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Question 1 of 142
1. Question
A 60 year old lady is on medication for ischaemic heart disease, hypertension and hyperlipidaemia. During the night, she complains of wheezing and shortness of breath. What is the SINGLE most likely medication that is responsible for her symptoms?
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Question 2 of 142
2. Question
A 45 year old chronic smoker attends the outpatient department with complaints of persistent cough and copious amount of purulent sputum. He had a history of measles in the past. On examination, finger clubbing is noted and inspiratory crepitations an auscultation are heard. A chest X-ray shows tram track opacities. What is the SINGLE most likely diagnosis?
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Question 3 of 142
3. Question
A 28 year old male is admitted with acute exacerbation of asthma. He is initially treated with 100% oxygen, salbutamol nebulizers and hydrocortisone 100mg IV. Despite treatment, his oxygen saturation is 89% and respiratory rate is 30 breaths/minute. What is the SINGLE most appropriate next step in management?
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Question 4 of 142
4. Question
A 74 year old man who has been a smoker since he was 20 has recently been diagnosed with small cell lung cancer. What Is the SINGLE most likely serum electrolyte picture that confirms the presence of syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
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Question 5 of 142
5. Question
A 39 year old woman attends the Emergency Department with sudden onset chest pain and shortness of breath. Her observations show the following:
Heart rate 110 beats/minute
Respiratory rate 25 breaths/minute
Oxygen saturation 90%
Temperature 37°C
An arterial blood gas was taken which shows the following:
PaO2 8.5 kPa (>10)
PaCO2 3.7 kPa (4.7-6)
pH 7.50 (7.35-7.45)
Bicarbonate (HCO3-) 21 mmol/L (22-26)
What is the SINGLE most appropriate term to describe her arterial blood gas?
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Question 6 of 142
6. Question
A 27 year old man who is a known asthmatic present to the Emergency Department with shortness of breath. He has a respiratory rate of 25 breaths/minute and a heart rate of 110 beats/minute. He has bilateral wheeze heard on auscultation. He looks drowsy, agitated and has poor respiratory effort. Which of the following is a criteria for life threatening asthma?
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Question 7 of 142
7. Question
A 20 year old man suddenly develops shortness of breath over the last day. It started when he was playing football. The shortness of breath was associated with right sided pleuritic chest pain. On examination, reduced air entry with hyper-resonance was noted over the right lung field. His oxygen saturation was 91% on room air. What is the SINGLE most likely diagnosis?
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Question 8 of 142
8. Question
A 39 year old chronic smoker attends the outpatient department with complaints of persistent cough and copious amount of purulent sputum. He has recurrent chronic chest infections in the past. Finger clubbing is noted in the examination and inspiratory crackles are heard on auscultation. A chest X-ray was done and results were normal. What is the SINGLE most likely diagnosis?
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Question 9 of 142
9. Question
An 83 year old man who has been suffering from chronic obstructive pulmonary disease is presented with marked deterioration at rest. He stopped smoking four years ago and is currently on a combination inhaler of Fastair (formoterol and beclomethasone), as required salbutamol, inhaled tiotropium and theophylline. On examination, his forced expiratory volume in one second (FEV1) is less than 30% and his oxygen saturations are 88% on room air. What is the next MOST appropriate management?
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Question 10 of 142
10. Question
A 29 year old woman has been short of breath for the last 15 hours and is feeling unwell. She has a history of having panic attacks. An arterial blood gas is taken:
PaO2 8.8 kPa (>10)
PaCO2 3.2 kPa (4.7-6)
pH 7.50 (7.35-7.45)
Bicarbonate (HCO3-) 20 mmol/L (22-26)
What is the SINGLE most likely diagnosis?
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Question 11 of 142
11. Question
A 50 year old man has had hoarseness of voice and a left drooping eyelid for the past 2 months. He also has diminished sweating on same side of face. Finger clubbing is noted on examination. He smokes 20 cigarettes a day for the last 30 years. What is the SINGLE most likely diagnosis?
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Question 12 of 142
12. Question
A 55 year old man attends the Emergency Department with acute shortness of breath that has worsened over the past 24 hours. He is known to have severe COPD. His respiratory rate is 30 breaths/minute. An arterial blood gas (ABG) is performed on room air and shows the following:
pH 7.31 (7.35-7.45)
PCO2 12 (4.7-6.0 kPa)
PaO2 11 (10-14 kPa)
Bicarbonate (HCO3) 25 (22-26 mmol/L)
What is the most likely diagnosis based on the ABG findings?
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Question 13 of 142
13. Question
A 54 year old woman attends the Emergency Department with worsening shortness of breath. She is a heavy smoker. There is a stony dullness on percussion of her left lung. Breath sounds are diminished in her left lung. A chest X-ray is seen below:
What is the SINGLE most appropriate management?
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Question 14 of 142
14. Question
A 15 year old boy presents to the Emergency Department with a sudden onset of chest pain and increasing shortness of breath during a beach volleyball game. He has a medical history of asthma and is on a beta-2 agonist inhaler. On examination, there is no cyanosis but there are reduced breath sounds on the left side. Which of the following is the SINGLE most appropriate investigation?
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Question 15 of 142
15. Question
A 56 year old man complains of increased volume of sputum with specks of blood and chest pain. He has a history of recurrent chronic chest infections and deep vein thrombosis which happened 3 years ago. Finger clubbing was noted on examination. A chest X-ray shows tramlines but is otherwise normal. What is the SINGLE most likely diagnosis?
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Question 16 of 142
16. Question
A 75 year old man with a longstanding history of COPD presents to the Emergency Department with acute onset shortness of breath. He has a 30-pack-year smoking history and recently stopped smoking. On examination, he is afebrile, his heart rate is 100 beats/minute, his respiratory rate is 28 breaths/minute, blood pressure is 111/69 mmHg and SpO2 is 82%. Respiratory examination reveals use of accessory muscles of respiration and bilateral wheezing. He was immediately started on oxygen with FiO2 24% via Venturi face mask along with nebulised salbutamol, ipratropium and IV hydrocortisone 100mg. After initial treatment SpO2 is 84%. An ABG was performed which shows:
pH 7.27 (7.35-7.45)
PaO2: 7.6 kPa (10-14 kPa)
PaCO2: 7.0 kPa (4.7-6.0)
Bicarbonate 26 mmol/L (22-26)
Chest X-ray was performed which shows hyperinflated lungs bilaterally. What is the next appropriate treatment for this patient?
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Question 17 of 142
17. Question
A 21 year old man has exercised induced asthma and is using a salbutamol inhaler as required and beclometasone inhaler 400 mcg/day. He complains of wheeze and shortness of breath during exercise despite using salbutamol inhaler just before exercise. What is the SINGLE most appropriate action?
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Question 18 of 142
18. Question
A 38 year old woman is brought to the A&E after falling down the stairs and injuring her rib. She complains of shortness of breath. A chest X-ray was performed to rule out a rib fracture. Bilateral hilar lymphadenopathy was seen on the chest X-ray. On auscultation, there are vesicular breath sounds. On examination, there are red lesions on bath her shins which are tender. What is the SINGLE most likely diagnosis?
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Question 19 of 142
19. Question
A 22 year old, tall thin man comes to the Emergency Department with difficulty breathing and chest pain. It developed 2 hours ago while he was driving. The onset was sudden and without any history of trauma. He has no cardiac or pulmonary problems in the past. His oxygen saturation is 92% on air and his respiratory rate is 26 breaths/minute. What is the SINGLE most appropriate investigation?
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Question 20 of 142
20. Question
A 59 year old chronic smoker presents to his GP clinic with the complaint of breathlessness. His wife, who has accompanied him today, reports that the patient had been having difficulty with breathing especially for the past week. His oxygen saturation was 81% on air, his pulse was 90 beats/minute and his blood pressure was recorded at 110/75 mmHg. He was given nebulised salbutamol and thereafter, his oxygen saturation and symptoms improved. Chronic obstructive pulmonary disease (COPD) was suspected and he was asked to come back another time to perform a spirometry. The spirometry performed on this patient showed a decreased FEV1. A few months later he was referred for a full pulmonary function test for confirmation as he was not responding well. What other findings can also be observed in a patient with COPD in a full pulmonary function test?
