blood gases sampled > 3 weeks apart?
. PaCO2 5.6 kPa
. PaO2 7.2 kPa
. PaO2 8.4 kPa with secondary polycythaemia
. PaO2 8.6 kPa with right heart failure
. PaO2 8.8 kPa

Correct Answer & Explanation

. PaO2 7.2 kPa

Explanation

NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed.

Question 806

Topic: Infection, Pharmacology & VTE

A 5-year-old child presents with a fever of 39°C, inability to bear weight on the left leg, and exquisite tenderness over the proximal tibial metaphysis. MRI confirms acute hematogenous osteomyelitis without an abscess. What is the most appropriate initial management?

. Immediate surgical debridement and cortical windowing
. Empiric intravenous antibiotics and observation
. Outpatient oral antibiotics
. Percutaneous bone biopsy prior to starting antibiotics
. Application of a long leg cast

Correct Answer & Explanation

. Empiric intravenous antibiotics and observation

Explanation

In pediatric acute hematogenous osteomyelitis without a discrete drainable abscess, empiric intravenous antibiotics are the first-line treatment. Surgery is reserved for cases that fail to respond clinically within 48-72 hours or present with a subperiosteal collection.

Question 807

Topic: 1. General Principles & Basic Science

Which cell type produces surfactant?

. Alveolar macrophage
. Endothelial cell
. Goblet cell
. Type I pneumocyte
. Type II pneumocyte

Correct Answer & Explanation

. Type II pneumocyte

Explanation

Correct Answer: E- Type II pneumocyte Explanation Type II pneumocytePhospholipid molecules that reduce surface tension in the alveolar air–liquid interface are called surfactant. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Alveolar macrophage Alveolar macrophage is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Endothelial cell Endothelial cell is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Goblet cell Goblet cell is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Type I pneumocyte Type I pneumocyte is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls.

Question 808

Topic: 1. General Principles & Basic Science
A 26-year-old man presents with fever, headache, and a moderately productive cough. The chest X-ray shows increased interstitial markings. Laboratory examinations show an elevated lactate dehydrogenase (LDH), anemia, and cold agglutinins. What is the most likely diagnosis?
. Chlamydia pneumonia
. Extrinsic allergic alveolitis
. Mycoplasma pneumonia
. Non-Hodgkin lymphoma
. Pneumocystis jirovecii

Correct Answer & Explanation

. Mycoplasma pneumonia

Explanation

Mycoplasma pneumonia is the correct answer. Acute, cold, autoimmune, hemolytic anemia is commonly seen in adolescents and young adults following infection with Mycoplasma pneumoniae. Hemolysis occurs approximately 1–2 weeks following infection and is most commonly associated with a rise in polyclonal anti-I IgM antibodies. The typical patient is a young adult with a respiratory tract infection accompanied by headache, myalgia, cough, and fever, with a chest X-ray showing bronchopneumonia.

Question 809

Topic: Infection, Pharmacology & VTE
A 72-year-old woman is admitted with sudden-onset, left-sided pleuritic chest pain with shortness of breath. She is being treated for asthma, which has been well controlled on a low dose of inhaled corticosteroids and long-acting beta-agonist. She underwent a left hemiarthroplasty 12 days ago and was discharged because she was doing well. Her chest is clear on auscultation. She is tachycardic (132 bpm) and an electrocardiogram shows sinus tachycardia. Her peak expiratory flow rate (PEFR) is 300 l/min (best 400 l/min). Arterial blood gases are as follows: pH 7.34, PaO2 7.6 kPa, PaCO2 3.5 kPa. She is started on oxygen. A chest X-ray is normal. What would be the most appropriate immediate action you as the medical FY2 should take?
. Request a chest X-ray in expiration
. Request d-dimers urgently
. Start low-molecular-weight heparin, suspecting pulmonary embolus, and request a ventilation/perfusion (V/Q) scan
. Start low-molecular-weight heparin, suspecting pulmonary embolus, and request computed tomographic pulmonary angiography
. Start nebulised bronchodilators and monitor the PEFR

Correct Answer & Explanation

. Start low-molecular-weight heparin, suspecting pulmonary embolus, and request computed tomographic pulmonary angiography

Explanation

Start low-molecular-weight heparin, suspecting pulmonary embolus, and request computed tomographic pulmonary angiography (CTPA). A CTPA is the imaging investigation of choice in this case, after starting low-molecular-weight heparin.

