Self-Assessment in Respiratory Medicine (out of print)

Which of the following statements about the diagnosis of pleural mesothelioma is/are correct?

A 54-yr-old male is referred to you because of an unexpected finding on a chest CT performed after blunt chest trauma during a car accident. The lesion seen on the CT (below) extends about 1.5 cm above and 1.5 cm below the level shown in the figure. On consultation, the patient has no respiratory complaints but reports that he felt a little bit tired during the last month and had less energy. Walking was more difficult for him. His past medical history was uneventful. On physical examination no abnormalities were found. Haematology and chemistry including β-human chorionic gonadotropins (β-hCG), alpha fetoprotein and thyroid stimulating hormone (TSH) were normal.

Which one of the following is the next most appropriate step?

A 25-yr-old female has suffered severe peripartum bleeding. She received 20 packed red blood cell transfusions and five fresh frozen plasma transfusions. After delivery, she had to be intubated and was placed on mechanical ventilation for respiratory failure. She is deeply sedated but occasionally triggers the ventilator. On the third day of mechanical ventilation, her arterial blood gas analysis shows a PaO₂ 50 mmHg (6.65) kPa, PaCO₂ 47 mmHg (6.251 kPa) and pH of 7.33. The ventilator settings are: inspiratory oxygen fraction (FIO₂) 0.8; assist control with tidal volume (VT) 420 mL, frequency 18 breaths/min; inspiratory time (tI)/expiratory time (tE) 0.3; and peak end-expiratory pressure (PEEP) 10 cmH₂O. Plateau pressure is 32 cmH₂O. She weighs 60 kg. Chest radiography reveals bilateral diffuse pulmonary infiltrates.

What would be the most appropriate change in the ventilator settings for this patient?

A 39-yr-old female presents with painful erythema nodosum. Her physical examination is unremarkable and her SpO₂ on room air is 98%. Her chest radiograph shows bilateral hilar lymphadenopathy. Spirometry reveals an FEV1 of 79% predicted, an FVC of 89% predicted and an FEV1/FVC ratio of 77%, with a TLCO of 82% predicted.

Which one of the following would be the most appropriate next step?

A 28-yr-old female complains of a 1-week history of severe hacking dry cough, slight dyspnoea and weakness. On examination, she is mildly unwell, but fully orientated and not cyanosed. However, she is pyrexial, pale and slightly jaundiced. The chest is clear on auscultation but the radiograph shows patchy, bilateral bronchopneumonic infiltrates. A full blood cell count shows normochromic anaemia with Hb of 9 g·dL⁻¹ and neutrophil leukocytosis. Liver function tests show mild elevation of unconjugated bilirubin and raised lactate dehydrogenase (LDH). Blood urea and electrolytes are normal. There is no proteinuria.

Which of the following investigations would be most likely to provide a diagnosis?

A 43-yr-old male complains of sudden bilateral chest pain, aggravated by inspiration and accompanied by malaise and slight fever. Physical examination shows some tenderness on both sides of the chest, but normal breath sounds. His chest radiograph appears normal, but ultrasound reveals small bilateral pleural effusions. The patient reports that, 1 week ago, one of his children was admitted to the hospital with acute meningitis.

Which of the following is the most likely micro-organism causing his illness?

A 34-yr-old asthmatic female comes to the emergency room with progressive dyspnoea and non-productive cough over the past 3 days. Her best recorded peak expiratory flow is 60% and she has a S_pO₂ of 90%. She has stopped taking inhaled corticosteroids because she is 27 weeks pregnant and does not feel comfortable receiving medication while she is pregnant. She has been having mild symptoms for weeks. Now the symptoms have been getting worse and she has been waking at night for the past 10 days. She feels breathless and although she has used her relief inhaler every day in the past week and 3 times in the last hour, she does not feel better.

Which one of the following is the most appropriate initial treatment for this patient?

A 45-yr-old male complains of dyspnoea on minimal exertion, orthopnoea and near fainting. In the past few years, the patient has reportedly suffered from several episodes of haematemesis and an oesophagogastroduodenoscopy had shown that this was due to oesophageal varices. On physical examination, he is pale, his blood pressure is 110/75 mmHg, heart rate is 74 beats/min and regular, and SpO₂ in room air is 94%. There is a split second heart sound, pulmonary auscultation is normal, abdominal examination suggests ascites and he has bilateral lower limb oedema. Echocardiography reveals an estimated systolic pulmonary artery pressure of 45 mmHg and a left ventricular ejection fraction of 55%.