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Question 21 of 142
21. Question
A 59 year old woman attends the Emergency Department with sudden onset shortness of breath, and chest pain. She was discharged from the hospital 3 days ago after recovering from a total hip replacement surgery. She was discharged with low molecular weight heparin and has been taking it as prescribed. She denies any history of cardiac or pulmonary diseases. Her oxygen saturation is 96% on room air. She has a heart rate of 80 beats/minute, respiratory rate of 18 breaths/minute and blood pressure of 120/70 mmHg. A chest X-ray and ECG has been performed in the department which was reported as normal. Other imaging of the lungs cannot be carried out immediately. What is the SINGLE most appropriate action?
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Question 22 of 142
22. Question
A 33 year old chronic smoker attends the outpatient department with complaints of persistent cough, copious amount of purulent sputum and dyspnoea. He has a history of recurrent chest infections in the past. Coarse crackles are found at the base of his lung on auscultation. Bronchiectasis is suspected. What is the SINGLE most definitive test to diagnose bronchiectasis?
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Question 23 of 142
23. Question
A 24 year old man presents with acute respiratory distress after being stabbed in the back. The trachea is not deviated, but he has engorged neck veins and reduced air entry on his right chest. He has a blood pressure of 80/50 mmHg, a pulse of 135 beats/minute, and a respiratory rate of 35 breaths/minute. What is the SINGLE most likely diagnosis?
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Question 24 of 142
24. Question
A 62 year old man has been smoking 15 cigarettes a day for the past 40 years. His is a retired builder and has been working since he was 24 years old. He presents with chest pain, shortness of breath, and has lost significant weight over the last couple of years. Chest X-ray shows bilateral fibrosis and left-sided pleural effusion. What is the SINGLE best investigation that will likely lead to a diagnosis?
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Question 25 of 142
25. Question
A 33 year old man has mild headache and myalgia for 2 days followed by high fever, chills, rigors and a cough. His cough was initially dry but progressed to be productive. He has just returned from a conference in Greece where he mentions that he swam and used the hot tubs in the hotel. He has a temperature of 38.1°C and is seen to be dyspnoeic. Chest X-ray shows patchy alveolar infiltrates. What is the SINGLE most likely organism which would have caused his symptoms?
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Question 26 of 142
26. Question
A 28 year old female who has returned from the USA to the UK presents to Accident & Emergency with shortness of breath and a cough beginning 3 days after her return to the United Kingdom. Her cough initially contained blood but is now dry. Her only significant history is that she is on the combined oral contraceptive pill. What is the SINGLE most likely diagnosis for this woman’s symptoms?
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Question 27 of 142
27. Question
A 37 year old woman presents to the Emergency Department with shortness of breath and coughing with blood stained sputum. She flew from Thailand to United Kingdom 3 days ago. She denies any fever. Her oxygen saturation is 92% on room air. She has a heart rate of 105 beats/minute, respiratory rate of 25 breaths/minute and a blood pressure of 120/90 mmHg. What is the SINGLE investigation that would lead to a definitive diagnosis?
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Question 28 of 142
28. Question
A 56 year old lady with lung cancer presents with urinary retention, postural hypotension, diminished reflexes and sluggish pupillary reaction. What is the SINGLE most likely explanation for her symptoms?
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Question 29 of 142
29. Question
A 70 year old man admits to asbestos exposure 20 years ago. He was a heavy smoker but has quit smoking 3 years ago. He has noted weight loss and hoarseness of voice. Which is the SINGLE most likely type of cancer associated with the risk factors and symptoms present?
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Question 30 of 142
30. Question
A 29 year old woman is brought to the Emergency Department due to an asthma attack. She was put on 60% oxygen using a venturi mask and managed with nebulizers and intravenous corticosteroids. After an hour, a repeat arterial blood gas showed worsening respiratory acidosis with increasing PaCO2. Her most recent arterial blood gas show the following:
pH 7.20 (7.35 -7.45)
Pa027 kPa (10-14)
PaCO2 = 11 kPa (4.7-6.0)
Bicarbonate 26 mmol/l (22-26)
Her wheezy chest has now become silent. What is the next most appropriate management?
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Question 31 of 142
31. Question
A 55 year old man attends the Accidents & Emergency with complaints of a productive cough for the past 14 days. He feels unwell and complains of mild shortness of breath. His observations show that he has a temperature of 38.9°C, a respiratory rate of 25 breaths/minute, heart rate of 90 beats/minute, and a blood pressure of 110/80 mmHg. A chest X-ray shows right lower lung consolidation. His blood results are unremarkable. The triage note states that he has had a severe allergic reaction involving anaphylaxis to penicillin in the past. What is the SINGLE most appropriate management?
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Question 32 of 142
32. Question
A 48 year old presents with increasing shortness of breath over the last few months and a dry cough. He has worked in coal mines for 18 years. Chest x-ray and CT scan of the chest demonstrates characteristic upper zone mass-like scarring with calcification and volume loss. The lung opacifications are seen to be associated with radiating strands. What is the SINGLE most likely diagnosis?
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Question 33 of 142
33. Question
A 48 year old farmer presents with malaise, dry cough, chest tightness and shortness of breath. The shortness of breath and cough started only a few hours ago. On auscultation, a wheeze is heard throughout the chest. He has a temperature of 39.2°C, a pulse of 96 beats/minute, a blood pressure of 110/70 mmHg and a respiratory rate of 29 breaths/minute. His chest X-ray shows diffuse micronodular interstitial shadowing. What is the SINGLE most appropriate diagnosis?
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Question 34 of 142
34. Question
A 68 year old man with advanced non-small cell lung carcinoma diagnosed nine months ago on biopsy presents with the complaints of dyspnoea and sub-sternal chest pain. An X-ray was done and showed a large left hilar mass. He is currently undergoing radiotherapy for his condition and he was relatively well for about two months until he developed thoracic back pain radiating around both sides of his chest. Additional scans showed metastases to T5, T6 and T7 with a mass compressing his spinal cord. The patient is currently on 260 mg of sustained release morphine every 12 hours and he describes his pain control as adequate. Some other symptoms that he suffers from include anorexia, weight loss of about 15 kilograms over the past five months and generalised weakness. He is unable to carry out his daily activities and finds it difficult to do household chores. His wife died five years ago and he has one son who currently lives overseas. Upon further questioning, the patient has no written advance directive but on several occasions, he has told his general practitioner that he wants nothing more done as far as his treatment is concerned. The patient is a devout Catholic and has expressed concerns over receiving his proper last rites. What is the SINGLE next best step in the management of this patient?
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Question 35 of 142
35. Question
A 27 year old woman attends the outpatient department with a fever and dry cough. She has had a headache, muscle pain and joint pain for more than a week. She has a temperature of 37.5°C, a pulse of 100 beats/minute, a blood pressure of 110/70 mmHg and a respiratory rate of 20 breaths/minute. A chest X-ray report shows patchy bilateral consolidation. What is the SINGLE most likely causative organism?
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Question 36 of 142
36. Question
A 50 year old man presents to the Emergency Department with a dry cough and shortness of breath that has been worsening over the past six months. He has a heart rate of 90 beats/minute, blood pressure of 138/82 mmHg and oxygen saturation of 89% He seems pale, exhausted and has clubbing in his fingers. Auscultation of his chest shows bilateral fine crepitations. His spirometry results are as follows;
FEV1 = 66%
FVC = 58%
FEV1/FVC = 0.9
What is the most likely diagnosis?
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Question 37 of 142
37. Question
A 55 year old smoker has right-sided chest pain and right shoulder pain which worsens when taking deep breaths. He has worsening shortness of breath over the past 6 months. On examination, he has a miotic right eye and partial ptosis on the right. There is also wasting of small muscles of the right hand. He has enhanced sensitivity to touch on his right arm. What is the SINGLE most appropriate next step?