Question 810

Topic: 1. General Principles & Basic Science

A 62-year-old patient has been admitted with a large, left-sided pneumothorax. He has a past history of chronic obstructive pulmonary disease (COPD), for which he has a home nebuliser and takes a high-dose Seretide inhaler. A chest drain was inserted some 60 h earlier, yet when you review it, the drain is still swinging and producing bubbles. Which of the following is the most appropriate next step?

. Cardiothoracic surgical review
. Change the drain for a larger bore one
. Remove the drain anyway
. Suction at -15 cm H20
. Suction at -25 cm H20

Correct Answer & Explanation

. Cardiothoracic surgical review

Explanation

Correct Answer: A- Cardiothoracic surgical review Explanation Cardiothoracic surgical review In this situation suction may cause further damage, therefore surgical review is preferred with consideration for thoracoscopy and surgical pleurodesis. In patients who are unfit for surgery, either medical pleurodesis or a Heimlich valve could be considered. Suction is not routinely recommended and in this situation may cause further damage. When used in primary spontaneous pneumothorax (PSP) suction must be used with caution. Pressures should be in the range of -10–20 cm H20. Caution is advised in PSP because of the risk of pulmonary oedema developing, which appears to be a more common problem in younger patients and in those with larger PSPs. Change the drain for a larger bore one Change the drain for a larger bore one is incorrect. There is no evidence that a larger bore chest drain will cause a non-traumatic pneumothorax to resolve more quickly. There is, however, a higher risk of complications. Remove the drain anyway Remove the drain anyway is incorrect. This would be dangerous as the continued bubbling suggests an ongoing air leak. Suction at -15 cm H20 Suction at -15 cm H2O is incorrect. Suction is not routinely recommended and in this situation may cause further damage. Suction at -25 cm H20 Suction at -25 cm H2O is incorrect. Suction is not routinely recommended and in this situation may cause further damage.

Question 811

Topic: 1. General Principles & Basic Science

A 28-year-old woman presents to the Emergency Department with an acute asthmatic attack. Which of the following lung function abnormalities is she likely to have?

. Increased airway conductance
. Increased forced expiratory ratio
. Increased forced vital capacity
. Increased gas transfer factor
. Increased residual volume

Correct Answer & Explanation

. Increased residual volume

Explanation

Correct Answer: E- Increased residual volume Explanation Increased residual volume Because of gas trapping there is an increase in residual volume and an increase in total lung capacity, but the ratio of residual volume (RV) to total lung capacity (TLC) is increased (TLC = vital capacity (VC) + RV). Increased airway conductance Increased airway conductance is incorrect. Airway conductance (the reciprocal of airway resistance) is decreased in acute asthma. Increased forced expiratory ratio Increased forced expiratory ratio is incorrect. The classic abnormalities are reduced forced expiratory volume in 1 s (FEV1) and reduced forced vital capacity (FVC) with a decrease in FEV1/FVC. Increased forced vital capacity Increased forced vital capacity is incorrect. The classic abnormalities are reduced forced expiratory volume in 1 s (FEV1) and reduced forced vital capacity (FVC) with a decrease in FEV1/FVC. Increased gas transfer factor Increased gas transfer factor is incorrect. Gas transfer would be difficult to measure in acute asthma, but can be elevated in stable asthma, where there might be chronic hyperinflation giving rise to a greater surface area for blood/gas interfacing.

