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1. General Principles & Basic Science MCQs

Practice Set 48 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 941

Topic: 1. General Principles & Basic Science

Which one of the following features is encountered least frequently in patients with sleep apnoea syndrome?

. Daytime sleepiness
. Female gender
. Hypertension
. Large neck size
. Snoring

Correct Answer & Explanation

. Female gender

Explanation

Correct Answer: B- Female gender Explanation Female gender Typically patients are male, middle aged and obese. Daytime sleepiness Daytime sleepiness is incorrect. Daytime sleepiness is a cardinal feature of obstructive sleep apnoea syndrome (OSAS). Other symptoms include night sweats, personality change, morning confusion and headache. Hypertension Hypertension is incorrect. Hypertension is commonly associated with OSAS. There might be an associated increased risk of pulmonary hypertension and cardiac arrhythmias. Large neck size Large neck size is incorrect. Large neck size (typically collar size > 17 inches) is classically associated with OSAS. Snoring Snoring is incorrect. Snoring is another cardinal feature of OSAS.

Question 942

Topic: 1. General Principles & Basic Science

A 26-year-old patient admitted with suspected pneumonia and an abnormal chest X-ray mentions to the attending physician that he has an azygos lobe. Where would you visualise the azygos lobe on an anterior–posterior chest X-ray?

. Left lower zone
. Left upper zone
. Right lower zone
. Right middle zone
. Right upper zone

Correct Answer & Explanation

. Right upper zone

Explanation

Correct Answer: E- Right upper zone Explanation Right upper zone This is a ‘know it or you don’t’ question. An azygos lobe is seen in about 0.5% of routine chest X-rays and is a normal variant. It is seen as a ‘reverse comma sign’ behind the medial end of the right clavicle. Left lower zone Left lower zone is incorrect. An azygos lobe is seen as a ‘reverse comma sign’ behind the medial end of the right clavicle. Left upper zone Left upper zone is incorrect. An azygos lobe is seen as a ‘reverse comma sign’ behind the medial end of the right clavicle. Right lower zone Right lower zone is incorrect. An azygos lobe is seen as a 'reverse comma sign' behind the medial end of the right clavicle. Right middle zone Right middle zone is incorrect. An azygos lobe is seen as a 'reverse comma sign' behind the medial end of the right clavicle.

Question 943

Topic: Infection, Pharmacology & VTE

A 70-year-old woman with a history of rheumatoid arthritis comes to the clinic for review. Recently she has been suffering from increased shortness of breath. She takes diclofenac and methotrexate for her arthritis. Other history of note includes smoking of ten cigarettes per day. On examination, her blood pressure is 145/82 mmHg and she is mildly clubbed. On auscultation there are inspiratory crackles throughout both lung fields.

Investigation:

Hb 12.2 g/dl

WCC 5.6 x 109/l

PLT 200 x 109/l

Sodium 139 mmol/l

Potassium 4.9 mmol/l

Creatinine 139 µmol/l Anti-GBM antibodies Negative

FEV1 84%

FVC 81% Gas transfer coefficient (Kco) Reduced pO2 7.8 kPa

pCO2 3.5 kPa What is the most likely diagnosis?

. Asthma
. Chronic obstructive pulmonary disease
. Methotrexate pneumonitis
. Pulmonary embolus
. Pulmonary haemorrhage