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Question 38 of 142
38. Question
A 79 year old lady is brought in by ambulance to the Emergency Department with shortness of breath that worsened dramatically overnight. She has been feeling unwell for the past two week with a cough and slight shortness of breath of which her general practitioner has prescribed her amoxicillin seven days ago. The ambulance crew tells you that she initially had saturations of 70% before being started on oxygen. She is not known to have COPD but has been a heavy smoker for the past 50 years of her life. On examination, she is seen to be struggling to breath. Her respiratory rate is 26 breaths/minute, heart rate is 105 beats/minute and blood pressure is 110/70 mmHg. A chest X-ray was performed which is shown below.
What is the SINGLE most likely diagnosis?
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Question 39 of 142
39. Question
A 12 year old boy has been coughing and wheezing for the past few months. He feels short of breath occasionally. His father has hay fever and his mother suffers with eczema. He was sent for a spirometry which shows an obstructive spirometry pattern with an improvement in FEV1 of 15% postbronchodilator. He was prescribed salbutamol inhalers by the respiratory nurse. Which other medication according to BTS/SIGN asthma guidelines, if any, would need to be prescribed alongside salbutamol inhalers?
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Question 40 of 142
40. Question
A 35 year old man presents with progressive breathlessness and a non-productive cough. He has been more lethargic over the past few months. He has a history of polyarthralgia with painful red lumps appearing on his shins. They are cherry sized and are about 20 or more in number. His chest X-ray shows bilateral hilar lymphadenopathy. What is the SINGLE most likely diagnosis?
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Question 41 of 142
41. Question
An 8 year old boy diagnosed with asthma is on salbutamol inhaler and beclomethasone inhaler. He takes his beclomethasone inhaler everyday as prescribed and does not miss any doses. However, he wakes up at night with wheezing and having shortness of breath. He uses around 6 times of his salbutamol inhaler a week. He occasionally finds exercise difficult because he becomes very short of breath. What is the SINGLE most appropriate management?
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Question 42 of 142
42. Question
A 10 year old girl is brought to the emergency department by her dad after having fallen in the park. Her elbows are full of cuts and she has not stopped crying since the injury. Her medical history includes asthma. What is the SINGLE most appropriate analgesia to administer?
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Question 43 of 142
43. Question
A 59 year old man with a medical history of chronic obstructive pulmonary disease presents to the Emergency Department with breathlessness. He finds it extremely difficult to breathe while in the supine position and has to sit up in bed or in a chair at night due to his severe dyspnoea. His respiratory rate is 30 breaths/minute and his heart rate is 110 beats/minute. His oxygen saturation on presentation was 89%. An arterial blood gas test was done for him and he was commenced on 100% oxygen however, he is still dyspnoeic. The results of his arterial blood gas are as follows:
pH 7.31 (7.35-7.45)
PaO2 11.6 kPa (10-14 kPa)
PaCO2 9.8 kPa (4.5-60kPa)
What is the SINGLE most appropriate initial action?
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Question 44 of 142
44. Question
A 55 year old man with chronic obstructive pulmonary disease (COPD) develops mild oral thrush. He rinses his mouth thoroughly after use of his steroid inhaler and mentioned the use of a spacer occasionally. Which of the following is the most appropriate action?
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Question 45 of 142
45. Question
A 33 year old man has a temperature of 38.5°C, productive cough and chest pain on the right side on inspiration. He has a blood pressure of 100/60 mmHg and a pulse rate of 108 beats/minute. He appears slightly short of breath and has an oxygen saturation of 94% on room air. What is the SINGLE most likely organism causing the patient’s symptoms?
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Question 46 of 142
46. Question
A 32 year old man presents to the Emergency Department with shortness of breath and chest pain. He denies any fever. He has recently had a left ankle surgery under general anaesthesia a week ago. He has been immobile since then. His oxygen saturation are 89% on room air. He has a heart rate of 110 beats/minute, a respiratory rate of 28 breaths/minute and a blood pressure of 120/90 mmHg. An X-ray done in the department is shown below:
What is the SINGLE most appropriate action?
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Question 47 of 142
47. Question
A 64 year old retired builder has been experiencing shortness of breath and chest pain for the past 6 months. His medical history includes a 44 year pack smaking history. He has travelled by air to Vietnam 6 times in the span of two years. He was further investigated with a chest X-ray which showed mediastinal lymphadenopathy and right sided pleural effusion with loss of volume in the affected hemithorax. A subsequent CT scan shows irregular pleural thickening. What is the SINGLE most likely cause of his condition?
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Question 48 of 142
48. Question
A 58 year old man presents to the general practitioner with the primary complaint of shortness of breath and a chronic cough. He has been having increasing shortness of breath for the past 2 years and that his symptoms have escalated to such a stage that he is now unable to walk more than 50 meters. He has a 20 pack year smoking history. There are fine inspiratory crackles that can be appreciated bilaterally upon auscultation of his lungs. His oxygen saturation is 91% on room air.
A lung function test was subsequently carried out and the results are as follows:
FEV1 3.3 litres which is 72% of predicted
FVC 4.1 litres which is 73% of predicted
FEV1/FVC ratio 0.8
A repeat lung function test after salbutamol inhalers were as follows:
FEV1 3.4 litres which is 74% of predicted
FVC 4.3 litres which is 77% of predicted
FEV1/FVC ratio 0.79
What is the SINGLE most likely diagnosis for this patient?
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Question 49 of 142
49. Question
A 67 year old smoker presents with cough, breathlessness and wheeze. 24% oxygen by Venturi face mask was initiated and nebulized salbutamol and hydrocortisone were administered. As his dyspnoes did not improve, intravenous aminophylline was administered and an arterial blood gas was sent. He has a respiratory rate of 32 breaths/minute. His arterial blood gas results show:
pH 7.32 (7.35 -7.45)
PaO2: 10.1 kPa (10-14 kPa)
PaCO2: 7.7 kPa (4.7-6.0)
Bicarbonate 25 mmol/L (22-26)
What is the SINGLE most appropriate next step in management?
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Question 50 of 142
50. Question
A 65 year old retired builder complains of persistent dull chest pain and shortness of breath. He is a smoker and started smoking from a young age. He looks thin and his clothes are oversized. Finger clubbing is noted on examination. What is the SINGLE most likely diagnosis?
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Question 51 of 142
51. Question
A 32 year old female smoker has a history of wheeze, shortness of breath and fever. Her past medical history includes eczema. FEV1/forced vital capacity (FVC) was measured 6 weeks after she recovered from her lower respiratory tract infection and was found to be less than 0.7. Her FEV1 had significant improvement after taking bronchodilators. What is the SINGLE most likely diagnosis?
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Question 52 of 142
52. Question
A 55 year old man attends A&E with a history of coughing for 2 weeks and a fever. On examination, he is alert. Auscultation reveals left basal crackles on his chest. He has a heart rate of 90 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 93/63 mmHg, a temperature of 39°C and oxygen saturation of 94%. His urea is 5 mmol/L (<7). What is his CURB-65 score?
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Question 53 of 142
53. Question
A 55 year old man is admitted to the cardiac intensive care unit following myocardial infarction. His medical history includes mesothelioma which was diagnosed 2 years ago. He has a 20 pack-year smoking history. He works as a builder. 2 days later, he has a cardiac arrest in the cardiac intensive care unit and dies. What is the SINGLE most appropriate action?
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Question 54 of 142
54. Question
A 75 year old man attends the respiratory clinic following a referral from his GP. He has been experiencing a chronic cough, shortness of breath, fatigue and dull-left sided chest pain for the past 6 months. He also has been experiencing unexplained weight loss. He has a smoking history equating to 20 pack-years, and after 40 years of employment at a shipyard, he retired 15 years ago. He was prescribed amoxicillin, salbutamol and beclomethasone dipropionate inhalers 3 months ago by an out of hours GP at the urgent care centre following an episode of fever, wheezing and coughing which did little for his symptoms. An urgent X-ray requested by the GP has been reported as showing pleural plaques and a left-sided pleural effusion. Following a discussion between the respiratory consultant and the patient, the patient agrees for a CT scan. Unfortunately, he continued to deteriorate was admitted into the hospital. His symptoms were palliated with opiates and he died on the 3rd day. Which of the following is the SINGLE best reason to inform the local coroner’s office of the death of this patient?