Which of the following is the most likely diagnosis?

A 56-yr-old female suffers from obstructive apnoea/hypopnoea syndrome. On polysomnography, her AHI was 42 events·h⁻¹ and her oxygen desaturation index (⩾4%) was 40 events·h⁻¹. Due to discomfort with this treatment, she refused the proposed CPAP therapy, although a sleep study confirmed that her AHI was reduced to 5 events·h⁻¹ by CPAP. Attempts to convince the patient to try nasal CPAP therapy again after adapting the mask and machine have been unsuccessful.

Which one of the following alternative treatments is the most promising to relieve the symptoms in this patient?

A 60-yr-old homeless male is brought to the emergency department because of severe dyspnoea. The patient states that he can hardly walk anymore because of shortness of breath. This makes it difficult for him to purchase and carry his daily amount of two to three bottles of wine to his shelter. He occasionally smokes if he manages to get some cigarettes. Until he lost his home 10 yrs ago, he never smoked and only drank occasionally. His medical history is uneventful apart from tonsillectomy in childhood. During transfer from the ambulance stretcher to the hospital bed, he becomes cyanotic and more dyspnoeic as soon he is in upright position. The patient also has jaundice, digital clubbing and spider naevi. Physical examination shows some basilar wheeze. Cardiac auscultation is normal. The liver appears to be small; the spleen is of normal size and there are no signs of ascites or abdominal varices. Hepatojugular reflux is negative. Laboratory tests show moderately elevated liver enzymes (ALT 312 U·L⁻¹) and normal CRP. Haemoglobin concentration is 10.1 g·dL⁻¹ with a mean cellular volume of 107 fL. The leukocyte count is normal. PaO₂ on room air in sitting position is 61 mmHg (8.113 kPa), PaCO₂ is 32 mmHg (4.256 kPa) and pH is 7.42.

What is the most likely diagnosis?

A 48-yr-old lorry driver suffers from excessive sleepiness and shortness of breath on minimal exertion. He has gained 35 kg in the last 10 yrs and now weighs 165 kg. The patient’s body mass index is 46 kg·m⁻². His blood pressure is 135/90 mmHg and his pulse rate is 76 beats/min. He has bilateral leg oedema and neck vein distension. His second heart sound is accentuated. Lung auscultation is normal. An arterial blood gas analysis on room air reveals a PaO₂ of 52 mmHg (6.9 kPa), PaCO₂ of 65 mmHg (8.6 kPa), pH of 7.33, SpO₂ of 87% and serum bicarbonate concentration of 33 mmol·L⁻¹. A sleep study shows a mean nocturnal oxygen saturation of 83% and an AHI of 58 events·h⁻¹, with predominantly obstructive apnoeas/hypopnoeas, some central apnoeas of up to 55 s in duration and several periods of rapid eye movement sleep-associated periods of hypoventilation with increases in PtcCO₂. You decide to start the patient on nocturnal continuous positive airway pressure therapy via an oral–facial mask. After 4 weeks, the patient does not report a clear improvement in sleepiness. Therefore, you decide to change the mode of ventilation.

Which one of the modes schematically depicted below is most appropriate?

In a 73-yr-old otherwise healthy heavy smoker with normal lung function, endobroncial biopsy of a tumour in the left lower lobe reveals nonsmall cell lung cancer. CT scans are shown below.

Which one of the following is the most appropriate next action?

A 46-yr-old male presents to your outpatient clinic. He suffers from increasing shortness of breath, increasing amounts of sputum and recurrent bronchopulmonary infections. He has infertility and had two operations for nasal polyposis and recurrent sinusitis. His lung function shows a combined obstructive–restrictive pattern. The CT scan of the thorax shows abnormalities in both lower lobes (below). Liver function tests and blood glucose concentration are within normal limits.

Which one of the following is the most likely diagnosis in this patient?

A 24-yr-old medical student is consulting you before departing to Africa where he plans to climb Mt Kilimanjaro (5,895 m). Apart from seasonal allergic rhinitis, his medical history is unremarkable and he is physically very fit. He asks for your advice regarding prevention of altitude-related illness. You recommend a gradual ascent not exceeding 300–500 m every 24 h above 2,500 m, avoidance of physical overexertion and a low sleeping altitude if feasible. The student asks you to prescribe a drug for prevention of acute mountain sickness.