Question 812

Topic: 1. General Principles & Basic Science
A 32-year-old chronic intravenous heroin abuser presents to the Emergency Department with increasing shortness of breath and general debility. He has been using heroin for the past 15 years and has had a number of hospital admissions for overdoses, skin infections, and respiratory infections over the past few years. On examination: he is pyrexial (37.6 °C), blood pressure 115/72 mmHg, pulse 75 bpm. His right chest is dull to the mid-zone. Investigations show: Hemoglobin 10.5 g/dl, White cell count 9.2 × 10^9/l, Platelets 215 × 10^9/l, Sodium 139 mmol/l, Potassium 4.6 mmol/l, Creatinine 135 µmol/l. A postero-anterior chest X-ray shows a right-sided pleural effusion to the mid-zone. A pleural aspiration failed to produce a specimen. Which of the following is the most appropriate investigation with respect to the pleural effusion?
. Bronchoscopy
. Contrast-enhanced computed tomography of the chest
. Lateral chest X-ray
. Thoracoscopy
. Ultrasound scan of the chest and aspiration

Correct Answer & Explanation

. Ultrasound scan of the chest and aspiration

Explanation

Ultrasound scan of the chest and aspiration is the correct answer. Ultrasound is more sensitive in detecting effusions than chest radiographs and can be performed at the time of aspiration to improve the success rate and reduce the risk of complications. Ultrasound-guided aspiration is recommended by the British Thoracic Society to improve the success rate of aspiration and reduce the risk of complications, such as pneumothorax.

Question 813

Topic: 1. General Principles & Basic Science

A 26-year-old office secretary who smokes 10-15 cigarettes per day presented in the clinic after a couple of episodes of haemoptysis. She also said that she had felt tired recently and gave a history of treatment for a respiratory tract infection a couple of months ago. She said that she feels she never fully recovered from that infection and has been persistently coughing ever since. On examination, she looked pale, had minimal pedal oedema and diffuse crepitations on chest auscultation. Her urine was positive for protein and blood. A full blood count showed anaemia and the chest X-ray showed blotchy shadows over the lung fields. She is ANCA negative. What is your probable diagnosis?

. Bronchogenic carcinoma
. Goodpasture syndrome
. Granulomatosis with polyangiitis
. Pulmonary tuberculosis
. Sarcoidosis

Correct Answer & Explanation

. Goodpasture syndrome

Explanation

Correct Answer: B- Goodpasture syndrome Explanation Goodpasture syndrome This is a case of Goodpasture syndrome, which usually occurs in people over the age of 16 years. It starts with an upper respiratory infection, followed by cough, intermittent haemoptysis and tiredness. Later on, anaemia develops and a massive episode of haemoptysis can occur. The typical chest X-ray picture is a manifestation of intrapulmonary haemorrhage. These features are followed, in weeks or months, by the development of glomerulonephritis. The basic cause of the disease is a type II cytotoxic reaction against the basement membrane of both the kidneys and lungs. Glomerulonephritis might present as asymptomatic proteinuria and/or microscopic haematuria. This is followed later on by the development of the acute nephritic syndrome, nephrotic syndrome and chronic renal failure. Bronchogenic carcinoma Bronchogenic carcinoma is incorrect. Despite her smoking history lung cancer would be very unlikely in a 26-year-old. The urinalysis findings, and chest radiograph appearances are not in keeping with bronchogenic carcinoma. Her total smoking exposure is also unlikely to be associated with the development of a bronchogenic carcinoma. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Granulomatosis with polyangiitis may present with predominant respiratory symptoms, often with symptoms of granuloma formation, e.g. nosebleeds for a number of months before diagnosis. Alternatively patients may present with renal disease, those presenting with respiratory symptoms are said to have around an 80% chance of eventual renal dysfunction. Pulmonary tuberculosis Pulmonary tuberculosis is incorrect. This is a history of vasculitis. There is no history of fever or exposure to TB and the symptoms and test results are more in keeping with vasculitis. Sarcoidosis Sarcoidosis is incorrect. The symptoms are in keeping with vasculitis. Sarcoidosis would not be associated with positive urinalysis unless history was suggestive of renal calculi. ANCA would be negative in sarcoidosis and chet radiograph would most likely show bilateral hilar lymphadenopathy +/- pulmonary infiltrates.