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Question 55 of 142
55. Question
A 68 year old woman presents to the emergency department from her nursing home complaining of shortness of breath. She has a temperature of 38.7°C and productive cough. Her sputum is noted to be a rusty colour. On auscultation, crackles are heard over the right lung base. A chest X-ray was done and shows right lower lobe consolidation. She has a blood pressure of 100/65 mmHg and a pulse rate of 102 beats/minute. A urinalysis shows 1+ leukocytes with no nitrates or protein. What is the SINGLE most likely organism causing her symptoms?
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Question 56 of 142
56. Question
A 72 year old woman presents with the complaint of tiredness and cough with sputum production for two days. Her temperature in hospital is measured at 39°C. Blood test has been requested. The following are the available results with the remaining of the results still pending:
Sodium 137 mmol/L (135-145 mmol/L)
Potassium 3.8 mmol/L (3.5-5.0 mmol/L)
Urea 5.5 mmol/L (20-7 mmol/L)
Creatinine 189 μmol/L (70-150 μmol/L)
Bicarbonate 23 mmol/L (22-26 mmol/L)
Chloride 96 mmol/L (95-105 mmol/L)
What is the SINGLE most likely diagnosis?
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Question 57 of 142
57. Question
An 82 year old presents to the Emergency Department with shortness of breath after falling on a radiator. His blood pressure is 150/88 mmHg, respiratory rate is 33 breaths/minute and oxygen saturation 88% on 12L of high flow oxygen via face mask. A chest X-ray reveals:
What is the most appropriate management?
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Question 58 of 142
58. Question
A 25 year old tall rugby player comes to the Emergency Department complaining of chest pain and shortness of breath that developed earlier in the day. He was hit in the chest by a player of the opponent team during a rugby match. He has no significant medical history. The triage nurse takes his observations and notices that his oxygen saturations are 89% on air, respiratory rate is 26 breaths/minute, heart rate is 100 beats/minute. You have been called to look at him. What is the SINGLE most appropriate initial action?
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Question 59 of 142
59. Question
A 42 year old woman has a sore throat and difficulty swallowing over the past few weeks. She has asthma which she takes salbutamol inhalers as required, salmeterol and beclomethasone inhalers regularly, and oral montelukast regularly. She takes cetirizine for hay fever during the summer months. On examination, she has a white patch on the pharynx. Which medication is likely the cause of her symptoms?
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Question 60 of 142
60. Question
A 66 year old woman presents with shortness of breath, cough, and pleuritic chest pain that has been worsening over the past 6 weeks. She is a heavy smaker with a 50-pack- year smoking history. There is dullness on percussion over her left lung fields with absent breath sounds on the left lower chest. Her respiratory rate is 26 breaths/minute. The following chest X-ray was taken:
What is the SINGLE most appropriate action?
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Question 61 of 142
61. Question
A 65 year old man presents to the Emergency Department with a cough and difficulty with breathing especially in the supine position. He finds a slight relief in the sitting position by leaning forward. He is a chronic heavy smoker for 30 years. His blood pressure is 129/85 mmHg, respiratory rate is 34 breaths/minute, pulse rate is 106 beats/minute and oxygen saturation is 86% He was commenced on 4L of 28% oxygen. His arterial blood gas results are shown below.
pH 7.32 (7.35-7.45)
PaO2: 9.4 kPa (10-14)
PaCO2: 7.8 kPa (4.7-6.0)
Bicarbonate 24 mmol/L (22-26)
What is the next appropriate management?
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Question 62 of 142
62. Question
34 year non-smoker attends the GP surgery for cough for the past 13 weeks. She has no history of asthma as a child or atopy in herself or family. She has tried cough linctus for her dry cough which has not helped. She does not have a blocked sensation of her nose and does not have a fever. A full blood count, CRP and chest X-ray which was requested following her presentation are seen to be normal. Spirometry was performed by the respiratory nurse which results are normal. Following her results, a 6-week course of inhaled corticosteroids was prescribed which improved her symptoms. What is the SINGLE most likely diagnosis?
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Question 63 of 142
63. Question
A 28 year old male is admitted with acute exacerbation of asthma. He has a temperature of 38.1°C and a productive cough. He is treated initiated with 100% oxygen and salbutamol nebulisers. Despite treatment, his oxygen saturation is 88% and his respiratory rate is 34 breaths/minute. What is the SINGLE most appropriate next step in management?
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Question 64 of 142
64. Question
A 64 year old man who was previously exposed to asbestos for 35 years while working as a builder has chest pain and shortness of breath. The diagnosis of mesothelioma has been made. His shortness of breath has been worsening over the last couple of days. A recent chest X-ray shows bilateral pleural effusion. What is the SINGLE most appropriate management?
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Question 65 of 142
65. Question
A 60 year old man presents to his general practitioner with the primary complaint of shortness of breath. He complains that he has been having increasing shortness of breath for the past seven months and that his symptoms have escalated to such a stage that he is now unable to walk the length of his hallway at home without becoming breathless. Further questioning reveals that the patient is also suffering from a dry cough that has been present for the past five months. His past medical is significant for hypertension, diagnosed when he was 55 years of age, which he takes ramipril for. The patient says that he is compliant with his medication. The patient says that he has worked in a warehouse for the past 30 years and specifically mentions that he has not been exposed to asbestos. Upon examination, the patient appears unwell and gaunt. Finger clubbing is noted and fine inspiratory crackles can be appreciated bilaterally upon auscultation of his lungs. His vitals are as follows:
Blood pressure 145/86 mmHg
Temperature 36.8 “C
Respiratory rate 23 breaths per minute
Oxygen saturation 89% on room air
A lung function test was subsequently carried out and the results are as follows:
FEV1 66% of predicted FVC 64% of predicted
FEV1/FVC ratio 0.8
What is the SINGLE most likely diagnosis for this patient?
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Question 66 of 142
66. Question
A 17 year old boy attends the GP surgery accompanied by his mother. He complains of having a nocturnal cough and wheeze for the past few months. He also has wheezing when he starts to exercise. His older brother was recently diagnosed with asthma. He suffers from hay fever during the summer months. A spirometry was performed but the results are normal. What is the SINGLE most appropriate test?
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Question 67 of 142
67. Question
An 85 year old man who has been suffering from chronic obstructive pulmonary disease presents with increased shortness of breath at rest. His symptoms have worsened over several months. He is currently on a combination inhaler of Fastair (formoterol and beclomethasone), as required salbutamol, inhaled tiotropium and theophylline. He smokes 30 cigarettes a day. On examination, his forced expiratory volume in one second (FEV1) is less than 30% and his oxygen saturations are 87% on room air. He has had an arterial blood gas on two separate occasions 3 weeks apart which demonstrates a p02 of 7.28 and 7.29. What is the SINGLE most appropriate management?
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Question 68 of 142
68. Question
A 22 year old man presents with episodes of dyspnoea, starting suddenly. This usually occurs when he is in a crowded area like a lift. When he is breathless, he also notices tingling around his mouth and he feels light-headed. These episodes usually go away after a while. An arterial sample was taken for blood gases during one of the episodes. What is the SINGLE most likely result of the arterial blood gas (ABG)?
Normal Values:
PaO2 > 10 kPa
PaCO2 4.7-6 kPa
pH 7.35 -7.45
Bicarbonate (HCO3-) 22-26 mmol/L
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Question 69 of 142
69. Question
A 29 year old HIV positive man attends the outpatient department with complaints of persistent cough and copious amount of purulent sputum. He also has dyspnoea and chest pain. On auscultation, inspiratory crepitations are heard at the base of the lung. A chest X-ray shows tram track opacities. What is the SINGLE most likely diagnosis?
