Masterclass Respiratory by mikeholy


									Masterclass Respiratory

     Semester 9 2010
Paper 1
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.
Paper 1
21 50 year old nanny has recently been diagnosed with Motor
   Neurone Disease. She is referred for the assessment of
   respiratory muscle involvement. There is no history of exertional
   breathlessness and respiratory examination is unremarkable.

22 66 year old office worker with a history of a 100 pack years of
  smoking and asthma presents with breathlessness. His baseline
  spirometry shows airflow obstruction.

   Which of the above would indicate that emphysema is
   contributing to airflow obstruction.
Paper 1

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
Paper 2

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
Paper 2
18 A 16 year old VCE student develops acute respiratory distress after
   arguing with her boyfriend at a Chinese restaurant and presents to a
   local 24 hour medical clinic where you are doing a locum.

   She complains of swelling of her tongue and tightness in her chest.

   On Examination she has multiple raised red blemishes on her skin.

   The most appropriate acute intervention is
   a) phenergan
   b) ventolin
   c) subcutaneous adrenaline
   d) hydrocortisone
   e) paper bag
Paper 3
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 difficulty breathing.

     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 from a 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
Paper 3
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 full strength 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

     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
Paper 3
23 The blood gases shown above show
  which of the following:
  a) uncompensated respiratory acidosis
  b) compensated respiratory acidosis
  c) uncompensated metabolic acidosis
  d) compensated metabolic acidosis
  e) normal
Paper 3
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
Paper 3

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%
Paper 3
44    To reach this ideal, his oxygen therapy requirements are most likely to be;
     a) none
     b) 2-4 litres per minute via nasal prongs
     c) 6 litres per minute via nasal prongs
     d) 2 Litres per minute via closed face mask

45   After several days, despite improvement of his condition, nursing staff report that Mr Brown has a cyclical
     snoring pattern when asleep. They note his oxygen saturation and pulse decrease between snoring
     episodes, and normalize when he is awake.

     The appropriate response is to
     a) increase his oxygen therapy
b) decrease his oxygen therapy
     c) encourage him to lose weight and decrease alcohol intake
     d) refer him to respiratory medicine for investigation
Paper 3
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.
Paper 3
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.
Paper 4
23 A 24 year old medical student presents to staff clinic complaining of daytime
   A detailed sleep history reveals that he sleeps for on average 5 hours a night,
   and wakes refreshed. He falls asleep during his stimulating lunchtime respiratory
   lectures. He has 2 part time jobs , a hectic social life and a demanding girlfriend
   ( note: his history not mine!!) .
   He consumes 6 large diet cokes a day and 3 mars bars.
   He denies illicit drug or alcohol usage.

   The likely cause of his daytime somnolence is –
   a) Sleep disordered breathing
   b) Narcolepsy
   c) Excessive Caffeine
   d) Imbalanced daytime activity and night time sleep
   e) Circadian rhythmn disturbance.
Paper 4
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
Paper 4
25 If he is found to have Stage 4 disease and receives
  maximum available treatment his median survival is

  a) 3 months
  b) 6 months
  c) 14months
  d) 28months
  e) 40 months
27Airway assessment should include all of the following
  A. Ability to open mouth
  B. Subluxability of the temporomandibular joint
  C. Thyro-mental distance
  D. Cervical spine mobility an stability
  E. Size of the uvula

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