Correct Answer & Explanation

. Methotrexate pneumonitis

Explanation

Correct Answer: C- Methotrexate pneumonitis Explanation Methotrexate pneumonitis The lung function picture, coupled with bibasal crackles and the patient taking a medication known to be capable of causing pneumonitis is consistent with methotrexate pneumonitis. Management includes cessation of methotrexate, cessation of smoking and supplemental oxygen therapy. Corticosteroids may also be of value. Other drugs which can lead to pulmonary fibrosis include bleomycin, busulfan, amiodarone, gold, penicillamine, crack cocaine and heroin. Asthma Asthma is incorrect. Asthma would be associated with bilateral wheeze rather than crackles and obstructive spirometry with a likely normal Kco. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease is incorrect.Although this woman smokes, the forced expiratory volume in 1 s (FEV1) is not disproportionately reduced, so fibrosis rather than obstruction is the more likely cause. Pulmonary embolus Pulmonary embolus is incorrect. This is not a presentation of pulmonary embolus, where one might suspect a clear chest to auscultation, pleurituc chest pain +/- evidence of deep vein thrombosis (DVT). The presence of crackles along with the pulmonary functiontest results and the medication history make methotrexate pneumonitis the most likely option. Pulmonary haemorrhage Pulmonary haemorrhage is incorrect. The reduced gas transfer coefficient (Kco) and anti-glomerular basement membrane (anti-GBM) antibody negativity make pulmonary haemorrhage less likely.

Question 944

Topic: 1. General Principles & Basic Science

Which one of the following statements about the FEF25%–75% (forced expiratory flow rate between 25% and 75% of the forced vital capacity) in pulmonary function tests is true?

. It is effort-dependent
. It is not affected in smokers
. It is not impaired in bronchiolitis obliterans
. It is useful to identify tracheal obstruction
. It reflects the status of the small airways

Correct Answer & Explanation

. It reflects the status of the small airways

Explanation

Correct Answer: E- It reflects the status of the small airways Explanation It reflects the status of the small airways The forced expiratory flow rate between 25% and 75% of the forced vital capacity (FEF25%–75%) primarily reflects the status of the small airways. It is more sensitive than the forced expiratory volume in 1 second (FEV1) for identifying early airway obstruction. It is effort-dependent It is effort-dependent is incorrect. FEF25%–75% is effort-independent. This portion of the flow volume curve is the most effort independent portion. It is not affected in smokers It is not affected in smokers is incorrect. FEF25%–75% is impaired in smokers and in patients with graft versus host disease who have associated lung pathology. It is not impaired in bronchiolitis obliterans It is not impaired in bronchiolitis obliterans is incorrect. FEF25%–75% is impaired in bronchiolitis obliterans. It is useful to identify tracheal obstruction It is useful to identify tracheal obstruction is incorrect. FEF25%–75% is not useful for identifying large airway disease.

Question 945

Topic: 1. General Principles & Basic Science

A 44-year-old woman who is known to have brittle asthma is admitted to the Emergency Department. She is started on a Venturi mask designed to deliver 40% O2. How does the Venturi mask achieve this?

. Air entrainment
. Intermittent positive pressure
. Passive mixing of air and O2
. Rebreathing delivered O2
. Turbulent flow

Correct Answer & Explanation

. Air entrainment

Explanation

Correct Answer: A- Air entrainment Explanation The Venturi effect is the reduction in pressure when a fluid flows through a constricted portion of pipe, probably related to an increase in its velocity. The effect is employed in the development of Venturi masks, where the reduction in pressure along a narrowed portion of the mask leads to entrainment of air, mixing inspired O2 with room air to deliver a specific percentage of O2 at a specific flow rate. Intermittent positive pressure Intermittent positive pressure (Option B) is incorrect. In Venturi masks the reduction in pressure along a narrowed portion of the mask leads to entrainment of air. Passive mixing of air and O2 Passive mixing of air and O2 (Option C) is incorrect. Rebreathing delivered O2 Rebreathing delivered O2 (Option D) is incorrect. In Venturi masks the reduction in pressure along a narrowed portion of the mask leads to entrainment of air. Turbulent flow Turbulent flow (Option E) is incorrect. In Venturi masks the reduction in pressure along a narrowed portion of the mask leads to entrainment of air.

Question 946

Topic: 1. General Principles & Basic Science

A 51-year-old lifelong smoker, who has worked for many years in a shipyard, presents with a 7- month history of increasing breathlessness. On examination, he has a blood pressure of 145/85 mmHg and a pulse of 75 bpm; his body mass index (BMI) is 31 kg/m2 and he also appears to have finger clubbing. Auscultation of the chest reveals bibasal inspiratory crackles. The chest X- ray is reported as showing evidence of pleural plaques. Pulmonary function testing reveals a mixed obstructive/restrictive picture. Which of the following is the most likely cause of his breathlessness?

