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1. General Principles & Basic Science MCQs

Practice Set 46 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 901

Topic: 1. General Principles & Basic Science

A 35-year-old man presents with multiple small nodules on chest X-ray. Which of the following is the most likely diagnosis?

. Bronchopulmonary aspergillosis
. Granulomatosis with polyangiitis
. Metastasis of renal carcinoma
. Polyarteritis nodosa
. Sarcoidosis

Correct Answer & Explanation

. Sarcoidosis

Explanation

Correct Answer: E- Sarcoidosis Explanation Sarcoidosis Sarcoidosis is graded on the appearance of bilateral hilar lymphadenopathy and/or pulmonary infiltrates, with the infiltrates referred to as ‘miliary reticulonodular’. There may be calcification of the hilar lymph nodes or lung parenchyma in chronic sarcoidosis. Bronchopulmonary aspergillosis Bronchopulmonary aspergillosis is incorrect. In bronchopulmonary aspergillosis, a cystic space containing a rounded opacity is seen on chest X-ray. An air space is seen between the fungus and the cavity wall (the ‘halo sign’) in aspergilloma. Granulomatosis with polyangitis Granulomatosis with polyangitis is incorrect. Granulomatosis with polyangitis might be seen as pulmonary infiltrates or multiple pulmonary nodules on chest X-ray, which tend to cavitate. Metastasis of renal carcinoma Metastasis of renal carcinoma is incorrect. Lung metastases from renal carcinoma are seen as solid masses; there may be several, but they are masses rather than nodules. Polyarteritis nodosa Polyarteritis nodosa is incorrect. Polyarteritis nodosua is a vasculitis affecting muscular arteries. It does not affect the lungs, although a related vasculitic disease, eosinophilic granulomatosis with polyangitis, does affect the lungs in the form of pulmonary infiltrates and asthma.

Question 902

Topic: 1. General Principles & Basic Science

A 36-year-old lorry driver who smokes heavily presents with a 2-day history of cough associated with fever. He also complains of right-sided chest pain on inspiration. On examination he is slightly cyanosed. His temperature is 38°C, respiratory rate 38/min, BP 100/70 mmHg and pulse 130 bpm. He has basal crepitations and dullness to percussion at the right lung base. What is the most important next step in confirming the diagnosis?

. Blood cultures
. Chest X-ray
. d-Dimer
. ESR (erythrocyte sedimentation rate)
. Sputum sample

Correct Answer & Explanation

. Chest X-ray

Explanation

Correct Answer: B- Chest X-ray Explanation Chest X-ray The classic presentation of pneumonia is with cough and fever, with or without sputum production, dyspnoea and pleurisy. Most patients have constitutional symptoms such as malaise, fatigue and asthenia, and many also have gastrointestinal symptoms. Examination of the lung might reveal decreased vesicular breath sounds, localised foci of crepitations, dullness to percussion and sometimes a bronchial wheeze. The chest X-ray is a pivotal test for the confirmation of pneumonia. Blood cultures Blood cultures is incorrect. Blood cultures will identify infection within the blood stream and may be suggestive of pneumonia if pneumococcus is cultured. However, blood cultures are not a diagnostic test for pneumonia. d-Dimer d- Dimer is incorrect. d-Dimer would be an inappropriate test here as the history is suggestive of pneumonia, not of pulmonary embolus.ESR (erythrocyte sedimentation rate)ESR (erythrocyte sedimentation rate) is incorrect. ESR is raised in a wide variety of inflammatory and infective conditions and is not a diagnostic test in itself. It is now rarely performed, other than when a diagnosis of temporal arteritis is suspected. Sputum sample Sputum sample is incorrect. A sputum sample will undoubtedly be helpful here but a sputum sample in isolation does not confirm a diagnosis of pneumonia, furthermore it may take several days before a result is available. Chest radiograph will give a more immediate result and reveal the diagnosis of pneumonia and is therefore the most appropriate answer here.