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Question 70 of 142
70. Question
A 33 year old woman who is 30 weeks gestation develops shortness of breath and chest pain over a period of 2 days. She is admitted for further investigations. She has an oxygen saturation of 89%, blood pressure of 100/70 mmHg, respiratory rate of 20 breaths/minute and heart rate of 80 beats/minute. A CT pulmonary angiogram shows evidence of an embolism at the arteries supplying the right middle and lower lobe of the lung. An echocardiogram showed preserved left ventricular ejection fraction of 65%. What is the SINGLE most appropriate management?
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Question 71 of 142
71. Question
A 54 year old male chronic smoker presents with progressive dyspnoea. He complains of cough, wheeze and about a tablespoon full of mucopurulent sputum which he has been coughing out daily for the past 15 months. Spirometry was performed which showed an FEV1/FVC of 2.4/3.7. He was given inhaled salbutamol and spirometry was repeated. His FEV1/FVC after inhaled salbutamol was 2.5/3.8. What is the SINGLE most likely diagnosis?
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Question 72 of 142
72. Question
A 50 year old woman presents to Accident & Emergency with the complaint of shortness of breath and a dry cough which started a day ago. This was preceded by four days of experiencing flu-like symptoms. Further questioning reveals that she recently attended a conference in the United States for five days where she stayed in the hotel that was provided for attendees. A chest X-ray was done which shows pulmonary infiltrates.
The patient’s vitals are noted as follows: Temperature 39.1 “C
Respiratory rate 21 breaths per minute
Blood pressure 100/57 mmHg
Heart rate 90 beats/minute
Blood tests were done and the results are as follows:
Haemoglobin 139 g/L (130-180 g/L)
White cell count 2.34 x 10^9/L (4-11 x 10^9/L)
Sodium 126 mmol/L (135-145 mmol/L)
Potassium 4.1 mmol/L (3.5-5.0 mmol/L)
Urea 3.9 mmol/L (2.5-6.7 mmol/L)
What is the SINGLE best treatment option for this patient?
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Question 73 of 142
73. Question
A 33 year old man is referred for a chest X-ray as he complains of a persistent cough chest pain and excessive purulent sputum. He has a history of recurrent chest infections, 3 of which, in the past 2 years have required hospital admission. He is a non-smoker. On examination, there are inspiratory crackles over the lower zones of the chest and drumstick-shaped fingers were noted. What is the SINGLE most likely diagnosis?
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Question 74 of 142
74. Question
A 68 year old smoker has left sided chest pain which worsens when taking deep breaths. His medical history includes diabetes mellitus and hypertension. On examination, he has a miotic left eye and partial ptosis on the left. There is also wasting of small muscles of the left hand. What is the SINGLE most likely diagnosis?
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Question 75 of 142
75. Question
A 55 year old woman has been having shortness of breath and a dry cough over the past 3 months. She started methotrexate 10 months ago for rheumatoid arthritis. She is a non-smoker. She has no history of recent travels. A physical examination shows a heart rate of 100 beats/minute, oxygen saturation of 89%, respiratory rate of 23 breaths/minute, temperature of 37.6°C and bilateral basal crackle. A chest X-ray reveals hazy opacity with prominent reticulation within the upper lung fields. Her lung function test reveals an FEV1/FVC ratio of 0.81. Sputum cultures were negative for any bacterial pathogens including acid-fast bacilli. What is the SINGLE most appropriate action?
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Question 76 of 142
76. Question
An obese 60 year old man has a right hemicolectomy for a tumour of the caecum 4 days ago. He suddenly becomes breathless, dizzy and describes chest discomfort. The chest discomfort worsens when he takes a deep breath. On examination, he has good air entry on both lungs. His oxygen saturation is 90% on room air and he has a pulse rate of 110 beats/minute. A chest X-ray was performed and is seen below.
An ECG shows sinus tachycardia. What is the SINGLE most likely diagnosis?
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Question 77 of 142
77. Question
A 45 year old man has been having a productive cough for the past 3 weeks. He has been having a fever since then. He has not gone to work for the past 2 weeks as he feels too unwell. He presents to the hospital with chest pain and shortness of breath. On auscultation, there is decreased breath sounds on the right upper lobe with crackles. Percussion is dull in the same area. He has a temperature of 39°C, a respiratory rate of 28 breaths/minute and a pulse rate of 110 beats/minute. His blood results are as follows:
Haemoglobin 129 g/L (130-180)
White cell count 15 x 10°/L (4-11)
Platelets 450 x 10°/L (150-400)
CRP 110 mg/L (<10)
What is the SINGLE most likely diagnosis?
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Question 78 of 142
78. Question
An 82 year old man has been experiencing coughing, breathlessness, malaise and left sided pleuritic chest pain for 2 weeks. The breathlessness has been increasing over the last few days and he now gets breathless on minimal exertion. He worked as a plumber until he retired. He is a smoker and started when he was 16 years of age with a 40 pack- year history. His temperature is 38.9°C, pulse rate is 89 beats/minute, respiratory rate is 22 breaths/minute, blood pressure 130/70 mmHg and oxygen saturation is 95%. On auscultation, there are crepitations and reduced air entry at the base of the left lung. A chest X-ray was performed which shows blunting of the left costophrenic angle and left lower lobe consolidation. What is the SINGLE most likely diagnosis?
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Question 79 of 142
79. Question
A 63 year old man has advanced COPD. He is currently unable to mobilise the way he used to a few months ago. He is on relaxation therapy for his panic and anxiety and is on chronic oxygen therapy for his breathlessness however, he still complains of being unable to breathe. What is the SINGLE most appropriate agent to assist with his breathlessness?
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Question 80 of 142
80. Question
An 8 year old boy has recently been diagnosed with asthma and has been prescribed his inhalers and a spacer. His mother would like to know more about cleaning the spacer device. Which of the following is the correct method for cleaning a spacer device?
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Question 81 of 142
81. Question
A 61 year old man presents with sudden onset chest pain and shortness of breath six hours after removal of his chest drain. He had a lobectomy of his right lung for a lung abscess 2 days ago and is an inpatient in the ward. His oxygen saturation is 86%, blood pressure is 110/70 mmHg, heart rate is 102 beats/minute and respiratory rate is 26 breaths/minute. On examination, he is dyspnoeic and he has absent breath sounds on his right chest. What is the SINGLE most appropriate management?
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Question 82 of 142
82. Question
A 55 year old smoker attended the GP surgery with complaints of chronic productive cough and dyspnoea. He has been coughing for 18 months. Occasionally, he can cough up a tablespoon full of sputum with occasional specks of blood. He has a 25 pack-year smoking history. He does not take any regular medication. What is the SINGLE most appropriate initial investigation?
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Question 83 of 142
83. Question
A 61 year old smoker has left-sided chest pain and left shoulder pain and arm pain which worsens when taking deep breaths. He has had worsening shortness of breath over the past 12 months. On examination, he has a miatic left eye and partial ptosis on the left. There is also wasting of small muscles of the left hand. A chest X-ray reveals soft tissue opacity at the apex of the left lung. What is the SINGLE most appropriate investigation?
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Question 84 of 142
84. Question
A 21 year old lady who smokes has a history of wheezing, chest tightness and coughing at night. She also notices these symptoms occur when she goes out in the cold and breathes cold air. She was started on propranolol for migraine prophylaxis but when she took it she started wheezing more. What is the SINGLE most likely diagnosis?
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Question 85 of 142
85. Question
A 23 year old woman who is on several medications and inhalers for her asthma presents to the hospital with palpitations. Her heart rate is 110 beats/minute. Her peak expiratory flow rate is 400 L/minute. What is the SINGLE most appropriate management?
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Question 86 of 142
86. Question
A 27 year old man presents with chest pain and respiratory distress following a road traffic accident. On examination, his neck veins are noted to be distended and trachea is deviated to the right. Breath sounds are absent on the left and diminished on the right lung field. He has a blood pressure of 80/40 mmHg and a heart rate of 120 beats/minute. What is the SINGLE most appropriate next action?