. Asbestosis
. Asbestos-related pleural plaques
. Chronic obstructive pulmonary disease
. Idiopathic pulmonary fibrosis
. Obesity

Correct Answer & Explanation

. Asbestosis

Explanation

Correct Answer: A- Asbestosis Explanation Asbestosis Shipbuilding, car manufacture, boiler making and plumbing industries are all associated with a risk of asbestos exposure. Hence this man’s occupation puts him at significant risk. The findings on auscultation of the chest, coupled with the finger clubbing and the restrictive component seen on pulmonary function testing all point towards asbestos-related pulmonary fibrosis (asbestosis). Asbestos-related pleural plaques Asbestos-related pleural plaques is incorrect. Although this man does indeed have asbestos-related pleural plaques seen on chest X-ray, plaques themselves are not thought to contribute to breathlessness. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease is incorrect. The crackles, clubbing and evidence of airflow restriction are not in keeping with breathlessness secondary to chronic obstructive pulmonary disease. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. There is a clear occupational history here suggesting asbestos exposure. Therefore asbestosis is more likely than idiopathic pulmonary fibrosis. Obesity Obesity is incorrect. There is clearly more than obesity going on here to account for his breathlessness given the auscultation and investigation findings.

Question 947

Topic: 1. General Principles & Basic Science

A 50-year-old man patient was referred by his GP because of a long-standing history of persistent cough productive of mucopurulent sputum. He also noticed increasing shortness of breath. The patient has been treated several times for recurrent chest infections. What is the most likely diagnosis?

. Asthma
. Bronchiectasis
. Chronic cardiac failure
. Extrinsic allergic alveolitis
. Lung cancer

Correct Answer & Explanation

. Bronchiectasis

Explanation

Correct Answer: B- Bronchiectasis Explanation Bronchiectasis Bronchiectasis should be suspected when there is a history of persistent cough productive of mucopurulent or purulent sputum throughout the year. Patients have frequently been treated for recurrent chest infections and labelled as ‘bronchitic’, often despite the absence of a history of smoking. Patients can produce mucoid sputum early in their disease, developing purulent sputum when they suffer an exacerbation associated with a viral upper respiratory tract infection. Such exacerbations can be associated with pleuritic chest pain, haemoptysis, fever and sometimes wheeze. People who present as adults often recall a chesty cough or wheezy bronchitis associated with upper respiratory tract infections in childhood, followed by complete resolution of symptoms in their teens and early adult life before these return after a viral trigger. Upper respiratory tract symptoms such as nasal drip are common, and in about 30% of cases there is a history of chronic sinusitis. Patients with bronchiectasis also suffer from undue tiredness, which many find more troublesome than the productive cough. Asthma Asthma is incorrect. Asthma is not associated with chronic sputum production; cough in asthma is dry unless there is an intercurrent infection. Chronic cardiac failure Chronic cardiac failure is incorrect. Where cough is present in cardiac failure it is usually associated with frothy sputum. The description here of chronic purulent sputum is suggestive of bronchiectasis. Extrinsic allergic alveolitis Extrinsic allergic alveolitis (EAA) is incorrect. EAA is not associated with a chronic productive cough. Furthermore, there is no mention of any potential allergen to induce EAA. Lung cancer Lung cancer is incorrect. Lung cancer can be associated with cough, but would not usually be a cough persistently productive of mucopurulent sputum. Given that no smoking history or other ‘red flag’ symptoms are mentioned (eg haemoptysis), bronchiectasis is a more likely diagnosis.

