1. General Principles & Basic Science MCQs

Correct Answer: A - Asthma. The symptoms of asthma are non-specific: shortness of breath, wheezing, chest tightness, and cough. These are manifestations of airway narrowing and airway hyper-responsiveness. Asthma is suggested by the variability in symptom severity and periodicity, provocation by specific or non-specific stimuli, and reversibility with bronchodilators or corticosteroids. Nocturnal waking is a classic feature of persistent asthma.

Correct Answer: B- An extensor plantar response is common Explanation An extensor plantar response is common Extensor plantar responses are seen in chronic obstructive pulmonary disease (COPD) due to carbon dioxide retention, which results in carbon dioxide narcosis. Aminophylline/theophylline combinations are the first- line treatments Aminophylline/Theophylline combinations are the first-line treatments is incorrect. Aminophylline and theophylline are indicated in patients with exacerbations of COPD only if nebulised bronchodilators and steroids are ineffective. Exacerbation is usually due to anaerobic infection Exacerbation is usually due to anaerobic infection is incorrect. Exacerbations of COPD are usually due to viral infections or Gram positive bacteria such as Streptococcus pneumoniae and Haemophilus influenzae. Oxygen therapy should be continued until the symptoms subside Oxygen therapy should be continued until the symptoms subside is incorrect. Oxygen therapy is indicated for treatment of hypoxia and should aim for a pO2 of 8 kPa (60 mmHg), particularly for ‘blue bloaters’ (with type II respiratory failure). Any further increase in at risk patients (ie patients with chronic type 2 respiratory failure) may result in carbon dioxide retention and respiratory acidosis. Respiratory acidosis is associated with a lowering ofbicarbonate levels Respiratory acidosis is associated with a lowering ofbicarbonate levels is incorrect. In respiratory acidosis thebicarbonate and hydrogen levels are usually raised because of carbon dioxide retention and the renal retention of bicarbonate.

Occupational asthma. This patient works as a paint sprayer, and asthma is known to be associated with isocyanates, which can be a component of industrial paints or lacquers. The clue to his condition is that he improved during his prolonged holiday. Workers who keep a peak-flow diary usually show marked deterioration in their peak flow associated with the working week.

Correct Answer: D- Pneumonia Explanation Pneumonia The classic presentation of pneumonia is of a cough and fever with the variable presence of sputum production, dyspnoea and pleurisy. Most patients have constitutional symptoms such as malaise, fatigue and asthenia, and many also have gastrointestinal symptoms. Although patients with pneumonia usually present with these characteristic clinical features, there can be major differences in presentation, depending on host factors and the aetiological agent. Bronchial breathing is heard over an airless lung, such as in consolidation, atelectasis or dense fibrosis. There is some resemblance to the sounds heard over the normal trachea, but, by comparison with normal breath sounds, bronchial breathing is higher in pitch and more blowing in quality. It does not have to be loud. Bronchial breath sounds are classically heard throughout both inspiration and expiration. Very quiet breath sounds are heard over hyperinflated lungs, as in emphysema, or when breath sounds are prevented from reaching the chest wall by a layer of air, fluid or fibrosis. Asthma Asthma is incorrect. Global expiratory wheeze or reduced air entry would be the classical finding in asthma. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is incorrect. Global expiratory wheeze or reduced air entry would be the classical findings in COPD. Emphysema Emphysema is incorrect. Global expiratory wheeze or reduced air entry would be the classical findings in asthma or COPD including emphysema. Pneumothorax Pneumothorax is incorrect. Pneumothorax would be associated with an absence of breath sounds.

Intravenous heparin for acute treatment. Heparin-induced thrombocytopenia (HIT) is caused by IgG antibodies that recognize multimolecular complexes of platelet factor 4 and heparin. Typically, the fall in platelet count begins 5–10 days after starting heparin. Most patients with HIT develop venous or arterial thrombosis. The thrombocytopenia is typically moderate in severity.

When absolute stability is achieved with compression plating, the fracture heals via primary bone healing (direct contact healing) without the formation of a provisional callus. This process relies entirely on the direct progression of cutting cones and Haversian remodeling across the fracture site.

Posteromedial displacement of the distal fragment forces the proximal spike anterolaterally, directly risking stretch or entrapment of the radial nerve.

Primary (Haversian) bone healing requires absolute stability. It directly remodels the fracture site via osteoclastic cutting cones and osteoblastic bone formation without an intermediate soft callus.