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Question 87 of 142
87. Question
A 24 year old man is seen in the Emergency Department with symptoms of dyspnoes and wheezing. He has been having episodes of coughing. His medical history includes asthma. His oxygen saturations are initially 89% and he is immediately started on 100% oxygen by face mask. What is the SINGLE most appropriate next step in management?
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Question 88 of 142
88. Question
A 48 year old man was admitted with cough and dyspnoea. He has a long history of smoking. He has noticed some recent weight loss. A chest X-ray was performed and showed consolidation on the lower left lobe. He was started on antibiotics and is due for discharge. What is the SINGLE most appropriate follow up investigation to perform after discharge?
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Question 89 of 142
89. Question
A 63 year old man complains of a productive cough over the past 10 months and the development of persistent daily expectoration of purulent sputum. He describes coughing up a tablespoon full of sputum a day. He has occasional haemoptysis. He has last 8 kg over the past few months. He finds himself to be very fatigued. He has a 35- year pack history of smoking. On examination, coarse crackles are audible on auscultation on both lungs. A chest X-ray is normal other than an increase in bronchovascular markings. What is the SINGLE most likely diagnosis?
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Question 90 of 142
90. Question
A 79 year old man with longstanding chronic obstructive pulmonary disease has become progressively breathless over the last 2 years. His medications for his COPD include salbutamol and salmeterol inhalers, inhaled corticosteroids and theophylline. His forced expiratory volume in one second (FEV1) is less than 30%. His oxygen saturations are 89% on room air. What is the next appropriate management?
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Question 91 of 142
91. Question
A 65 year old known case of hepatocellular carcinoma with lung and bone metastasis presents with shortness of breath, gastric reflux and bloatedness. The symptoms have been on going for a the past week. He is on the palliative care register and takes regular morphine for the pain. A recent DEXA scan shows his bones to be osteoporotic. On examination, there are crackles in the base of the left lung. He has a temperature of 38.1°C. A chest X-ray was performed which shows basal consolidations on the left lung. What is the SINGLE most appropriate medication to administer?
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Question 92 of 142
92. Question
A 17 year old boy with a history of asthma suddenly develops chest pain and increasing breathlessness during a game of football. He has reduced breath sounds on the right side. His oxygen saturation is 94% on air. What is the SINGLE most appropriate investigation?
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Question 93 of 142
93. Question
A 48 year old man with a 30 pack year smoking history is found to have an incidental finding of a chest X-ray showing 2 cm hilar mass and was referred to the respiratory team for a biopsy. The histology report has returned with findings of large polygonal cells containing keratin pearls and intercellular bridges. What is the SINGLE most likely type of lung cancer?
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Question 94 of 142
94. Question
A 34 year old woman with a smoking history has had an uneventful laparoscopic cholecystectomy 18 hours ago. She is now complaining of shortness of breath. She has a temperature of 37.8°C, heart rate of 108 beats/minute, blood pressure of 130/80 mmHg. respiratory rate of 25 breaths/minute and an oxygen saturation of 96%. There are signs of reduced air entry at the right base. Chest X-ray shows no obvious abnormality but a minimal degree of collapse at the base of the right lung. What is the SINGLE most appropriate next step?
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Question 95 of 142
95. Question
A 63 year old man is on his first post-operative day having undergone a total knee replacement for asteoarthritis which severely impaired his mobility for the past 4 months. He complains to the nurse of a sudden onset of breathlessness. The nurse takes his vitals and informs you that he has a temperature of 38.5°C with a blood pressure of 118/80 mmHg, oxygen saturation of 99%, respiratory rate of 26 breaths/minute and a pulse rate of 90 beats/minute. His medical history includes prostate cancer. What investigation will you perform immediately?
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Question 96 of 142
96. Question
A 61 year old man presents to the GP surgery with his wife as his wife is worried about his recent change in weight over the past 3 months. He has been having a chronic cough for the past 12 months and was diagnosed with COPD 6 years ago. He has a 25 pack- year smoking history. His vitals are stable. His full blood count and renal function are within normal limits. A chest X-ray shows evidence of a diffuse opacity overlying the left hilum. What is the SINGLE most appropriate investigation to yield a diagnosis?
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Question 97 of 142
97. Question
A 62 year old man who used to work in the shipyard industry presented to the hospital with gradual increase in shortness of breath, chest pain and weight lost. He has been feeling fatigue and having a mild fever for the past few weeks. On examination, finger clubbing and a palpable chest wall mass was noted. A computed tomography was performed which showed patchy infiltrates, pleural thickening and pleural effusion. He died 7 days later. What is the SINGLE most appropriate management to deal with this patient’s death certificate?
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Question 98 of 142
98. Question
A 35 year old man has had copious amounts of sputum and chronic cough for several years. He has been having recurrent lower respiratory tract infections since he was a child. Each infection presents with breathing difficulties, fever and wheezing. He is a non- smoker. On examination, he has course crackles across his lung fields. He has no family history of asthma. What is the SINGLE most likely diagnosis?
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Question 99 of 142
99. Question
A 20 year old man presents to the A&E complaining of one day of haemoptysis. He been short of breath and coughing for the past 3 days. He reports having a runny nose, sare throat, myalgia, lethargy and high fevers for the past week. His temperature is 39.5°C, heart rate of 140 beats/minute, blood pressure of 80/50 mmHg, and respiratory rate of 35 breaths per minute. Inspiratory crackles are heard during the auscultation of his chest. Chest X-ray revealed bilateral middle and lower lobe cavitations. His blood tests show the following:
Haemoglobin 132 g/L (130-180)
White cell count 12 x 10″/L (4-11)
Neutrophils 7.1 x 10″/L (2-7.5)
Platelets 350 x 10°/L (150-400)
What is the most likely causative organism?
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Question 100 of 142
100. Question
A 21 year old man has been more wheezy for the past few months. He feels short of breath occasionally. His wheezing can interfere with his daily activities. He is a known asthmatic and was diagnosed when he was 11 years old. He has been using salbutamol inhaler and a low-dose inhaled corticosteroid for the last 10 years. He takes the salbutamol inhaler 6 times a week, on average. Which other medication according to BTS/SIGN asthma guidelines would need to be prescribed?
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Question 101 of 142
101. Question
A 14 year old girl with asthma is having frequent night coughs and mild exercise-induced wheezing. She is compliant with her asthma medication of inhaled corticosteroid and short-acting bronchodilator as required. Her inhaler technique is good. What is the SINGLE most appropriate next step in management?
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Question 102 of 142
102. Question
A 16 year old girl attends the GP surgery with a history of a worsening cough at night which has been present for the past few months. Sometimes she wakes up feeling short of breath. She also feels wheezy and chest tightness when doing any form of exercise. Her medical history includes eczema at a young age. What is the most appropriate next diagnostic step?
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Question 103 of 142
103. Question
A 61 year old man has suddenly become very short of breath. In the last hour, he has had a CT-guided biopsy of a mass in the right lung. His temperature is 36.5°C, heart rate is 120 bpm, BP 90/60 mmHg, and SaO2 is 78% on 15 litres of oxygen. He looks cyanosed, his trachea deviates towards the left, and breath sounds are much louder over the left hemithorax. His right chest is more resonant than the left on percussion. Which is the SINGLE most appropriate course of action?
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Question 104 of 142
104. Question
A 68 year old male presents to Accident & Emergency with the complaint of a cough. He said that he first noticed the cough two days ago. He is coughing up about a tablespoon full of purulent sputum a day. He has no other complaints. His past medical history is significant for hypercholesterolaemia for which he takes atorvastatin. He is also on aspirin, diclofenac, lansoprazole as well as a regular salbutamol inhaler for asthma. He had a severe allergic reaction to amoxicillin a year ago which he was hospitalised for. Upon examination, he appears to be unwell. He is short of breath with a respiratory rate of 22 breaths per minute and his oxygen saturation on room air is 97%. A chest X-ray was done which showed right middle zone consolidation. What is the SINGLE most appropriate antibiotic for this patient?