Question 948

Topic: 1. General Principles & Basic Science
A 38-year-old school teacher from an inner city primary school comes for review in the Emergency Department. She has a chronic cough, night sweats, and has lost weight over the past few weeks. Over the past few days, she has begun to suffer increasing occipital headaches and drowsiness. She smokes 15 cigarettes per day. On examination in the Emergency Department, she is pyrexial 37.9 °C, her BP is 122/70 mmHg, and her pulse is 75/min and regular. There are scattered crackles and wheeze on auscultation of the chest. Investigations: Hb 10.9 g/dl, WCC 12.9 × 10^9/l, PLT 201 × 10^9/l, Na+ 133 mmol/l, K+ 4.9 mmol/l, Creatinine 105 μmol/l, CSF lymphocytosis, opening pressure 24 cm H2O, protein 1.5 g/l, TB PCR positive. Which of the following is the optimal initial drug regimen?
. Amikacin, isoniazid, levofloxacin, rifampicin
. Isoniazid, pyrazinamide, levofloxacin, ethambutol, prednisolone
. Isoniazid, pyrazinamide, rifampicin, ethambutol, prednisolone
. Isoniazid, rifampicin, azithromycin, ethambutol
. Isoniazid, rifampicin, azithromycin, ethambutol, prednisolone

Correct Answer & Explanation

. Isoniazid, pyrazinamide, rifampicin, ethambutol, prednisolone

Explanation

NICE guidelines recommend the following: Patients with active meningeal tuberculosis (TB) should be offered a treatment regimen, initially lasting for 12 months, comprising isoniazid, pyrazinamide, rifampicin and a fourth drug (for example, ethambutol) for the first 2 months, followed by isoniazid and rifampicin for the rest of the treatment period; a glucocorticoid at the normal dose range (in adults equivalent to prednisolone 20–40 mg if on rifampicin, otherwise 10–20 mg); with gradual withdrawal of the glucocorticoid considered, starting within 2–3 weeks of initiation.

Question 949

Topic: 1. General Principles & Basic Science

A 25-year-old man with a known history of alcohol and drug abuse presents with a 14-day history of fever, dry cough and tiredness. He is emaciated. His temperature is 39.4°C and he has cervical and axillary lymphadenopathy. His chest X-ray shows bilateral pulmonary shadowing. What is the most likely cause for his illness?

. Alcoholic cardiomyopathy
. Pneumococcal pneumonia
. Pneumocystis pneumonia
. Pulmonary tuberculosis
. Tricuspid endocarditis

Correct Answer & Explanation

. Pneumocystis pneumonia

Explanation

Correct Answer: C- Pneumocystis pneumonia Explanation Pneumocystis pneumonia The history is suggestive that the patient is immunocompromised. Pneumocystis pneumonia can present with a normal X-ray or bilateral interstitial shadowing, which is often perihilar in distribution. Both tuberculosis and Pneumocystisinfection are likely in an immunocompromised patient, but the X- ray findings (i.e. the bilateral nature of the changes) are more suggestive of Pneumocystis rather than tuberculous infection. Alcoholic cardiomyopathy Alcoholic cardiomyopathy is incorrect. The clinical picture is one of infective pneumonia rather than of alcoholic cardiomyopathy. Pneumococcal pneumonia Pneumococcal pneumonia is incorrect. Pneumococcal pneumonia usually presents with lobar consolidation. Pulmonary tuberculosis Pulmonary tuberculosis is incorrect. Pulmonary tuberculosis, which is increasing in prevalence (especially in immunocompromised patients), might manifest as consolidation, cavitation, fibrosis and calcification on a chest X-ray but does not usually present with such a high fever. Tricuspid endocarditis Tricuspid endocarditis is incorrect. The clinical picture is one of infective pneumonia rather than of tricuspid endocarditis.

Question 950

Topic: 1. General Principles & Basic Science

A 45-year-old man, presenting with weight loss and cough, is found to have small-cell lung cancer. Which of the following best describes the additional biochemical and clinical features that can occur in this condition?

. Acidosis is commonly seen
. Cushing syndrome, if present, is characterised by buffalo hump, striae and central obesity
. Hypercalcaemia is commonly seen
. Hypertrophic pulmonary osteoarthropathy is a very rare feature
. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs in > 60% of cases