Correct Answer: B- Computed tomography of the thorax Explanation Computed tomography of the thorax Where a chest X-ray has been requested in primary or secondary care and is incidentally suggestive of lung cancer, a second copy of the radiologist's report should be sent to a designated member of the lung cancer multidisciplinary team (MDT), usually the chestphysician. The MDT should have a mechanism in place to follow up these reports to enable the patient’s GP to have a management plan in place. Patients with known or suspected lung cancer should be offered a contrast-enhanced chest computed tomographic (CT) scan to further define the diagnosis and stage the disease. The scan should also include the liver and adrenals. Bronchoscopy Bronchoscopy is incorrect. Chest CT should be performed before an intended fibre-optic bronchoscopy or any other biopsy procedure. d-Dimer d- Dimer is incorrect. d-Dimer is an appropriateinvestigation for pulmonary embolus. The history here is suggestive of lung carcinoma. Sputum sample Sputum sample is incorrect. Sputum sampling would not reveal the correct diagnosis here. This is not a history suggestive of respiratory infection. Ventilation/perfusion scan Ventilation/perfusion scan is incorrect. Ventilation/perfusion scans are used to investigate for pulmonary emboli in patients who cannot have CT pulmonary angiograms, eg owing to contrast allergy or severe renal impairment. This is not a history suggestive of pulmonary embolism.

Correct Answer: C- Infection with multidrug-resistant tuberculosis Explanation Infection with multidrug-resistant tuberculosis Multidrug-resistant tuberculosis is defined as resistance to rifampicin and isoniazid, with or without resistance to other anti-TB drugs. Initial drug resistance is uncommon in previously untreated white patients born in the UK (< 2%). Higher levels of resistance occur in ethnic minority groups, particularly those of the Indian subcontinent and people of black African ethnic origin, with isoniazid resistance occurring in 4–6% of such patients. HIV- positivity, independent of ethnic group, is also a marker for increased drug resistance: a positive HIV result increases the chances of single- or multiple-drug resistance at least four-fold compared with an HIV- negative individual. Treatment is complex, time consuming and demanding for both the patient and the physician. Such treatment should only be carried out by physicians with substantial experience in managing complex resistant cases, and only in hospitals with appropriate isolation facilities. This might require transfer of the patient to an appropriate unit. Treatment of these patients has to be planned on an individual basis and needs to include reserve drugs. Such treatment must be closely monitored not only because of increased toxicity but, perhaps more importantly, full compliance is essential to prevent the emergence of further drug resistance. The treatment must therefore be directly observed throughout, both on an inpatient and an outpatient basis. Treatment should start with five or more drugs to which the organism is, or is likely to be susceptible, and should continue until sputum cultures become negative. Drug treatment then has to be continued with at least three drugs to which the organism is susceptible on in-vitro testing for a minimum of a further 9 months and perhaps up to or beyond 24 months, depending on the in-vitro drug-resistance profile, the available drugs and the patient’s HIV status. Consideration might also have to be given to resection of pulmonary lesions under drug cover. Aspiration pneumonia Aspiration pneumonia is incorrect. There is nothing in this history to suggest this gentleman would develop an aspiration pneumonia. In particular there is no history given of alcohol or drug excess, vomiting, reduced consciousness, swallowing difficulty or neuromuscular impairment; multidrug- resistant TB is far more likely. Carcinoma of the lung Carcinoma of the lung is incorrect. There is nothing in this history to suggest an underlying lung malignancy. In particular the patient is young and no smoking history is mentioned. Multidrug- resistant TB is more likely. Infection with an atypical mycobacterium Infection with an atypical mycobacterium is incorrect. Mycobacterium tuberculosis has already been identified in this case. Poor response to treatment due to multidrug- resistant M. tuberculosis is more likely than superadded infection. Underlying bacterial pneumonia Underlying bacterial pneumonia is incorrect. M. tuberculosis has already been identified in this case and it is more likely that this is a multidrug-resistant strain of M. tuberculosis, hence the poor response to treatment, rather than a superadded infection.

Correct Answer: C - Familial primary pulmonary hypertension. Primary pulmonary hypertension presents with breathlessness, fatigue, angina (due to right ventricular ischaemia) or presyncope/syncope. About 6% of all patients with primary pulmonary hypertension have a family history of the condition, which exhibits an autosomal dominant pattern of inheritance with incomplete penetrance. Physical signs include: Elevated JVP, left parasternal heave, pansystolic murmur (tricuspid regurgitation), right ventricular S4, and peripheral oedema.