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Question 105 of 142
105. Question
A 6 year old girl has had 2 short episodes of cough and wheeze over the last 12 months. These 2 acute episodes responded quickly to bronchodilator. She has no symptoms or abnormal physical signs at the moment. She has slight eczema and her mother has a history of asthma when she was young. What is the SINGLE most appropriate investigation?
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Question 106 of 142
106. Question
A 50 year old woman returned by air to the UK from Australia. 3 days later, she presents with sharp chest pain and breathlessness. Her ECG is normal. A chest X-ray was performed and is seen below:
What is the SINGLE most appropriate investigation?
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Question 107 of 142
107. Question
A 68 year old man has malaise and cough for 5 days. He has a temperature of 38.5°C There is dullness on percussion of the left lung base. What is the SINGLE most appropriate investigation?
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Question 108 of 142
108. Question
A 2 year old girl presents with a 4 day history of fever which started with a cough. She has a respiratory rate of 45 beats/minute, oxygen saturation of 94% and a temperature of 38.9C. There are crepitations at the left base on auscultation of the lung fields. Urine dipstick was found to be negative. What is the SINGLE investigations most likely to lead to diagnosis?
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Question 109 of 142
109. Question
A 55 year old man presents with increasing breathlessness, noisy breathing and a history of hoarseness of voice. He has a chronic cough that is productive. He has noticed his symptoms worsening over the past 3 weeks. He smokes 15 cigarettes a day for the past 25 years. His spirometry results show the following:
- FEV1 60% predicted
- FEV1/FVC ratio 0.67 past bronchodilation.
What is the SINGLE most likely diagnosis?
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Question 110 of 142
110. Question
A 61 year old man on the surgical ward complains of cough and dyspnoea. He has been coughing out blood. He is 6 days post right pneumonectomy. His temperature is 37.2°C, pulse rate is 89 beats/minute, blood pressure is 130/88 mmHg, and respiratory rate 18 breaths/minute. A chest x-ray is seen below:
What is the most likely diagnosis?
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Question 111 of 142
111. Question
A 35 year old man presented to the Accident and Emergency department with a productive cough and fever. A chest x-ray demonstrated right lower zone pneumonia. His CURB-65 score was 1 and he discharged with oral antibiotics. 5 days later he represents with ongoing fever (38.9°C) and pleuritic chest pain. On examination there is reduced breath sounds at the right base with crepitations. A repeat chest x-ray demonstrates a new right-sided pleural effusion. What is the most important investigations to perform?
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Question 112 of 142
112. Question
A 19 year old man has a history of exercise induced asthma which has previously been controlled using a salbutamol inhaler as required. He is taking beclomethasone inhaler regularly but he now gets asthma attacks with exercise. What is the SINGLE most appropriate action?
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Question 113 of 142
113. Question
A 6 year old girl attends the GP surgery with her mother with concerns about coughing and wheezing, which is worse at night. Her symptoms have been ongoing for a few weeks. She is afebrile. She denies a productive cough. Her mother suffers from asthma. What is the most appropriate diagnostic step?
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Question 114 of 142
114. Question
A 16 year old boy who attends boarding school feels unwell. He developed a dry cough for the last few days. On examination, there are target lesions seen on the back of his hands. A chest X-ray was performed and it shows bilateral consolidations. What is the SINGLE most likely causative organism?
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Question 115 of 142
115. Question
A 24 year old male is admitted with acute severe asthma. He is treated initiated with 100% oxygen, nebulised salbutamol, and IV hydrocortisone. Ipratropium bromide was also added to the nebulisers. Despite the initial treatment, there has been no improvement. What is the SINGLE most appropriate next step in management?
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Question 116 of 142
116. Question
A 64 year old man has been progressively breathless over the past 10 days. He complains of a pleuritic chest pain and a cough. He has no significant medical history. On examination, he has decreased chest movements on the left side. There is absent breath sounds on the base of the left lung. There is dullness on percussing the base of his left lung. What is the SINGLE most likely diagnosis?
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Question 117 of 142
117. Question
A 10 year old boy who takes regular dose inhaled steroids for his long standing asthma has been advised to use bronchodilators to control his acute attacks. His parents are unsure when he should use his bronchodilator. What is the SINGLE most appropriate investigation to perform?
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Question 118 of 142
118. Question
A 32 year old previously healthy woman has developed pain and swelling on both knees and ankles with a nodular rash over her shins. She describes feeling more fatigue aver the past few weeks with a mild grade fever. As part of the investigation a chest X-ray was performed. What is the SINGLE most likely appearance on the chest X-ray?
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Question 119 of 142
119. Question
A 50 year old chronic smoker attended the outpatient department with complaints of chronic productive cough, dyspnoea and wheeze. A chest X-ray was ordered and reported as hyperinflated lung with flattened hemidiaphragm and a small cardiac silhouette. Full blood count shows an increase in haematocrit. What is the SINGLE most likely diagnosis?
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Question 120 of 142
120. Question
A 26 year old smoker has a history of wheezing, chest tightness and breathlessness at night and early morning for the past few weeks. Her past medical history includes eczema. What is the SINGLE most likely diagnosis?
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Question 121 of 142
121. Question
A 54 year old patient 7 days after a total hip replacement presents with acute onset breathlessness, and chest pain. On examination, an elevated jugular venous pressure was observed. Her right calf looks swollen. Her pulse rate is 95 bpm and respiratory rate is 24/min. Which SINGLE investigations will be most helpful in leading to a diagnosis?
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Question 122 of 142
122. Question
A 33 year old man attends the Emergency Department with acute shortness of breath that has worsened over the past 48 hours. He is known to have severe asthma. His respiratory rate is 30 breaths/minute. He has been given salbutamol nebulisers and oral prednisolone. He is on 100% oxygen by face mask. An arterial blood gas (ABG) performed an hour later shows the following:
pH 7.32 (7.35-7.45)
PCO2 7.9 (4.7-6.0 kPa)
PaO2 11 (10-14 kPa)
Bicarbonate (HCO3) 30 (22 – 26 mmol/L)
What is the most likely diagnosis based on the ABG findings?
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Question 123 of 142
123. Question
A 53 year old woman with metastatic breast cancer is managed in the hospice for her end of life care. She is bed bound and has been deteriorating. She sleeps more than she is awake and has not been able to tolerate food for the past day. She develops a rattling noise from the throat and noisy breathing over the past few hours which is distressing her. What is the SINGLE most appropriate management?
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Question 124 of 142
124. Question
A 34 year old HIV positive man presents to the outpatient clinic with fever, dry cough and shortness of breath. He is tachypnoeic but his chest is clear. Oxygen saturation is normal at rest but drops on walking. What is the SINGLE most likely diagnosis?
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Question 125 of 142
125. Question
A 46 year old woman complains of breathlessness that has worsened over the past year. She is asymptomatic at present. Recently, she has been experiencing shortness of breath on climbing a flight of stairs which was not the case a few months ago. Her medical history includes bronchial asthma from a young age, and she has been a heavy smoker for the past 25 years. Her two younger brothers suffer from asthma. A chest X-ray was requested, which is seen below.
Which of the following investigations could differentiate COPD from Asthma?
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Question 126 of 142
126. Question
A 71 year old man with a longstanding history of COPD presents to the respiratory clinic with worsening shortness of breath. He is currently on a triple combination inhaler of a LABA, LAMA and inhaled corticosteroid. He uses salbutamol inhalers as required. He had a recent course of oral corticosteroids 6 weeks ago for COPD exacerbation. He has a 45- pack-year smoking history and recently stopped smoking. On examination, he is afebrile, his heart rate is 82 beats/minute, his respiratory rate is 25 breaths/minute, blood pressure is 121/79 mmHg and SpO2 is 88%.
A recent ABG shows:
pH 7.33 (7.35-745)
PaO2: 7.2 kPa (10-14 kPa)
PaCO2: 8.2 kPa (4.7-6.0)
Bicarbonate 27 mmol/L (22-26)
What is the next appropriate treatment for this patient?