Which one of the following is the most appropriate?

A 73-yr-old retired insulating engineer presents with a 6-month history of increasing dyspnoea. He had worked with asbestos for 2 yrs, 35 yrs previously. He has seronegative rheumatoid arthritis, finger clubbing and basal crackles on chest examination. The CT scan is shown below.

Which one of the following is the most likely diagnosis?

A 35-yr-old female presents to her family physician with unproductive cough and fever up to 37.8°C (axillary) during the past 48 h. On physical examination, she presents end-inspiratory crackles at the left lung base on auscultation, with no other abnormal findings. Chest radiography reveals a small consolidation in the left lower lung field. Her S_pO₂ was 97% on room air.

Which of the following investigations is necessary for the management of this patient?

A 45-yr-old female is admitted to the hospital because of severe dyspnoea and acute chest pain. Fever and cough are not present on admission. The patient reports mild dyspnoea on exertion for the past 2 yrs and an episode of pneumothorax 6 months ago. On admission, her blood pressure is 130/80 mmHg, her heart rate is 100 beats/min and regular, and her respiratory rate is 32 breaths/min. Chest radiography reveals small bilateral pneumothoraces. CT shows multiple round cysts involving the whole parenchyma; three micronodules, enlargement of axillary lymph nodes and a renal mass were also detected.

Which of the following statements about this case is/are correct?

A 54-yr-old male smoker with a history of type II diabetes, hypothyroidism and obstructive sleep apnoea developed angina on exertion. A coronary angiogram showed that several cardiac vessels were critically occluded. Severe aortic stenosis was also diagnosed. Coronary artery bypass grafting and aortic valve replacement were performed. The patient had a good post-operative recovery and was assigned to cardiac rehabilitation and started on warfarin. Some weeks into the programme, he starts to complain of a cough, low-grade fever and worsening dyspnoea. A chest radiograph shows a moderate left-sided pleural effusion. A thoracentesis reveals the following: pH 7.35; glucose 3.5 mmol·L⁻¹; lactate dehydrogenase (LDH) 590 U·L⁻¹; and protein concentration 3.8 g·dL⁻¹. Differential cell count revealed increased lymphocytes.

Blood glucose is 5.6 mmol·L⁻¹ and serum LDH is 410 U·L⁻¹.

Which one of the following is the most likely diagnosis?

A 57-yr-old male with a history of ischaemic heart disease, intermittent claudication, alveolar proteinosis and diabetes, with poor adherence to his medications, presents with a cough, wheeze and phlegm of several weeks’ duration. He has had low-grade fever and lost 4 kg in weight. Microscopic sputum examination reveals weakly acid fast-staining, filamentous branching organisms. A Ziehl–Neelsen stain of the patient’s sputum is shown below (reproduced from Sullivan et al. (2011), with permission from the publisher).

Which one of the following is the most likely diagnosis?

A 35-yr-old female is admitted to the emergency department with a history of repeated chest infections, diarrhoea, otitis media, pneumonia, lethargy and some weight loss. She has areas of vitiligo and a past history of haemolytic anaemia. Chest radiography shows bilateral mid-zone infiltrates. Pulmonary function tests show a mild restrictive ventilatory defect, with a reduced lung volume and diffusing capacity. A transbronchial lung biopsy shows a noncaseating granuloma.

Which one of the following options is the most likely diagnosis?

A 55-yr-old male consults you because of breathlessness, which has become gradually worse over a period of 1 yr. He also has a cough but does not produce phlegm. He is able to walk for 10 min (distance 400–500 m) after which he has to rest because of shortness of breath. He has no chest pain on exertion. His complaints have been present throughout the entire year but become worse in a humid environment and during the winter. He has no known allergies and no family history of lung disease. He is a current smoker with a history of 40 pack-yrs. His general practitioner prescribed salbutamol 400 μg as needed. The patient reports that this gives him a little more air. His medical history is otherwise uneventful. The physical examination is unremarkable. A laboratory work-up including haemoglobin, haematocrit and a differential white blood cell count, and chest radiography, were normal. Spirometry reveals the following results.

Which of the following is the most likely diagnosis?

Which of the following statements about lung cancer treatment is/are correct?