Question 814

Topic: Infection, Pharmacology & VTE
A 24-year-old medical student (height 165 cm, weight 78 kg) has been complaining of a few months' history of shortness of breath on exertion and of coughing up blood once. She is a few days away from her final examinations and smokes 20 cigarettes per day. She takes no medication except for the oral contraceptive pill. Her only past medical history of note is a DVT after a long flight from Australia. What is the most likely diagnosis?
. Goodpasture syndrome
. Hyperventilation syndrome due to stress
. Pulmonary embolism
. Sarcoidosis
. Tuberculosis

Correct Answer & Explanation

. Pulmonary embolism

Explanation

Correct Answer: C - Pulmonary embolism. Acute pulmonary embolism can present in diverse ways. A syndrome of pleuritic pain or haemoptysis, in the absence of circulatory collapse, is the most frequent mode of presentation. Obesity and a high oestrogen content in oral contraceptives have been linked to thromboembolic events. Most patients with pulmonary embolism were found to have smoked at one time or to be active smokers. Goodpasture syndrome may present with pulmonary haemorrhage, but the duration of symptoms is too long for this diagnosis to be likely. Hyperventilation syndrome does not cause haemoptysis. Sarcoidosis and tuberculosis are less likely given the specific risk factors for thromboembolism (obesity, previous DVT, contraceptive use, and smoking).

Question 815

Topic: 1. General Principles & Basic Science

A 59-year-old woman with severe rheumatoid arthritis presents to the Respiratory Clinic with worsening shortness of breath. She has had rheumatoid arthritis for 17 years and she is now managed with a methotrexate- based regime. Other medical history of note includes hypertension, for which she is treated with ramipril 10 mg daily. On examination, she has evidence of severe rheumatoid joint disease. Crackles are heard on auscultation of the chest.

Investigation:

Hb 11.0 g/dl

WCC 4.8 x 109/l

PLT 345 x 109/l

Sodium 139 mmol/l

Potassium 4.5 mmol/l

Creatinine 140 µmol/l Chest X-ray shows patchy consolidation, small pulmonary nodules and small bilateral pleural effusions. Computed tomography (CT) of the thorax shows patchy ground-glass opacities (peribronchovascular region), bronchial wall thickening, areas of bronchial dilatation and centrilobular pulmonary nodules. Pulmonary function testing demonstrates a restrictive pattern, with reduced diffusion capacity for carbon monoxide (Dlco) with a fall in oxygenation on exercise. Which of the following is the most likely diagnosis?

. Bronchiectasis
. Chronic eosinophilic pneumonia
. Cryptogenic organising pneumonia
. Idiopathic pulmonary fibrosis
. Methotrexate-related pulmonary fibrosis

Correct Answer & Explanation

. Cryptogenic organising pneumonia

Explanation

Correct Answer: C- Cryptogenic organising pneumonia Explanation Cryptogenic organising pneumonia Cryptogenic organising pneumonia (COP) occurs in patients with rheumatoid arthritis or other connective tissue disorders, and is associated with the typical radiographic and pulmonary function test picture seen here. Corticosteroids are the treatment of choice for COP, although relapse occurs on withdrawal of steroids in around 30% of cases. Bronchiectasis Bronchiectasis is incorrect. In bronchiectasis, chronic sputum production would be expected as a predominant symptom with a history of recurrent respiratory infections. Although bronchiectasis may not be visible on a chest radiograph it would almost certainly be noted onCT scanning and pulmonary function tests would show an obstructive not restrictive pattern of spirometry.Although bronchial dilatation has indeed been noted on this lady’s imaging, there is clearly more going on here to explain her symptoms. Chronic eosinophilic pneumonia Chronic eosinophilic pneumonia is incorrect. Chronic eosinophilic pneumonia is associated with an obstructive picture on pulmonary function testing. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Idiopathic pulmonary fibrosis is classically associated with a ‘usual interstitial pneumonia’ which can be detected on High- resolution computed tomography (HRCT) in approximately 80% of cases and classically affects the lung bases. Methotrexate-related pulmonary fibrosis Methotrexate-related pulmonary fibrosis is incorrect. Methotrexate-related pulmonary fibrosis is typically associated with ‘non-specific interstitial pneumonia’. CT features are variable and can include centrilobular nodules, reticulation and diffuse parenchymal opacification. However, the radiology findings in this case, particularly the peribronchial distribution that is mentioned, are more suggestive of bronchiolitis obliterans organising pneumonia (BOOP).