Question 903

Topic: 1. General Principles & Basic Science
A 45-year-old man who races pigeons becomes breathless. Which of the following features is suggestive of extrinsic allergic alveolitis (EAA)?
. Almost immediate onset of symptoms after exposure
. Eosinophilia of sputum
. Circulating IgG precipitins
. Positive skinprick testing
. Type I hypersensitivity reaction

Correct Answer & Explanation

. Circulating IgG precipitins

Explanation

Circulating IgG precipitins are suggestive of EAA. EAA is characterized by type III (immune-complex) and type IV (cell-mediated) hypersensitivity reactions to inhaled antigen(s).

Question 904

Topic: 1. General Principles & Basic Science
A 38-year-old woman is brought to the Emergency Department by her husband as she has taken to her bed over the past 48 hours with a worsening cough productive of purulent, blood-stained sputum, fevers, and shortness of breath, such that she is unable even to walk a few paces. She has no past medical history of note and her only medication is the oral contraceptive pill. Apparently she has been suffering from influenza for a few days before she took to her bed. On examination she is pyrexial 38.9 °C, her BP is 95/50 mmHg, and she is tachycardic with a pulse of 105 bpm. There are signs of bilateral lower lobe consolidation. Investigations: Hb 13.4 g/dl, WCC 17.2 × 10^9/l, PLT 203 × 10^9/l, Na+ 136 mmol/l, K+ 4.4 mmol/l, Creatinine 110 μmol/l, CXR: Bilateral lower lobe consolidation with evidence of cavitation. Which of the following is the most likely diagnosis?
. Haemophilus influenzae
. Klebsiella pneumoniae
. Mycoplasma pneumoniae
. Staphylococcus aureus
. Streptococcus pneumoniae

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus leads to pneumonia with cavitation and is recognized to occur after initial influenza infection. The key clue to the infecting organism here is the history of influenza which is associated with Staphylococcus aureus pneumonia.

Question 905

Topic: 1. General Principles & Basic Science
A 52-year-old woman with chronic obstructive pulmonary disease is assessed for long-term oxygen therapy (LTOT). She is found to be suitable for LTOT. What is the minimum number of hours per day that she should be using the oxygen?
. 3
. 5
. 10
. 12
. 15

Correct Answer & Explanation

. 15

Explanation

Correct Answer: E - 15. In the early 1980s, two large studies (MRC and NOTT) concluded that the minimum duration of long-term oxygen therapy (LTOT) should be 15 hours/day at a flow rate that keeps the arterial Po2 above 8.0 kPa (60 mmHg), and preferably up to 18 hours/day. At 3 years, survival was shown to be 50% better in the LTOT group compared with conventional treatment alone. Indications for LTOT: Two arterial blood gas measurements should be made at least 3 weeks apart. Indications for LTOT in patients with COPD are: Pao2 on air < 7.3 kPa with a normal/elevated Paco2 and an FEV1 < 1.5 l; or Pao2 7.3–8.0 kPa with evidence of cor pulmonale, peripheral oedema, or nocturnal hypoxaemia. 3, 5, 10, and 12 hours are incorrect as they do not reflect current recommendations.

Question 906

Topic: 1. General Principles & Basic Science

A thin 24-year-old man complains of constant daytime sleepiness. He mentions involuntary naps, often in the middle of activity, which occur suddenly and without warning. He also caused an accident when he fell asleep while driving home from work. The patient works as an office manager and has no history of exposure to chemicals. Which of the following treatments would be indicated?