Correct Answer: B- Bronchiectasis Explanation Bronchiectasis Some 3–4% of patients with rheumatoid arthritis develop bronchiectasis. This is characterised by recurrent haemoptysis. The history of expectorating phlegm on most days and frequent chest infections is suggestive of the diagnosis. A high-resolution computed tomography scan of her lungs will establish the diagnosis. Atypical pneumonia Atypical pneumonia is incorrect. This lady may indeed acquire infections with atypical organisms but the history suggests there is an underlying chronic respiratory disorder leaving her vulnerable to recurrent chest infections. Therefore, bronchiectasis is the most appropriate answer. Lung cancer Lung cancer is incorrect. Her lack of smoking history coupled with a history of rheumatoid arthritis and long (5-year) history of chronic productive cough with recurrent respiratory infections is more in keeping with bronchiectasis than malignancy. Pulmonary embolism Pulmonary embolism is incorrect. Although pulmonary emboli can be associated with haemoptysis, there are features in this history such as duration of symptoms, presence of daily sputum production and history of recurrent chest infections which make pulmonary embolism an unlikely cause of her haemoptysis. Tuberculosis Tuberculosis is incorrect. Tuberculosis can cause productive cough and haemoptysis. However, the duration of symptoms is too long to consider tuberculosis as a likely diagnosis. In addition, Mycobacterium tuberculosis would not respond to typical antibiotics used for respiratory tract infections.

Correct Answer: E- Trial of high-dose inhaled steroids Explanation Trial of high-dose inhaled steroids Cough-variant asthma represents one end of the asthma spectrum, with airway inflammation but minimal bronchoconstriction. Hence peak-flow measurement may not be as useful in establishing the diagnosis and potential benefit of steroids as a trial of steroids itself. There might not be a typical asthma history; the cough is typically worse in the mornings, in the cold air and after exercise. Methacholine challenge testing can be negative. Spirometry might be normal, with no evidence of bronchodilatation, and peak flows are often stable. Treatment is with high-dose inhaled steroids for at least 2 months, or a short course of oral steroids. Response to steroids is helpful when making the diagnosis of asthma. Bronchodilators often have little effect. Ambulatory oesophageal pH monitoring Ambulatory oesophageal pH monitoring is incorrect. pH monitoring is performed in people with suspected reflux who have not responded to empirical treatment with a proton-pump inhibitor, or if there is diagnostic uncertainty. Computed tomography scan of her chest Computed tomography scan of her chest is incorrect. Computed tomography is not usually required unless there is a suspicion of interstitial lung disease or cancer, or when all other investigations and treatments have failed. ENT examination with direct laryngoscopy ENT examination with direct laryngoscopy is incorrect. Ear, nose and throat (ENT) examination might be helpful if there is a suspicion of a postnasal drip – along with reflux and asthma, this is a common cause of chronic cough. Serial peak flows Serial peak flows is incorrect. This is a description of cough-variant asthma and therefore peak expiratory flows may well be normal and unhelpful in making the correct diagnosis.

Correct Answer: B-3 months Explanation 3 months This young woman’s only risk factor is the long-haul flight, which is only a temporary risk factor. That being said, this would be considered a provoked PE, as such 3 months’ anti-coagulation is sufficient. 4–6 weeks 4–6 weeks is incorrect. Previous guidelines suggested that a duration of 4–6 weeks’ anticoagulation is adequate when a DVT has occurred post surgery. However, 2012 guidelines suggest a minimum of 3 months’ anticoagulation for all provoked DVTs. 6 months 6 months is incorrect. Patients with unprovoked PE should be treated initially for 3 months, with review at the 3 month stage for consideration of extension to 6 months, where there is thought to be increased risk of a recurrence. 6 months of anticoagulation is recommended for DVT or PE in the presence of active malignancy. The decision to stop or continue anticoagulation after 6 months in such patients should be made on an individual basis. 1 year 1 year is incorrect. Patients with unprovoked PE should be treated initially for 3 months, with review at the 3 month stage for consideration of extension to 6 months, where there is thought to be increased risk of a recurrence. 6 months of anticoagulation is recommended for DVT or PE in the presence of active malignancy. The decision to stop or continue anticoagulation after 6 months in such patients should be made on an individual basis. Lifelong Lifelong is incorrect. Lifelong anticoagulation is generally only recommended for a history or recurrent DVT/PE.