Question 816

Topic: 1. General Principles & Basic Science

A 69-year-old former coal-miner is referred to you by the on-call team. There is a smoking history and he has been managed by his GP for chronic obstructive pulmonary disease (COPD). He has been admitted with dyspnoea that is now so bad that he is unable to manage at home and cannot walk from the chair to the bathroom. He has a cough that is productive of black sputum. Lung function tests show a mixed restrictive and obstructive picture. A chest X-ray shows marked changes with massive fibrotic masses, predominantly in the upper lobes. There are also changes consistent with lung destruction and emphysema. His rheumatoid factor is positive. Which diagnosis fits best with this clinical picture?

. Asthma
. Category 1 pneumoconiosis
. Chronic obstructive pulmonary disease
. Progressive massive fibrosis
. Tuberculosis

Correct Answer & Explanation

. Progressive massive fibrosis

Explanation

Correct Answer: D- Progressive massive fibrosis Explanation Progressive massive fibrosis Progressive massive fibrosis (PMF) is associated with fibrotic masses in the apices, sometimes up to 10 cm in diameter. There are also emphysematous changes. There is a mixed obstructive and restrictive lung defect with reduced transfer factor. Rheumatoid factor and antinuclear antibody are often positive. There is usually a history of dust inhalation (eg coal dust), and PMF can progress rapidly, even in the absence of further dust exposure, leading to respiratory failure and eventually death. Category 2 pneumoconiosis progresses to PMF in around 7% of cases. The rate of progression of category 3 pneumoconiosis is much higher, at around 30%. The 0–3 classification is defined by the International Labour Organisation and reflects an increasing density of small opacities on the chest radiograph. Asthma Asthma is incorrect. The majority of this history is not in keeping with asthma, eg black sputum, no mention of wheeze, mixed spirometry pattern (airflow restriction is not in keeping with asthma), fibrotic masses, lung destruction and emphysema on chest X-ray (in pure asthma the chest X-ray will be normal or show hyperinflation). Category 1 pneumoconiosis Category 1 pneumoconiosis is incorrect. Category 1 pneumoconiosis is the least severe form of pneumoconiosis and chest radiograph will show just a few opacities and normal lung markings will be clearly visible. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease is incorrect. Given this man’s smoking history and presence of emphysema on his chest X-ray it is reasonable to believe he has a degree of COPD. However, the Question: asks which option best fits the clinical picture and, given the additional features mentioned re his chest X-ray findings, black sputum, positive rheumatoid factor and his occupational history, then progressive massive fibrosis is the correct option. Tuberculosis Tuberculosis (TB) is incorrect. A previous history of pulmonary TB is a risk factor for the development of PMF in individuals with silicosis, but this scenario is not suggestive of active pulmonary TB. There is no history of weight loss, fevers, night sweats or purulent sputum. The chest radiograph does not show lymphadenopathy or consolidation.

Question 817

Topic: 1. General Principles & Basic Science

A 29-year-old breathless Afro-Caribbean woman is referred by the ophthalmologists with anterior uveitis and a suspected diagnosis of sarcoidosis. Which of the following clinical features is most strongly associated with sarcoidosis?