A 53-yr-old obese male (BMI 30.1 kg·m⁻²) is diagnosed with obstructive sleep apnoea with an AHI of 45 events·h⁻¹ and an oxygen desaturation index (ODI) of 40 events·h⁻¹. He is given auto-adjusting nasal CPAP therapy with an allowed pressure range of 5–15 cmH₂O. In the first night of adaptation, his AHI went down to 6 event·h⁻¹ and his ODI was 4 events·h⁻¹. Three days later, the patient reported that his sleepiness had already improved significantly. 1 month later, the patient returned to the sleep laboratory and complained of recurring daytime sleepiness. Ambulatory pulse oximetry showed an ODI of 34 events·h⁻¹. Data downloaded from the CPAP machine suggested an adequate compliance by the patient as the machine was used 5.48 h per night on average. The applied pressures ranged from 5 to 13.5 cmH₂O and the 90th pressure percentile was 12 cmH₂O.

Which one of the following steps is the least promising in this situation?

A 45-yr-old, HIV-positive male is admitted to the hospital because of fever and severe dyspnoea. Physical examination shows tachypnoea and tachycardia. Chest auscultation reveals bilateral fine crackles. Radiography shows extensive, bilateral, patchy lung infiltrates. Arterial blood gas analysis on room air reveals PaO₂ 45 mmHg (5.985 kPa), PaCO₂ 11 mmHg (1.463 kPa) and pH 7.56. Oxygen therapy (inspiratory oxygen fraction (FI,O₂) 0.5) is promptly initiated. Arterial blood gas analysis after half an hour demonstrates PaO₂ 50 mmHg (6.65 kPa), PaCO₂ 15 mmHg (1.995 kPa) and pH 7.52. Brain natriuretic peptide concentration is normal.

Which of the following statements regarding this patient is/are correct?

Which of the following is/are true in pleural effusions?

A 68-yr-old male is admitted to the emergency room complaining about shortness of breath, fever, chills and cough with purulent sputum production for the last 2 days. He is a nonsmoker without any previous medical history. The patient looks tired but other than that he is in good condition without any confusion. Vital signs are blood pressure 105/70 mmHg, heart rate 110 beats/min, breathing rate 32 breaths/min, and temperature 38.9 ^oC. Bronchial breath sounds are heard on auscultation of the right chest. Blood tests reveal a white blood cell count of 9,000 cells per mm³ with a left shift, haematocrit 46%, Urea 22 mmol·L⁻¹, creatinine 1.8 mg·dL⁻¹, sodium 142 mmol·L⁻¹ and oxygen saturation (room air) 92%. A chest radiograph demonstrates moderate cardiomegaly and a right lower lobe infiltrate with air bronchograms.

Which one of the following is the appropriate management decision for this patient?

A 75-yr-old female is referred for dyspnoea on exertion and chronic cough. Dyspnoea and cough have worsened continuously during the past 12 months. Pulmonary function testing reveals a FVC of 72% predicted, FEV₁ of 80% predicted and a T_LCO of 38% predicted. The chest radiograph shows bilateral patchy infiltrates mostly at the lung bases. On high-resolution CT, bilateral reticular opacities and clustered basal honeycombing are found. Open lung biopsy reveals randomly distributed foci of usual interstitial pneumonia (UIP) surrounded by normal lung parenchyma.

What is the most appropriate therapy for this patient?

A 57-yr-old male with ischaemic heart disease is admitted with an episode of acute pulmonary oedema. Assessment shows a systolic blood pressure of 140 mmHg, S_pO2 of 89%, P_aO2 59 mmHG (7.847 kPa), P_aCO2 26 mmHg (3.458 kPa) and pH of 7.34 in room air. After establishing initial therapy with nitrates, oxygen and loop diuretics, the emergency department team request your advice on the use of NIV or CPAP therapy.

Which of the following statements regarding treatment of this patient is/are true?

A 58-yr-old male hospitalised with a hip fracture for 1 week complains about shortness of breath, fever and cough with purulent sputum production for the past 2 days. He is a nonsmoker with a history of hypertension. The patient is in good clinical condition and in moderate respiratory distress. Vital signs are blood pressure 130/60 mmHg, heart rate 100 beats/min, breath rate 30 breaths/min and temperature 37.9 ^oC. Rales in the upright seated position and bronchial breath sounds are revealed on auscultation on the left chest posteriorly. A complete blood count shows a white blood cell count of 17,000 cells·mm⁻³ with 78% mature neutrophils, haematocrit 38%, blood urea nitrogen (BUN) 62 mg·dL⁻¹, creatinine 1.0 mg·dL⁻¹ and oxygen saturation on room air is 93%. A chest radiograph confirms left lower lobe pneumonia. The patient has not been on any antimicrobial therapy until now.