Correct Answer & Explanation

. Hypertrophic pulmonary osteoarthropathy is a very rare feature

Explanation

Correct Answer: D- Hypertrophic pulmonary osteoarthropathy is a very rare feature Explanation Hypertrophic pulmonary osteoarthropathy is a very rare feature Hypertrophic pulmonary osteoarthropathy is very rare in small-cell carcinoma of the lung. Acidosis is commonly seen Acidosis is commonly seen is incorrect. Acidosis is rarely seen. Cushing syndrome, if present, is characterised by buffalo hump, striae and central obesity Cushing syndrome, if present, is characterised by buffalo hump, striae and central obesity is incorrect. Due to the short natural history of this type of cancer, Cushing syndrome in small-cell carcinoma does not manifest classically by buffalo hump, striae or central obesity. Its presence is suspected by arterial hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness. Chemotherapy is the treatment of choice. Hypercalcaemia is commonly seen Hypercalcaemia is commonly seen is incorrect. Small- cell carcinoma is rarely associated with hypercalcaemia despite the high incidence of lytic bone metastases. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs in > 60% of cases Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs in > 60% of cases is incorrect. SIADH occurs in 5–10% of cases.

Question 951

Topic: Infection, Pharmacology & VTE

A 68-year-old female undergoes a right total knee arthroplasty. On postoperative day 4, she experiences sudden-onset pleuritic chest pain and dyspnea. Her ECG shows sinus tachycardia with an S1Q3T3 pattern. CT pulmonary angiography confirms a pulmonary embolism. Which of the following is the most appropriate initial treatment?

. Intravenous unfractionated heparin
. Oral rivaroxaban
. Inferior vena cava filter placement
. Systemic tissue plasminogen activator (tPA)
. Pulmonary embolectomy

Correct Answer & Explanation

. Intravenous unfractionated heparin

Explanation

In the acute postoperative period following major orthopedic surgery, a hemodynamically stable patient with a PE should be started on unfractionated heparin. This allows for rapid reversal if surgical site bleeding occurs, compared to DOACs or LMWH.

Question 952

Topic: Infection, Pharmacology & VTE
A 35-year-old farmer sustains a Gustilo-Anderson Type IIIA open tibia fracture heavily contaminated with soil. He has no known drug allergies. According to current evidence-based guidelines, which of the following is the most appropriate initial antibiotic regimen?
. Intravenous cefazolin only
. Intravenous cefazolin and an aminoglycoside
. Intravenous cefazolin and high-dose penicillin
. Intravenous ceftriaxone and clindamycin
. Intravenous vancomycin and piperacillin-tazobactam

Correct Answer & Explanation

. Intravenous cefazolin and high-dose penicillin

Explanation

For heavily contaminated agricultural wounds (high risk for Clostridium species), the addition of penicillin to a first-generation cephalosporin (or aminoglycoside combination) is recommended. This high-dose penicillin specifically helps prevent severe gas gangrene infections.

Question 953

Topic: Infection, Pharmacology & VTE

A 72-year-old male with a history of recurrent deep vein thrombosis and a known Factor V Leiden mutation is scheduled for an elective total hip arthroplasty. According to AAOS guidelines, which of the following is the most appropriate chemoprophylaxis strategy for this high-risk patient?

. Aspirin 81 mg twice daily for 2 weeks
. Low molecular weight heparin for up to 35 days
. Mechanical prophylaxis only
. Warfarin with a target INR of 1.5-2.0 for 14 days
. Inferior vena cava filter placement preoperatively

Correct Answer & Explanation

. Low molecular weight heparin for up to 35 days

Explanation

In patients at high risk for venous thromboembolism (VTE), such as those with known hypercoagulable states or prior DVT, aggressive pharmacologic prophylaxis like LMWH for up to 35 days postoperatively is recommended. Aspirin alone is insufficient for high-risk profiles.

Question 954

Topic: Biology, Genetics & Bone Healing

A 31-year-old male with a severe traumatic brain injury undergoes open reduction and internal fixation of an acetabular fracture. To prevent heterotopic ossification (HO), indomethacin is prescribed. What is the primary mechanism of action by which indomethacin prevents HO?