. A slowly worsening picture of breathlessness with no periods of improvement
. Bronchoalveolar lavage shows an eosinophilia
. Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO)
. Obstructive defect on spirometry
. Positive Mantoux test

Correct Answer & Explanation

. Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO)

Explanation

Correct Answer: C- Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO) Explanation Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO) Decreased gas transfer factor (DLCO) accompanied by elevated gas transfer coefficient (KCO) is characteristic of extrathoracic restriction and not of intrapulmonary restriction – both are usually decreased in intrapulmonary sarcoidosis. A slowly worsening picture of breathlessness with no periods of improvement A slowly worsening picture of breathlessness with no periods of improvement is incorrect. Spontaneous remission of respiratory symptoms is not uncommon and might allow a ‘wait and see’ policy to be adopted at the outset before embarking on immunosuppressive therapy. Bronchoalveolar lavage shows an eosinophilia Bronchoalveolar lavage shows an eosinophilia is incorrect. Bronchoalveolar lavage typically shows a lymphocytosis. Obstructive defect on spirometry Obstructive defect on spirometry is incorrect. Spirometry usually shows a restrictive defect. Positive Mantoux test Positive Mantoux test is incorrect. Mantoux or Heaf testing is usually negative and reflects cutaneous anergy.

Question 818

Topic: 1. General Principles & Basic Science

A 17-year-old girl has chronic cough and recurrent respiratory infections over the past 2–3 years. Which one of the following pieces of clinical information in her history would point most strongly to the development of bronchiectasis?

. History of eczema
. History of wheeze
. Pale stools and low weight
. Pepperpot calcification on chest X-ray
. Previous whooping cough in early childhood

Correct Answer & Explanation

. Previous whooping cough in early childhood

Explanation

Correct Answer: E- Previous whooping cough in early childhood Explanation Previous whooping cough in early childhood A history of previous whooping cough is a well-known risk factor for bronchiectasis. History of eczema History of eczema is incorrect. Eczema is not associated with bronchiectasis. History of wheeze History of wheeze is incorrect. Wheeze often occurs in bronchiectasis, but asthma would be the most likely diagnosis in an adolescent complaining of wheeze. Pale stools and low weight Pale stools and low weight is incorrect. Pale stools and low weight suggests cystic fibrosis. Pepperpot calcification on chest X-ray Pepperpot calcification on chest X-ray is incorrect. Pepperpot calcification on a chest X-ray suggests previous varicella infection, which rarely gives rise to further symptoms.

Question 819

Topic: 1. General Principles & Basic Science
A 30-year-old man from Russia is seen in the Emergency Department. He was diagnosed with pulmonary tuberculosis (TB) 4 months ago in Russia and is taking rifampicin and isoniazid. He comes because of a productive cough, fevers, weight loss, and malaise. What would you like to do next?
. Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug-resistant tuberculosis (MDRTB)
. Admit him to hospital, send a sputum sample and start him on amoxicillin
. Admit him to hospital, send a sputum sample and start him on amoxicillin and pyrazinamide
. Admit him to hospital, send a sputum sample and start him on pyrazinamide
. Send a sputum sample and arrange to see him in outpatients

Correct Answer & Explanation

. Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug-resistant tuberculosis (MDRTB)

Explanation

Correct Answer: A - Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug-resistant tuberculosis (MDRTB). The concern with this man is MDRTB. He is failing on his current regimen and has clinical features of active TB. Management should involve sending sputum for culture and PCR testing before starting further treatment. If he has confirmed MDRTB, ensure he is on five or more drugs to which the organism is likely to be susceptible. A single drug should never be added to a failing TB regimen, as this could induce further antibiotic resistance.

Question 820

Topic: 1. General Principles & Basic Science

During the incorporation of a non-vascularized cortical bone graft, which sequence of events is primarily responsible for the replacement of the necrotic graft with viable host bone?

. Osteoconduction via crawling substitution
. Creeping substitution mediated by osteoclast cutting cones
. Direct membranous ossification without intermediate steps
. Endochondral ossification via chondrocyte hypertrophy
. Spontaneous revascularization bypassing inflammation

Correct Answer & Explanation

. Creeping substitution mediated by osteoclast cutting cones

Explanation

Cortical bone grafts heal via creeping substitution. Osteoclasts at the tips of cutting cones resorb the dead bone, followed directly by osteoblasts laying down new bone.

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