Which one of the following is the appropriate empirical antibiotic therapy for this patient?

Which of the following radiological findings is characteristic of pulmonary Langerhans cell histiocytosis?

A 35-yr-old female was admitted with acute dyspnoea, 12 months after the birth of her second child. During the past 6 months, she has suffered from mild dyspnoea (Medical Research Council grade 2) despite the fact that she has never smoked. Chest radiography revealed a unilateral pneumothorax, which was treated appropriately. The follow-up CT scan is shown below.

Which one of the following is the most likely diagnosis?

Which of the following statements regarding the role of echocardiography and right heart catheterisation in the evaluation of pulmonary hypertension (PH) is/are correct?

A 64-yr-old male with stable COPD (FEV₁ 25% predicted) is offered a pulmonary rehabilitation (PR) course immediately after discharge from hospital following an acute exacerbation of COPD. His medical therapy has been optimised, but he is breathless on walking 200 m. The patient is sceptical about participating in the PR course.

In explaining the potential benefits to the patient, which one of the statements below is evidence based?

A 46-yr-old female with a BMI of 26 kg·m⁻² suffers from OSAS. The patient’s AHI in a recent sleep study was 34 events·h⁻¹ with an average of 30 obstructive and four central events per hour. You explain the available treatment options to the patient in the presence of her husband. She is not enthusiastic about nasal CPAP but agrees to try it. After 3 weeks, she declares that CPAP was not acceptable for her, mainly for psychological reasons. She asks for another treatment modality. Which is the next appropriate examination that helps to decide on an alternative treatment?

A 65-yr-old male presents to you with increasing cough and breathlessness for the past 2 months, weight loss of 7 kg over the same period, two episodes of haemoptysis and increasing fatigue. He is a smoker of 20 cigarettes/day for 40 yrs. Chest radiography shows a left upper lobe mass with mediastinal widening. Diagnostic work-up shows adenocarcinoma stage IV with cN2 disease and adrenal metastasis. The diagnosis was based on cytology and epidermal growth factor receptor (EGFR)/anaplastic lymphoma kinase (ALK) status are negative. The patient’s status is good and no comorbidities are present. Which one of the following is the appropriate treatment strategy for this patient?

In the National Emphysema Treatment Trial (NETT), cost-effectiveness of lung volume reduction surgery (LVRS) in patients with severe pulmonary emphysema was compared with medical treatment. The results revealed a cost-effectiveness ratio of LVRS of US$53,000 per qualityadjusted life yr (QALY) at 10 yrs of follow-up. These results suggest that:

Which of the following diseases is/are associated with upper lobe fibrosis and loss of volume on chest radiography?

A 35-yr-old Caucasian male from South Africa, currently a resident of London, UK, presents to the emergency room with productive cough and low-grade fever of approximately 6 weeks’ duration. Six months ago, during a stay in South Africa, he had received treatment with isoniazid, rifampicin, pyrazinamide and ethambutol for smear-positive pulmonary tuberculosis (TB). The treatment had led to rapid clinical improvement and he therefore stopped it upon return to London, after a duration of 8 weeks.

Clinical examination at admission reveals a BMI of 18 kg·m⁻² and a temperature of 37.8°C but no other abnormal findings. Chest radiography shows bilateral upper lobe infiltrates with a cavitary lesion in the right upper lobe. The sputum contains acid-fast bacilli. A HIV test is negative. Results of rapid molecular-based drug susceptibility tests are pending.

Which of the following should be recommended for this patient?

H: isoniazid; R: rifampicin; Z: pyrazinamide; E: ethambutol; S: streptomycin. Numbers before the letters denote the duration of treatment in months.

Which of the following conditions warrants/warrant preventive therapy for patients known to have latent tuberculosis infection?

A 75-yr-old female is admitted to the emergency department after a car accident. Besides complaining of lower back pain and some bruising of the chest, the patient seems well. She has been treated for rheumatoid arthritis for many years with methotrexate. Vital signs and physical examination do not reveal any abnormalities. The chest radiograph is normal except for spine osteophytic degeneration.

Two days after being sent home with analgesic treatment, the patient returns to the emergency department. She now complains of dyspnoea. Physical examination reveals reduced breath sounds on the left lung base. The chest radiograph shows a moderate-sized left pleural effusion but no pulmonary infiltrates. Pleural fluid with a milky appearance is drained. Which of the following pleural fluid analyses confirms the suspected diagnosis?

