Respiratory Cases: Diagnosis and Management, Exercises of Biology

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Masterclass Respiratory

19 Which of the following tests is most likely to establish a diagnosis in the following cases? a) Skin prick test b) Arterial blood gases c) Diffusing Capacity ( DLCO) d) Maximum Inspiratory and Expiratory Pressures e) Spirometry – pre and post bronchodilator

22 year old university student presents to the University medical centre prior to exams complaining of intermittent breathlessness. This occurs particularly following exercise. There is no past history of respiratory illness, she is a non smoker. Her only medication is the oral contraceptive pill and she has no allergies.

Respiratory examination is unremarkable.

20 22 year old University Student presents to the University Medical Centre where you are working with acute breathlessness and parasthesiae in the lips and hands. She reports just completing her final University exams. There is no prior history of respiratory disease and she is a non smoker. Her only medication is the oral contraceptive pill.

39 • A 56 year old man with longstanding rheumatoid arthritis presents to your general practice with gradually worsening shortness of breath on exertion over the past 6 months. On examination he is not cyanotic and vital signs are normal. His chest expansion is 2cm and he has fine metallic crackles to mid way up his posterior chest wall. His cardiovascular examination is normal. The most likely diagnosis is a) – Left ventricular failure b) – Pneumonia c) – Pulmonary fibrosis d) – Chronic obstructive pulmonary disease e) – Asthma

9 Patient with obstructive sleep apnoea are often undiagnosed.

Clinical features of obstructive sleep apnoea include all of the

following except:

A. Snoring during sleep

B. Excessive Daytime Somnolence

C. Feelings of choking during sleep

D. Pulmonary hypertension

E. Aortic Stenosis

20 A 42 year old previously well plasterer presents to emergency at midnight unable to sleep. He describes 12 hours of severe chest pain radiating to his left shoulder and difficultybreathing.

On examination he is afebrile, BP 140/90, pulse rate 78 beats per minute. As the night intern you order a CXR and interpret it yourself as normal. Arterial blood gases reveal – pH – 7.50 pCO2 – 32 PaO2 – 86 As the intern in charge of this patient your next step in this patients management should be – a) ECG b) FBE/ESR c) Discharge Home with outpatient followup and aspirin 600mg QID d) Cardiac enzymes e) V/Q scan

21 You are the second year resident in casualty in a country hospital. The ward covering intern rings you for advice. She wants you to interpret some arterial blood gases she has taken froma dyspnoeic patient post op. pH – 7.34 paO2- 40 PaCo2 – 46 HCO3 - 27 What is the most likely interpretation of the gases a) Venous sample b) Pulmonary embolism c) Metabolic acidosis in an arterial sample d) Respiratory acidosis in an arterial sample e) Post operative pneumonia

22 A 66 year old overweight retired truckie presents with fatigue, daytime somnolence and ankle oedema. He has a 60 pack year smoking history, and drinks 8 fullstrength beers a day. His BMI is 38 kg/m2. On examination he has marked centripedal obesity and a liver edge is palpable. He has moderate peripheral oedema to the knees. Respiratory function tests reveal FEV1 = 2.4L ( 62% predicted) FVC = 4.0L (92% predicted) FER = 60% DLCO = 62% predicted ABG’s PaO2=56 PaCo2=50mmHg pH=7. HCo3- = 29 Liver Function Tests ALT – 72 (<55 IU/L) AST – 50 (0–40 IU/L) GGT-100 (<50 IU/L) Albumin-32 (35–50 g/L) The most likely cause of his ankle oedema is – a) cirrhosis b) right heart failure secondary to severe COAD c) IVC Obstruction secondary to lung cancer d) Right heart failure secondary to sleep apnoea and COAD e) Nephrotic Failure

26 Patient with obstructive sleep apnoea are

often undiagnosed. Clinical features of obstructive sleep apnoea include all of the following except

A. Snoring during sleep

B. Excessive Daytime Somnolence

C. Feelings of choking during sleep

D. Pulmonary hypertension

E. Aortic Stenosis

43 Mr Brown (65 years old), has been admitted to the medical ward with community acquired left lower lobe pneumonia. He has a persistent dry cough, pain on inspiration and an oxygen saturation on arterial blood gases of 91% (room air). He has no relevant past history, with no other pathology on CXR.

His ideal oxygen saturation would be; a) 91% b) >100% c) 90% d) >95%

46 Ms White is 60 years old. She has a life-long history of asthma. She is a non-smoker. She is currently on salbutamol inhaler, 4 puffs prn and beclemethasone inhaler, 400mcg 2 puffs bd, oral prednisolone 5 mg daily and a 5 day course of oral antibiotics.

Ms White is in considerable discomfort from mouth and throat fungal infection. What is most likely to be causing these ulcers? a) inhaled steroids b) oral steroids c) oral antibiotics d) all of the above.

47 Which course of action would be first recommended to Ms White? a) cease the oral antibiotics b) cease the oral steroids c) cease the inhaled steroids d) rinse, gargle and spit after her inhaled steroids

48 Ms White has never used a spacer delivery device for inhaled medications. Why would you recommend her to try it on this occasion? a) It makes the inhalant taste better. b) It improves medication delivery to the lungs c) It decreases medication delivery to the oropharynx d) It is easier to use than a metered dose inhaler.

24 A 72 year old lawn bowler presents with a story of 3 brief episodes of bright blood mixed with clear sputum.

On examination there is evidence of clubbing, generally reduced breath sounds bilaterally and wheezes with no focal signs on auscultation. The rest of his general examination is unremarkable.

A CXR reveals a 3 cm Right upper lobe mass and sputum cytology confirms squamous cell carcinoma

The next most appropriate step in his management is a) referral to an oncologist for chemotherapy b) referral to a surgeon for excisional biopsy c) CT scan Chest and upper abdomen, PET scan and routine bloods d) Bone Scan and CT Brain e) LFT’s and ECG

25 If he is found to have Stage 4 disease and receives maximum

available treatment his median survival is about

a) 3 months

b) 6 months

c) 14months

d) 28months

e) 40 months