. Continuous positive airway pressure breathing device
. Diazepam
. Fluoxetine
. Modafinil
. Nortriptyline

Correct Answer & Explanation

. Modafinil

Explanation

Correct Answer: D- Modafinil Explanation Modafinil This patient has narcolepsy, which is a sleep disorder that causes hypersomnia and which usually starts in adolescence or young adulthood. Treatment involves the use of central nervous system stimulants such as modafinil to allow daytime functioning. Continuous positive airway pressure breathing device Continuous positive airway pressure (CPAP) breathing device is incorrect. CPAP breathing devices are used in the treatment of sleep apnoea. A typical patient with sleep apnoea is usually older and obese and there will be a long history of gradually worsening snoring with apnoeas, possibly witnessed by a partner (who will probably have moved out of the bedroom because of the noise). There is usually a history of fairly high alcohol intake and smoking. Diazepam Diazepam is incorrect. Diazepam, a benzodiazepine has a sedative effect and would exacerbate this patient’s symptoms. Fluoxetine Fluoxetine is incorrect. The selective serotonin reuptake inhibiting antidepressant fluoxetine is a potential cause of sleep disturbance (typically insomnia). It is not used in the treatment of sleep disorders. Nortriptyline Nortriptyline is incorrect. Nortiptyline is a treatment for insomnia. This patient has hypersomnia due to narcolepsy.

Question 907

Topic: 1. General Principles & Basic Science

A 64-year-old man is brought to the Emergency Department by his wife with drowsiness and confusion. He has a history of chronic obstructive pulmonary disease (COPD) and attends the Chest Clinic. He had been commenced on antibiotics by his GP 2 days earlier for an exacerbation of his COPD. Which of the following blood gases (on 2 l O2/min) fit best with this man’s condition?

. pH 7.14, Paco2 7.3 kPa, Pao2 9.1 kPa, bicarbonate 14 mmol/l
. pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/l
. pH 7.38, Paco2 5.3 kPa, Pao2 8.1 kPa, bicarbonate 30 mmol/l
. pH 7.38, Paco2 8.3 kPa, Pao2 8.1 kPa, bicarbonate 38 mmol/l
. pH 7.54, Paco2 3.3 kPa, Pao2 9.1 kPa, bicarbonate 24 mmol/l

Correct Answer & Explanation

. pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/l

Explanation

Correct Answer: B- pH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/ ExplanationpH 7.24, Paco2 9.3 kPa, Pao2 8.1 kPa, bicarbonate 29.2 mmol/l This is a ‘know it or you don’t’ question. This patient has acute on chronic respiratory acidosis. In respiratory acidosis there will be raised PaCO2 and hydrogen ion concentration. The elevation of the bicarbonate reflects renal buffering from his chronic respiratory failure. In acute respiratory acidosis every 1-kPa rise in CO2 produces 6 nmol/l of hydrogen ion and a 1-mmol/l increase in bicarbonate. In contrast, in chronic respiratory acidosis, the increase in hydrogen ions per kPa rise in carbon dioxide falls to about 2.5 nmol/l.pH 7.14, Paco2 7.3 kPa, Pao2 9.1 kPa, bicarbonate 14 mmol/lpH 7.14, Paco2 7.3 kPa, Pao2 9.1 kPa, bicarbonate 14 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.pH 7.38, Paco2 5.3 kPa, Pao2 8.1 kPa, bicarbonate 30 mmol/lpH 7.38, Paco2 5.3 kPa, Pao2 8.1 kPa, bicarbonate 30 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.pH 7.38, Paco2 8.3 kPa, Pao2 8.1 kPa, bicarbonate 38 mmol/lpH 7.38, Paco2 8.3 kPa, Pao2 8.1 kPa, bicarbonate 38 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.pH 7.54, Paco2 3.3 kPa, Pao2 9.1 kPa, bicarbonate 24 mmol/lpH 7.54, Paco2 3.3 kPa, Pao2 9.1 kPa, bicarbonate 24 mmol/l is incorrect. These results would not be expected with this man’s clinical presentation.