Which of the following statements concerning the nocturnal recording shown below is correct?

A 27-yr-old female in the 22nd week of pregnancy presents to her family physician because of recent onset of dyspnoea on moderate exertion and cough without sputum production causing frequent nocturnal awakening. She had been treated for bronchial asthma with inhaled corticosteroids and long-acting β-adrenergic agonists but stopped treatment at the beginning of the pregnancy because of fear of adverse effects on the fetus. On physical examination, she is in good general condition but lung auscultation reveals slight bilateral wheezing. Spirometry shows FVC of 90% predicted, FEV₁ of 50% predicted and FEV₁/FVC ratio of 55%. After inhalation of two puffs of salbutamol, FEV₁ improved to 90% predicted while FVC remained 90% predicted.

Which one of the following recommendations is most appropriate for this patient?

A 27-yr-old, previously healthy female presents with acute onset of dyspnoea and coughing spells with blood-tinged sputum. Chest radiography shows extensive bilateral opacities. The patient is hypoxic on room air (SpO₂ 84%). Sequential bronchoalveolar lavage reveals progressively bloodier fluid return. You decide to look for an autoimmune disease.

Which one of the following anti-body panels is least likely to confirm the diagnosis?

A 57-yr-old male previously diagnosed with non-Hodgkin’s lymphoma (NHL) presents with a cough and dyspnoea for 1 week. He has a history of night sweats. Examination shows a right-sided pleural effusion. A thoracentesis of the effusion reveals a milky fluid.

Which one of the following statements concerning the pleural fluid is most likely to be true?

A 45-yr-old banker complains of dyspnoea when he climbs the stairs to his office on the third floor. When he reaches the second floor, his chest feels tight and several times he has almost fainted so that he had to sit down until he recovered. Five yrs ago, he fractured his right ankle at a golf tournament. The fracture was complicated by a deep vein thrombosis of the right leg with concomitant pulmonary embolism. On lung function testing, lung volumes are normal and TLCO is 35% predicted. SpO₂ on room air is 86%, and arterial blood gas analysis reveals a PaO₂ of 57 mmHg (7.581 kPa), PaCO₂ of 30 mmHg (3.99 kPa) and pH of 7.47. Echocardiography shows a normally functioning left ventricle; the right ventricle is dilated and the systolic pulmonary pressure is estimated to be 50 mmHg.

Which of the following is the next appropriate step in the management of this patient?

Which of the following statements concerning initiation of β-blocker treatment in patients with advanced COPD (GOLD grade III or IV) on inhalation therapy with a long-acting β-agonist and inhaled corticosteroids is/are correct?

A 45-yr-old HIV-positive male (CD4 cells 250 cells per μL), is referred to you because of a tuberculin skin test with 7-mm induration. He has no specific complaints, has not had contact with tuberculosis patients in the past, and has not had a Bacille Calmette-Guérin (BCG) vaccination. Chest radiography is normal.

Which one of the following is the most appropriate next step?

A 38-yr-old nonsmoking and otherwise healthy farmer complains of increasing cough and dyspnoea on exertion of almost 3 yrs’ duration. Due to acute clinical worsening with dyspnoea even at rest and hypoxaemia (S_pO₂ of 88% on room air), the patient was admitted to the emergency department. There were no clinical and laboratory signs of infection. Pulmonary function testing was not feasible. A chest radiograph and CT were obtained. A bronchoscopy with a bronchoalveolar lavage was performed. It revealed a predominance of lymphocytes and only occasional eosinophils and macrophages. Open-lung biopsy findings are shown.

Which one of the following is the most likely diagnosis?

Which of the following statements concerning the nocturnal recording below is false?

A 24-yr-old female is visiting your outpatient clinic for regular follow-up of her asthma. You have known this patient for 7 yrs because she has allergic asthma (allergies to house dust mites, grass and tree pollen). During the pollen season, she has only minor complaints of intermittent allergic rhinitis, for which she uses an antihistamine as needed. At age 17 yrs, she was admitted to the hospital because of a severe asthma attack. Since then, she has been followed up regularly. Her last check-up was 3 months ago. She was stable at that time. Therefore you reduced her medication from budesonide/formoterol/(100/6 μg) twice a day to budesonide 100 μg twice a day and terbutaline 500 μg as needed. Since then she has remained completely asymptomatic both in the daytime and at night. She plays tennis twice a week without any problems. She has used her terbutaline twice during the past 3 months. She admits she has used the budesonide only once a day for the past 2 months because she felt so well.