Correct Answer: B- Asthma Explanation Asthma Asthma is a chronic inflammatory disease of the bronchial airways that is characterised by a desquamative eosinophilic bronchitis. The defining clinical characteristics of asthma are reversible airway narrowing and increased airway responsiveness to non-specific provocative stimuli. The alveolar functional structure is preserved. Extrinsic allergic alveolitis Extrinsic allergic alveolitis is incorrect. Extrinsic allergic alveloitis is characterised histologically by alveolar destruction and interstitial inflammation. Non-caseating granulomas are also present and asteroid bodies may be found in or adjacent to the granulomas. Pneumonia Pneumonia is incorrect. Aveoli typically become fluid filled and distended in pneumonia. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Marked architectural distortion and destruction are typically seen in idiopathic pulmonary fibrosis. Cryptogenic organising pneumonia Cryptogenic organising pneumonia is incorrect. In cryptogenic organising pneumonia there is excessive growth of granulation tissue causing chronic inflammation within the alveoli.

Correct Answer: A - A glucose level in pleural fluid of < 1.6 mmol/l is characteristic of a rheumatoid pleural effusion. These effusions are characterised by some or all of the following: Low glucose (< 1.6 mmol/l), high lactate dehydrogenase (> 700 IU/l), low pH (< 7.2), a high rheumatoid factor titre (> 1:320), and high cholesterol levels.

Correct Answer: B - Ceftazidime and tobramycin. The combination of ceftazidime and tobramycin is the antibiotic regimen of choice for the treatment of cystic fibrosis exacerbations in patients with Pseudomonas aeruginosa. Both ceftazidime and tobramycin have good anti-pseudomonal activity and combination therapy is preferred to minimise development of resistant strains. Treatment should be continued for 10-14 days.

Serum immunoglobulins are a reasonable next step to look for elevated IgE (consistent with possible allergic bronchopulmonary aspergillosis) and immunoglobulin deficiency (both IgA and IgG subclass deficiencies are possible).

Correct Answer: D - The man has previously had a BCG vaccination. Heaf tests are graded as follows: 0: No reaction, 1: 4–6 small dots, 2: Dots coalesce, normal skin in centre, 3: Dots coalesce, central skin filled in, 4: Solid induration > 10 mm, with or without vesiculation or ulceration. Grade 2 is a normal response in the presence of a previous BCG vaccination.

Correct Answer: C- High-resolution computed tomography Explanation High-resolution computed tomography The gold standard for the diagnosis of bronchiectasis is thin-section high-resolution computed tomography (HRCT) of the chest, which has replaced the more invasive investigation of bronchography. The diagnostic criteria for bronchiectasis on HRCT depend on finding both dilatation and thickening of the affected bronchi, dilatation being present if the internal diameter of the bronchus is greater than the diameter of its accompanying pulmonary artery. The classic appearance of a cross-section of a thick-walled dilated bronchus next to the accompanying pulmonary artery is the ‘signet ring’ sign. Bronchial dilatation is also recognised when airways are seen in longitudinal section on CT and there is a failure of tapering as the bronchus courses towards the periphery. Bronchoscopy Bronchoscopy is incorrect. Bronchoscopy in bronchiectasis may demonstrate larger than expected bronchi with visible mucopurulent secretions, but it will not detect bronchiectasis affecting distal airways. Given the test is invasive and not always diagnostic, it is not routinely used in diagnosing bronchiectasis. Bronchoscopy is indicated in cases of localised bronchiectasis to rule out a foreign body or obstructing lesion, eg carcinoma. Chest X-ray Chest X-ray is incorrect. The chest radiograph can be normal in at least 50% of patients with computed tomographic or bronchographic evidence of bronchiectasis. If it is abnormal the findings reflect thickened and dilated bronchi, which produce tramline opacities and ring shadows. Retained mucus might be seen as tubular opacities, and there can be associated volume loss of the affected lobe. Spirometry Spirometry is incorrect. Spirometry is normal or obstructive in bronchiectasis, depending on the severity, but spirometry alone is not a sufficient diagnostic test for bronchiectasis. Ventilation/perfusion scan Ventilation/perfusion scan is incorrect. Ventilation/perfusion scans are used in the diagnosis of pulmonary embolism. They are not used to investigate for bronchiectasis.