Question 908

Topic: Infection, Pharmacology & VTE
A 64-year-old woman is referred to the medical team from the orthopaedic ward. She underwent a right total hip replacement 6 days ago. She is known to suffer from mild chronic obstructive pulmonary disease and is on regular inhaled steroids and a short-acting β2-agonist. She now complains of left-sided chest pain and is also dyspnoeic. Your clinical diagnosis is pulmonary embolism. Which one of the following would not be a feature of pulmonary embolism in this patient?
. Bradycardia
. Dyspnoea
. Fever
. New-onset atrial fibrillation
. Tachypnoea

Correct Answer & Explanation

. Bradycardia

Explanation

Bradycardia is not a feature of pulmonary embolism. The clinical features of pulmonary embolism include dyspnoea, tachypnoea (respiratory rate > 20/min), tachycardia, atrial flutter/fibrillation, and fever.

Question 909

Topic: Biology, Genetics & Bone Healing

Which of the following Bone Morphogenetic Proteins (BMPs) is an FDA-approved osteoinductive agent currently utilized as an alternative to autologous bone graft in single-level anterior lumbar interbody fusion (ALIF)?

. BMP-2
. BMP-3
. BMP-4
. BMP-7
. BMP-9

Correct Answer & Explanation

. BMP-2

Explanation

Recombinant human BMP-2 (rhBMP-2) is utilized in spine surgery as a potent osteoinductive agent and is FDA-approved for specific fusions like ALIF. BMP-3 actually inhibits osteogenesis, and BMP-7 (OP-1) was previously used for nonunions but has less commercial utilization today.

Question 910

Topic: 1. General Principles & Basic Science

When inserting a cortical screw, increasing the core diameter of the screw primarily affects which of its mechanical properties?

. Increases pullout strength
. Decreases pullout strength
. Increases bending strength (fatigue resistance)
. Decreases torsional strength
. Increases the thread pitch

Correct Answer & Explanation

. Increases bending strength (fatigue resistance)

Explanation

The core diameter of a screw is the most critical factor determining its bending strength and fatigue resistance (proportional to the radius to the 4th power). Conversely, pullout strength is primarily determined by the outer diameter and thread depth.

Question 911

Topic: 1. General Principles & Basic Science

In articular cartilage, which zone is characterized by the highest concentration of proteoglycans, the lowest water content, and chondrocytes arranged in vertical columns?

. Superficial zone
. Transitional (middle) zone
. Deep (radial) zone
. Calcified zone
. Tidemark

Correct Answer & Explanation

. Deep (radial) zone

Explanation

The deep (radial) zone of articular cartilage contains the highest concentration of proteoglycans and the lowest water content. Its collagen fibers and chondrocytes are organized in vertical columns perpendicular to the articular surface to resist compressive loads.

Question 912

Topic: 1. General Principles & Basic Science

Following a primary repair of a Zone II flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) laceration, which of the following rehabilitation protocols is best supported by current evidence to maximize tendon excursion and minimize adhesions without risking rupture?

. Strict immobilization in a cast for 6 weeks
. Early active mobilization protocols with dorsal block splinting
. Immediate unresisted full active motion in all planes
. Continuous passive motion machine use exclusively for 4 weeks
. Dynamic extension splinting with no active flexion

Correct Answer & Explanation

. Early active mobilization protocols with dorsal block splinting

Explanation

Early active motion protocols (using a dorsal blocking splint to prevent hyperextension) are favored for Zone II flexor tendon repairs. They have been shown to significantly decrease tendon adhesions and improve functional outcomes compared to static immobilization.

Question 913

Topic: Biology, Genetics & Bone Healing

During open reduction and internal fixation of a transverse diaphyseal fracture, a surgeon applies a dynamic compression plate to achieve absolute stability and rigid fixation. Which mode of bone healing is primarily expected under these biomechanical conditions?

. Secondary bone healing via cartilaginous callus formation
. Primary bone healing via direct Haversian remodeling
. Endochondral ossification
. Intramembranous ossification with exuberant periosteal callus
. Fibrous nonunion progression

Correct Answer & Explanation

. Primary bone healing via direct Haversian remodeling

Explanation

Absolute stability (e.g., via compression plating) eliminates interfragmentary motion, leading to primary bone healing. This process occurs via cutting cones and direct Haversian remodeling without the formation of a visible fracture callus.