. Inhibition of osteoclast activity via RANKL suppression
. Direct inhibition of osteoblast differentiation from mesenchymal stem cells
. Inhibition of cyclooxygenase-mediated prostaglandin E2 (PGE2) synthesis
. Suppression of bone morphogenetic protein 2 (BMP-2) expression
. Upregulation of osteoprotegerin (OPG) in the fracture hematoma

Correct Answer & Explanation

. Inhibition of cyclooxygenase-mediated prostaglandin E2 (PGE2) synthesis

Explanation

Indomethacin is an NSAID that prevents heterotopic ossification by inhibiting the cyclooxygenase (COX) enzymes, thereby decreasing the synthesis of prostaglandins (specifically PGE2). PGE2 is a crucial mediator in the differentiation of mesenchymal stem cells into osteoblasts.

Question 955

Topic: 1. General Principles & Basic Science

A 55-year-old diabetic male presents with a rapidly expanding area of erythema, swelling, and extreme pain out of proportion to exam on his right lower leg. Crepitus is palpated, and a plain radiograph shows gas in the soft tissues. What is the most critical immediate step in management?

. STAT MRI of the lower extremity
. Broad-spectrum intravenous antibiotics and observation
. Hyperbaric oxygen therapy
. Emergent radical surgical debridement
. Vascular surgery consultation for suspected ischemia

Correct Answer & Explanation

. Emergent radical surgical debridement

Explanation

The clinical picture and gas in the soft tissues are pathognomonic for necrotizing fasciitis. While broad-spectrum antibiotics are necessary, emergent and aggressive surgical debridement is the definitive and life-saving treatment and must not be delayed for imaging.

Question 956

Topic: 1. General Principles & Basic Science
A new laboratory test trialled in 10,000 people showed a positive result in 11 people. Of the 10,000, 11 people have cystic fibrosis and ten of the 11 had a positive test result. What is the sensitivity of the test for cystic fibrosis?
. 0.01
. 0.09
. 0.1
. 0.9
. 1

Correct Answer & Explanation

. 0.9

Explanation

Correct Answer: 0.9. Sensitivity refers to the proportion of people with disease that have a positive test result. Sensitivity = a/(a + c). In this case, 10/11 = 0.9.

Question 957

Topic: 1. General Principles & Basic Science

A 40-year-old man complains of increasing shortness of breath and his chest X-ray shows an elevated hemidiaphragm on the left side; no other abnormalities are seen. What is the most likely investigation to elucidate the mechanical reason for his shortness of breath?

. Computed tomography (CT) thorax scan
. Echocardiography
. Electrocardiogram (ECG)
. Fluoroscopy
. Magnetic resonance imaging (MRI) scan

Correct Answer & Explanation

. Fluoroscopy

Explanation

Correct Answer: D- Fluoroscopy Explanation Fluoroscopy The diagnosis of unilateral paralysis, suggested by asymmetric elevation of the affected hemidiaphragm on X-ray, can be confirmed by fluoroscopy. During a forced inspiratory manoeuvre (the ‘sniff’ test), the unaffected hemidiaphragm descends forcefully, increasing intra- abdominal pressure and pushing the paralysed hemidiaphragm cephalad (paradoxical motion). Fluoroscopy is inaccurate for the diagnosis of bilateral paralysis. Computed tomography (CT) thorax scan Computed tomography (CT) thorax scan is incorrect. CT scan will demonstrate an elevated hemidiaphragm, but dynamic imaging is required to show diaphgragmatic paralysis which is the diagnosis here. Echocardiography Echocardiography is incorrect. The breathlessness here is not cardiac in origin, it is due to diaphragmatic paralysis, therefore cardiac investigations would not be helpful in making a diagnosis here. Electrocardiogram (ECG) Electrocardiogram (ECG) is incorrect. The breathlessness here is not cardiac in origin, it is due to diaphragmatic paralysis, therefore cardiac investigations would not be helpful in making a diagnosis here. Magnetic resonance imaging (MRI) scan Magnetic resonance imaging (MRI) scan is incorrect.Although MRI may demonstrate a structural defect, it is not a dynamic investigation and would not be the most helpful here.

Question 958

Topic: Infection, Pharmacology & VTE

A 20-year-old woman complains of a sudden onset of dyspnoea associated with pleuritic chest pain. She takes the oral contraceptive pill, and has a BMI of 31. Her O2 saturation is 92% on air. Chest X- ray is reported as normal, pregnancy test is negative. Which of the following methods of assessment is the most appropriate to confirm your diagnosis of pulmonary embolism?