According to the GINA guidelines, what would be the most appropriate next action?

A 66-yr-old male with a history of hypertension is hospitalised for colon cancer surgery. He undergoes a successful subtotal colectomy and ileocolic anastomosis, without any signs of complication. His immediate post-operative state is good, but on post-operative day 4 he develops sudden-onset shortness of breath and also has two episodes of haemoptysis. His blood pressure is 130/70 mmHg; his pulse is regular, with a rate of 110 beats/min and his respiratory rate is 28 breaths/min. His temperature is normal and his SpO₂ is 88% on room air, which improves to 95% on 2 L·min⁻¹ of oxygen via nasal cannula. He has mildly decreased breath sounds at his left lung base and a normal S1 and S2 without murmurs or gallops. His abdomen is soft and non-tender with normal bowel sounds. The patient does not have any oedema or tenderness in the lower extremities.

The laboratory analyses, including a complete blood cell count and basic metabolic panel, are normal. Arterial blood gas analysis on room air demonstrates a PaO₂ of 56 mmHg (7.28 kPa), a PaCO₂ of 30 mmHg (3.99 kPa), and a pH of 7.48, with an SpO₂ of 90%. Chest radiography reveals left basilar segmental atelectasis. The ECG shows tachycardia of 116 beats/min and a right bundle branch block, which is a new finding for this patient.

Which of the following is the next diagnostic test in order to confirm your diagnosis in this patient?

A 62-yr-old male complains of shortness of breath on mild exertion, such as climbing one flight of stairs. He has no chest pain. The referring general practitioner reports that the patient has a long history of arterial hypertension and a previous myocardial infarction with subsequent heart failure. Accordingly, the patient is on a β-blocker, an angiotensin-converting enzyme inhibitor and a diuretic. The last echocardiogram showed a left ventricular ejection fraction of 35%. The Epworth sleepiness scale reveals a score of 11. His wife reports that he is snoring irregularly with intermittent pauses. The patient has a body mass index of 34 kg·m⁻², no signs of oedema and the lungs are clear. Spirometry reveals a vital capacity of 92% predicted and FEV1 of 94% pred with a normal flow–volume loop.

Which of the following is/are correct?

A 62-yr-old male presents to the emergency department with acute shortness of breath and chest pressure. He was discharged from the hospital 5 days ago after a haemorrhagic stroke. His past medical history includes hypertension, obesity and obstructive sleep apnoea. On physical examination, the patient’s heart rate is 98 beats/min, blood pressure is 110/70 mmHg, respiratory rate is 24 breaths/min and SpO₂ is 86% on room air. Laboratory analyses, including a complete blood cell count, basic metabolic panel, cardiac enzymes and coagulation studies are normal. An ECG shows sinus tachycardia with an incomplete right bundle branch block and nonspecific T-wave abnormalities. Echocardiography reveals an estimated pulmonary artery pressure of 60 mmHg, tricuspid regurgitation and right atrial and ventricular enlargement. A diagnosis of pulmonary embolism (PE) is made, based on CT pulmonary angiogram of the chest, which reveals multiple thrombi extending into the lobar and segmental branches of the right pulmonary artery. In addition the CT scan reveals thrombi in the pelvic veins.

Which of the following is the best management option for this patient?

Large randomised controlled trials in patients with mild­to­moderate COPD have shown unambiguously that inhaled bronchodilators improve which of the following?

A 64-yr-old female presents to the emergency department complaining of sudden onset of dyspnoea with pleuritic chest pain in her left hemithorax for the past 3 h. The patient underwent coronary artery bypass graft surgery 9 months ago and has been in a stable condition ever since. Her treatment includes a β-blocker, an angiotensin-converting enzyme inhibitor, furosemide and low-dose aspirin. On examination she is dyspnoeic with a respiratory rate of 18 breaths/min; heart rate is 112 beats/min. Auscultation reveals decreased breath sounds at the base of the left lung. Her ankles are symmetrically swollen and non-tender. SpO₂ on room air is 88%. The ECG reveals a sinus tachycardia of 104 beats/min but no other abnormal findings. Chest radiography confirms a small pleural effusion on the left side.

Which of the following options is the most appropriate next step in the management of this patient?