Question 914

Topic: Biology, Genetics & Bone Healing

In aseptic loosening of a total hip arthroplasty, particulate wear debris initiates a macrophage-mediated inflammatory response. What is the critical final common pathway mediator directly responsible for osteoclast activation in this process?

. Tumor necrosis factor-alpha (TNF-alpha)
. Receptor activator of nuclear factor kappa-B ligand (RANKL)
. Interleukin-1 (IL-1)
. Transforming growth factor-beta (TGF-beta)
. Platelet-derived growth factor (PDGF)

Correct Answer & Explanation

. Receptor activator of nuclear factor kappa-B ligand (RANKL)

Explanation

While macrophages release inflammatory cytokines like TNF-alpha and IL-1 in response to wear debris, RANKL is the essential final common pathway mediator. RANKL binds to RANK on osteoclast precursors, stimulating their differentiation and leading to osteolysis.

Question 915

Topic: 1. General Principles & Basic Science
A 32-year-old patient with asthma has been stable with inhaled salbutamol when required. Recently she has had to use her inhaler more frequently and also at night. What is the next step in her therapy?
. Addition of oral corticosteroids
. Addition of oral leukotriene-receptor antagonist
. Addition of oral theophylline
. Inhaled ß2-agonist at maximum dose
. Regular inhaled budesonide, inhaled salbutamol when required

Correct Answer & Explanation

. Regular inhaled budesonide, inhaled salbutamol when required

Explanation

This patient requires an escalation in her asthma management. At this stage with frequent use of salbutamol, a regular inhaled steroid for preventative therapy is required. Inhaled budesonide is one appropriate option. Oral corticosteroids are reserved for step-5 management of asthma that is not controlled with inhaled steroids, long-acting bronchodilators, and additional oral therapies such as montelukast. Oral leukotriene-receptor antagonists are indicated as a trial after low-dose inhaled corticosteroids. Oral theophylline is indicated after maximal inhaled corticosteroids and LABA if the asthma is still not controlled. The deterioration of symptoms on short-acting ß2-agonist monotherapy indicates inhaled steroids are required, i.e., step-2 asthma therapy.

Question 916

Topic: 1. General Principles & Basic Science
A 58-year-old woman is admitted to the emergency department with suspected community-acquired pneumonia. She has a progressively worsening cough, productive of rusty sputum, and shortness of breath over the past 3 days. She smokes five cigarettes per day, has hypertension treated with lisinopril, but no other significant past medical history. On examination, her BP is 105/60 mmHg; pulse is 85/min and regular. There are signs of right lower lobe consolidation on auscultation. Respiratory rate is raised at 32, O2 sats on 40% O2 are 96%. Investigations: Hb 13.1 g/dl, WCC 15.8 × 10^9/l, PLT 203 × 10^9/l, CRP 230 mg/l, Na+ 138 mmol/l, K+ 4.5 mmol/l, Creatinine 122 μmol/l, Urea 6.9 mmol/l. According to CURB-65 criteria, which of the following is a measure of increased severity?
. Age 58
. CRP 230 mg/l
. Respiratory rate 32/min
. Urea 6.9 mmol/l
. WCC 15.8 × 10^9/l

Correct Answer & Explanation

. Respiratory rate 32/min

Explanation

Correct Answer: Respiratory rate 32/min. CURB-65 criteria provide a standardised assessment of the severity of pneumonia: confusion (AMT ≤ 8), urea > 7 mmol/l, respiratory rate ≥ 30 breaths per minute, blood pressure < 90 mmHg systolic or ≤ 60 mmHg diastolic, and age ≥ 65. Age 58 is incorrect as the threshold is 65. CRP is not a component of the CURB-65 score. Urea 6.9 mmol/l is below the threshold of 7 mmol/l. WCC is not part of the CURB-65 score.