. CTPA
. d-Dimer
. Echocardiography
. Right heart catheterisation
. Ventilation perfusion scan

Correct Answer & Explanation

. CTPA

Explanation

Correct Answer: A- CTPA Explanation CTPA CT pulmonary angiogram (CTPA), widely available in most Emergency units, is now seen as the diagnostic test of choice for for pulmonary embolus. d-Dimer d- Dimer is incorrect. A negative d-dimer test is useful for excluding pulmonary embolism (PE) in patients who are clinically thought to be at low risk, but a ‘positive’ result does not establish the diagnosis. We do not have full clinical information here to calculate this lady’s Well’s score, but it is likely she would be classed as high risk and therefore d-dimer testing would be inappropriate. Echocardiography Echocardiography is incorrect. Echocardiography might show right ventricular dilatation and evidence of pulmonary hypertension, which, in the proper clinical setting, might strengthen the clinical impression that a PE has occurred; however, a CTPA is the most likely test to give a definitive diagnosis here. Right heart catheterisation Right heart catheterisation is incorrect. Right heart catheterisation is not available in all hospitals and is an invasive investigation that should not be used to diagnose PE. If PE is present, this test will show elevated right heart pressures and pulmonary hypertension. In a small number of patients with massive PE, right heart catheterisation may be used to perform percutaneous thrombectomy to administer local thrombolysis to the site of the PE if there are contraindications to systemic thrombolysis. Ventilation perfusion scan Ventilation perfusion scan is incorrect. Ventilation/perfusion scans have been superceded by CTPA in the diagnostic work up of PE. Their use should now be restricted to individuals with contrast allergy or where the risk from radiation from CTPA is high.

Question 959

Topic: 1. General Principles & Basic Science

A 63-year-old woman who is a lifelong smoker is found to have non-small-cell lung cancer. Which of the symptoms below is most likely to be her presenting symptom?

. Breathlessness
. Chest wall pain
. Cough
. Haemoptysis
. Weight loss

Correct Answer & Explanation

. Cough

Explanation

Correct Answer: C- Cough Explanation Cough Non-small-cell lung cancer can present in a number of different ways. The most common presentation is cough (45%) followed by breathlessness (37%). Chest pain and haemoptysis occur in about a third of patients; anorexia and weight loss affect about a fifth; and 3% experience dysphagia. About 15% of patients are asymptomatic, their lung cancer being detected on a routine chest X-ray being performed for another reason. Breathlessness Breathlessness is incorrect. Cough is the most common presentation affecting 45% of patients compared to 37% of patients for breathlessness. Chest wall pain Chest wall pain is incorrect. Cough is the most common presentation affecting 45% of patients compared to 33% of patients for chest pain. Haemoptysis Haemoptysis is incorrect. Cough is the most common presentation affecting 45% of patients compared to 33% of patients for haemoptysis. Weight loss Weight loss is incorrect. Cough is the most common presentation affecting 45% of patients compared to around 20% of patients for anorexia and weight loss.

Question 960

Topic: 1. General Principles & Basic Science
A 26-year-old woman with previously well-controlled asthma on low-dose Seretide comes to the clinic for review. She has recently discontinued her inhaler and sticks only to PRN salbutamol as she is 4 months pregnant. On examination her BP is 100/60 mmHg, pulse is 79/min and regular. She has bilateral fine wheeze, and a peak flow of 350 l/min (510 predicted). Which of the following is the correct management for her?
. Fluticasone only
. Give monteleukast
. Oral prednisolone
. Restart previous dose of Seretide
. Salmeterol only

Correct Answer & Explanation

. Restart previous dose of Seretide

Explanation

BTS/SIGN guidelines recommend continuing the normal dose of long-acting β-agonists (LABA) and inhaled steroids in pregnancy as there is no evidence of increased risk to the mother or fetus. Restarting the treatment that previously provided effective control is the most appropriate step.

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