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Question 127 of 142
127. Question
A 49 year old man was admitted 5 days ago with fever, poor oral intake, cough and shortness of breath. His medical history includes a recent renal transplant which he has been on immunosuppressants. A chest X-ray during admission demonstrates streaky and fibrotic lesions in both lungs. As his symptoms worsened, the respiratory team performed a diagnostic bronchoscopy with branchoalveolar lavage which results demonstrate pneumocystis jiroveci cysts. What is the SINGLE most appropriate antibiotic to prescribe?
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Question 128 of 142
128. Question
A 55 year old woman with a persistent cough and history of smoking develops left sided chest pain exacerbated by deep breathing. She has a temperature of 38.2°C and basal crackles are heard on auscultation. What is the SINGLE most likely diagnosis?
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Question 129 of 142
129. Question
A 56 year old man who has a history of hypertension and asthma recently had a change of medication which was prescribed by his GP. Two days after starting the new medication, he develops wheezing and shortness of breath. What is the SINGLE most likely medication that would have caused this?
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Question 130 of 142
130. Question
A 25 year old tall man presents to A&E with increasing dyspnoea and right sided chest pain. He has been a heavy smoker for the past 4 years. He has no past medical history. What is the SINGLE most likely diagnosis?
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Question 131 of 142
131. Question
A 51 year old man has severe shortness of breath and left-sided chest pain over the past few hours. There is no history of trauma. His medical history includes COPD which he takes regular ipratropium for. He is a heavy smoker who smokes around 20 cigarettes a day. A portable chest-X ray was organised which shows a left-sided pneumothorax of more than 50% in volume. His oxygen saturations are 90%. What is the SINGLE most appropriate initial management?
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Question 132 of 142
132. Question
A 58 year old man who used to work in the shipyard industry was having chronic cough and shortness of breath for several months. He was given salbutamol nebulisers and intravenous antibiotics and admitted to the ward. Computed tomography was performed which showed patchy infiltrates, pleural thickening and pleural effusion. He died 3 days later after which this case was referred to the coroner. What is the SINGLE most likely reason for the referral to the coroner?
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Question 133 of 142
133. Question
A 50 year old man complains of a productive cough over the past 12 months and the development of greenish coloured sputum. He has a 20-year pack history of smoking. In the past 3 years, he has been admitted on 4 occasions to the hospital with cough and purulent sputum. On examination, clubbing is noted and coarse crackles are audible on auscultation. His lung function is impaired with evidence of an obstructive pattern. A chest X-ray was performed which was normal. This was followed by a high-resolution computed tomography which revealed bronchial dilatation, thickening bronchial walls, and lack of bronchial tapering. What is the SINGLE most likely diagnosis?
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Question 134 of 142
134. Question
A 10 year old girl with diagnosed asthma is having frequent coughs and wheezing that wakes her up at night. She is compliant with her asthma medications which consist of a short-acting 82 agonist inhaler as required, a very low dose of inhaled corticosteroid (50 micrograms two puffs twice a day) and a long-acting B2 agonist inhaler. Her inhaler technique is good. What is the SINGLE most appropriate next step in management according to the BTS/SIGN guidelines?
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Question 135 of 142
135. Question
A 68 year old man presented to his GP with the complaint of a persistent cough. He says that he had been suffering with the cough for about two months now. Further questioning reveals 4.5 kilograms of unintentional weight loss. The patient denies a fever, dyspnoea, sore throat, rhinorrhoea or chest pain but admits that he did cough up a few droplets of blood a few times. His past medical history is significant for chronic obstructive pulmonary disease (COPD). The patient has smoked a pack of cigarettes daily for thirty years but quit five years ago. On general inspection, the patient is noted to be thin with distinct pallor. Examination of the chest reveals no focal wheezes or crackles. There was no lymphadenopathy to be found.
His vitals are as follows:
Blood pressure 140/82 mmHg
Heart rate 80 beats/minute
Respiratory rate 17 breaths/minute
Oxygen saturation on room air 98%
A chest X-ray was done and showed a right perihilar mass.
What is the SINGLE most appropriate investigation in this scenario to confirm the diagnosis?
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Question 136 of 142
136. Question
A 40 year old woman presents to the Emergency Department with a history of sudden shortness of breath which started 2 days ago. She denies having any recent fever or cough. Her vitals were taken and are as follows:
Temperature 37.7 °C
Pulse rate 101 beats per minute
Blood pressure 127/81 mmHg
Sp02 89% on room air
On auscultation her breath sounds are normal
Her blood tests are as follows:
Haemoglobin 140 g/L (115-160)
White cell count 11 x 10″/L (4-11)
Platelets 330 x 109/L (150-400)
D-Dimer 1532 ng/mL (<500)
A PCR COVID-19 test was ordered and returned negative. Her chest x-ray can be seen below.
What is the SINGLE most likely diagnosis?
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Question 137 of 142
137. Question
A 33 year old man is brought into the emergency department following a road traffic accident. He is seen to be very short of breath. He has no breath sounds over the right side of his chest. On percussion, the right chest is noted to be hyper-resonant. On examination, his trachea is deviated to the left. His heart rate is 120 beats/minute. His blood pressure is 90/65 mmHg, and has an oxygen saturation of 85% on 15L of oxygen. What is the SINGLE most appropriate course of action?
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Question 138 of 142
138. Question
A 27 year old male is admitted with acute exacerbation of asthma. He is treated initiated with 100% oxygen and salbutamol nebulizers. Intravenous hydrocortisone was prescribed but it was not available in the department. He has a respiratory rate of 21 breaths/minute, a heart rate of 90 beats/minute and a oxygen saturation of 92%. What is the SINGLE most appropriate next step in management?
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Question 139 of 142
139. Question
A 35 year old lady had an emergency C-section following an obstructed labour. Three days post-op she develops a sudden onset of left sided chest pain associated with breathlessness. Her heart rate is 105 beats/minute. Her left leg is swollen and is pain an palpation. What is the SINGLE best investigation to provide a definitive diagnosis?
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Question 140 of 142
140. Question
A 65 year old woman is seen in the Emergency Department with shortness of breath, chest pain and a persistent cough. She is a non-smoker. There is dullness to percussion on the right side of his chest and decreased breath sounds on auscultation. She has a temperature of 36.7°C, heart rate of 70 beats/minute, and respiratory rate of 25 breaths/minute. A chest X-ray shows a right-sided pleural effusion. A thoracentesis is performed and the results of the pleural fluid analysis show a fluid/serum protein ratio of 0.7. Which is the most likely diagnosis?
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Question 141 of 142
141. Question
A 45 year old woman has been having shortness of breath, chest pain and dizziness for the past few hours. She had undergone a laparoscopic cholecystectomy two days prior. She has a history of type 1 diabetes mellitus. Her respiratory rate was 24 breaths per minute, her heart rate was 110 beats per minute, and her blood pressure was 140/90 mmHg. Her oxygen saturation was 90% on room air. Auscultation of the lungs revealed decreased breath sounds on the left lower lobe.
Arterial blood gas analysis shows:
PaO2 8.1 kPa (10)
PaCO2 4.2 kPa (4.7-6)
pH 7.46 (7.35-7.45)
Bicarbonate 22 mmol/L (22-26)
What is the most likely diagnosis?
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Question 142 of 142
142. Question
A 7 year old child presents to the Emergency Department with acute exacerbation of asthma. The child has a history of asthma and has been experiencing wheezing, shortness of breath, and coughing for the past 24 hours. Despite initial treatment with inhaled bronchodilators and corticosteroids, the child’s symptoms have not improved. The child appears tired and is using accessory muscles of respiration. His respiratory rate is 40 breaths/minute, and oxygen saturation is 92% on room air. His heart rate is 105 beats/minute. Auscultation reveals diffuse bilateral wheezing. The child’s peak flow measurement is currently 120 L/min. His personal best peak flow measurements at home are usually around 300 L/min. His arterial blood gas shows the following:
pH 7.35 (7.35-7.45)
PaO2: 8.3 kPa (10-14)
PaCO2: 6.0 kPa (4.7-6.0)
Bicarbonate 23 mmol/L (22-26)
Which of the following shows he has life-threatening asthma?
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