Question 917

Topic: 1. General Principles & Basic Science

A 65-year-old man known to have chronic obstructive pulmonary disease presented with progressive respiratory failure. He was treated in the Intensive Care Unit with mechanical ventilation and he improved. After extubation he was transferred to the ward. On the 2nd day on the ward his temperature spiked and he developed a productive cough with a yellow-green sputum. Blood results showed leucocytosis. A chest X-ray revealed a right-sided middle- and lower-lobe pneumonia. What is the most probable cause of his pneumonia?

. Aspiration pneumonia
. Haemophilus pneumonia
. Pneumococcal pneumonia
. Pseudomonal pneumonia
. Staphylococcal pneumonia

Correct Answer & Explanation

. Pseudomonal pneumonia

Explanation

Correct Answer: D- Pseudomonal pneumonia Explanation Pseudomonal pneumonia Pseudomonas is a common pathogen in patients with bronchiectasis and cystic fibrosis. It also causes hospital- acquired infections, particularly in intensive care units or after surgery. Nosocomial or hospital-acquired infections should be suspected in patients with an onset of symptoms at least 48 hours after admission to the hospital. The sputum colour also gives a clue to the most likely diagnosis. Treatment is with anti-pseudomonal penicillin, ceftazidime, meropenem or ciprofloxacin. Aspiration pneumonia Aspiration pneumonia is incorrect. There is no history given to suggest this gentleman has aspirated. Haemophilus pneumonia Haemophilus pneumonia is incorrect. Haemophilus pneumoniae is more typically seen as a cause of community acquired pneumonia. Pneumococcal pneumonia Pneumococcal pneumonia is incorrect. Pneumcoccal pneumonias are usually community acquired. This man has a nosocomial pneumonia and is likely associated with being invasively ventilated. Pseudomonas aeruginosa is a common cause of ventilator associated pneumonia. Staphylococcal pneumonia Staphylococcal pneumonia is incorrect. Staphylococcal pneumonias are typically seen in immunosuppressed patients and intravenous drug abusers or following a viral respiratory tract infection. Staphylococcus aureus can be a cause of nosocomial pneumonia but ventilator associated pneumonias occurring late into an admission are typically due to gram negative bacteria and therefore Pseudomonal pneumonia is more likely in this case.

Question 918

Topic: 1. General Principles & Basic Science

A 32-year-old nurse who has had a positive tuberculin skin test comes to you for advice. She had been in contact with a patient who had pulmonary tuberculosis some 6 days earlier, and has not received a BCG vaccination in the past. She is well and her chest X-ray is normal. She has started a course of isoniazid and rifampicin. Which of the following is the most appropriate occupational health advice?

. Continue isoniazid and rifampicin for at least 3 months
. Continue isoniazid and rifampicin for 1 month then isoniazid for a further 2 months
. Stay off work and have a repeat chest X-ray in 6 weeks
. Stay off work for 2 weeks while she is on the initial prophylactic isoniazid course
. Stay off work for 6 weeks

Correct Answer & Explanation

. Continue isoniazid and rifampicin for at least 3 months

Explanation

Correct Answer: A- Continue isoniazid and rifampicin for at least 3 months Explanation Continue isoniazid and rifampicin for at least 3 months The National Institute for Health and Care Excellence (NICE) Guideline 33 suggests that healthcare workers with a positive tuberculin test after exposure to tuberculosis (TB) should be treated with a combination of isoniazid and rifampicin for 3 months or isoniazid alone for a period of 6 months. The positive tuberculin test raises the possibility of latent TB infection in this healthcare worker, which can be associated with a not inconsiderable risk of infection for patients if there is later development of pulmonary TB. Continue isoniazid and rifampicin for 1 month then isoniazid for a further 2 months Continue isoniazid and rifampicin for 1 month then isoniazid for a further 2 months is incorrect. The National Institute for Health and Care Excellence (NICE) Guideline 33 suggests that healthcare workers with a positive tuberculin test after exposure to TB should be treated with a combination of isoniazid and rifampicin for 3 months or isoniazid alone for a period of 6 months. The positive tuberculin test raises the possibility of latent TB infection in this healthcare worker, which can be associated with a not inconsiderable risk of infection for patients if there is later development of pulmonary TB. Stay off work and have a repeat chest X-ray in 6 weeks Stay off work and have a repeat chest X-ray in 6 weeks is incorrect. There is no evidence this lady has active TB. She has latent TB, which is not infectious, and therefore she need not stay off work if she is well. Stay off work for 2 weeks while she is on the initial prophylactic isoniazid course Stay off work for 2 weeks while she is on the initial prophylactic isoniazid course is incorrect. There is no evidence this lady has active TB. She has latent TB, which is not infectious, and therefore she need not stay off work if she is well. Stay off work for 6 weeks Stay off work for 6 weeks is incorrect. There is no evidence this lady has active TB. She has latent TB, which is not infectious, and therefore she need not stay off work if she is well.

Question 919

Topic: 1. General Principles & Basic Science
A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting β2-agonists (salmeterol), oral leukotriene-receptor antagonists, and inhaled short-acting β2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy?
. Antibiotics
. Oral cromoglicate
. Oral steroids
. Oral theophylline
. Switch to nebuliser

Correct Answer & Explanation

. Oral theophylline

Explanation

Correct Answer: Oral theophylline. Theophylline is indicated in the treatment of chronic asthma when symptoms are not controlled despite inhaled corticosteroids, long-acting β-agonists, and leukotriene receptor antagonists. Antibiotics are only indicated for infective exacerbations. Oral cromoglicate is not used for asthma (inhaled is). Oral steroids are reserved for acute exacerbations or 'step 5' treatment. Nebulised salbutamol is reserved for acute exacerbations.

Question 920

Topic: 1. General Principles & Basic Science

A 36-year-old lorry driver who smokes heavily has been complaining of a 2-day history of cough associated with fever. He also complains of right-sided chest pain on inspiration. On examination, he is slightly cyanosed, has a temperature of 38 °C, a respiratory rate of 38/min, a BP of 100/70 mm/Hg and a pulse rate of 130 bpm. He has basal crepitations and dullness to percussion at the right lung base. What is the most likely diagnosis?

. Atelectasis due to carcinoma of the lung
. Lobar pneumonia
. Mesothelioma
. Pneumothorax
. Tuberculosis

Correct Answer & Explanation

. Lobar pneumonia

Explanation

Correct Answer: B- Lobar pneumonia Explanation Lobar 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. Examination of the lung might reveal decreased vesicular breath sounds, localised foci of crepitations, dullness to percussion and sometimes bronchial wheeze. The chest X-ray is a pivotal test for the confirmation of pneumonia. Atelectasis due to carcinoma of the lung Atelectasis due to carcinoma of the lung is incorrect. The acute history associated with signs of infection and the relatively young age of this patient make a diagnosis of pneumonia more likely than lung cancer with atelectasis. Mesothelioma Mesothelioma is incorrect. There is no history suggestive of asbestos exposure here. The acute nature of this gentleman’s symptoms combined with evidence of infection make pneumonia a more likely diagnosis. Mesothelioma would typically have a more gradual onset of symptoms and present with progressive dyspnoea and/or chest pain. Pneumothorax Pneumothorax is incorrect. The history is compatible with infection and the signs are not compatible with pneumothorax. In pneumothorax clinical examination would reveal decreased air entry and hyper resonance to percussion. Tuberculosis Tuberculosis is incorrect. The history given is of respiratory infection, so tuberculosis is a possibility; however, nothing in the history suggests an increased risk of tuberculosis (eg previous TB, contact with patients known to have TB, immunosuppression, alcoholism). Therefore a bacterial pneumonia is more likely.

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