Copy of Respiratory Module 1

A 65-year-old man presents with symptoms of paroxysmal nocturnal dyspnea on a background of known ischaemic heart disease. He had an echocardiogram performed last month which revealed a left ventricular ejection fraction of 25%. The respiratory parameters from a polysomnographic sleep study are shown below:

What is the most likely explanation for the change?

During diving, there is a change in external pressure as the depth of the dive changes.

According to Boyle’s Law, what actually occurs as a free diver rises to the surface?

Selexipag is a novel oral selective prostacyclin-receptor agonist that is currently being investigated for the treatment of pulmonary arterial hypertension.

What is the most common side effect associated with this medication?

Riociguat is a member of a new class of therapeutic agents called soluble guanylate cyclase stimulators and is useful in which of the following condition?

If an average 70kg man has a respiratory rate of about 18 breaths per minute and a tidal volume of 600 mL. What would his pulmonary ventilation be?

A 45 year old man is diagnosed with obstructive sleep apnea. His AHI is 50 events/ hour on an overnight sleep study. He has had a trial of CPAP at home which reduced his AHI to less than 5 events/hr, but found CPAP intolerable. Since he stopped using it, his daytime somnolence had become worse.

What other alternative does he have?

A 67 year old man with a BMI of 40 has been diagnosed with bulbar motor neuron disease for the last two years. He sees you in clinic complaining of having excess daytime sleepiness and had an Epsworth sleepiness score of 16/24. He then proceed to have a level III sleep study (Embletta system) which revealed the following information: Overall AHI 39.9 Oxygen saturation average 95.1% Frequent Hypopnoea and Obstructive Apnoea occurred during the sleep period with an average duration of 19.2 seconds and an average Oxygen desaturation to below 90% in 5.3% of the recording time.
His spirometry shows an FEV1 of 2.82 (78% predicted), FVC 3.81 (74% predicted), Ratio 0.78.

Apart from commencing a trial of CPAP, which of the following is the most appropriate next step in management?

A 40 year old man presents with complains of increasing dyspnea, worsening cough with increased sputum production and recurrent lower respiratory tract infection. He is infertile and has had a previous sinus surgery for recurrent nasal polyps and recurrent sinusitis. He has signs of situs inversus on examination.

Which of the following would provide the least useful information in establishing a diagnosis for this man?

Which of the following intervention has NOT been proven to improve survival in patients with chronic obstructive pulmonary disease (COPD)?

You are seeing a 65 year old man with severe COPD in clinic . His FEV1 is 28% predicted. However his disease has been stable on 3 bronchodilators (tiotropium,salmeterol and fluticasone) and had only one admission in the last four years following an infective exacerbation of his COPD. Given the stability of his condition, you decide to slowly withdraw his inhaled dose of fluticasone over a 3 month period.

What could potentially happen to him in the next 12 months following the withdrawal of his inhaled corticosteroid?

A 70 year old man with severe COPD (FEV1 of 30%), presents to your clinic for a review. He has a high symptom burden of COPD with a COPD Assessment Test (CAT) score of 20. His MMRC score is 3.
In the last 12 months, he has presented twice to hospital following an infective exacerbation of his COPD. He is currently on SalmeterolFluticasone inhaled twice daily and uses Salbutamol as required.
You decide to change his inhaler regime.

Which of the following inhaler would be most beneficial in preventing future COPD exacerbation for this man?

The use of high flow nasal oxygen is increasingly recognized as an important treatment modality for patients with acute hypoxemic respiratory failure. 

The following are benefits of such therapy compared to non-invasive ventilation, except?

A 56 year old man with a background of moderate COPD (FEV1 60% predicted) presents to your clinic for a review. He is an ex-smoker of 30 pack years. On your clinical assessment, he has a CAT score of 12 and mMRC of 2. His resting oxygen saturation is 90 percent on air. Over the last 12 months, he has presented twice to the emergency department with COPD exacerbations requiring antibiotic and steroid therapy. He is currently taking umeclidinium bromide 62.5mcg inhaled once daily and uses Salbutamol as required.

All of the following treatment advice would be appropriate for this man except?

The upper respiratory tract consists of the nasal cavity, pharynx and larynx. The lower respiratory tract consists of the trachea, bronchi and lungs.

If a person accidentally inhales a foreign object, for example a peanut, where in the respiratory tract is it most likely to lodge?

Which of the following patient group would most likely benefit from endobronchial valve placement?

Which of the following clinical feature would be most consistent with the diagnosis of ACOS (Asthma-COPD Overlap Syndrome)?

A D-dimer with a threshold of 500 mcg/L has been shown to be a highly sensitive test with a correspondingly high negative predictive value among patients with low pretest probability for PE. However, the Ddimer level tends to increase with age.

If so, what would be an optimal D-dimer cutoff value for a 63 year old?

Rivaroxaban is a direct oral anti-coagulant that is indicated for the treatment of DVT and PE.

Which of the following scenario could potentially determine its preference over oral Dabigatran?

A previously well 52 year old man from Queensland presents with acute dyspnea. On examination, he appears to be in severe respiratory distress with a RR of 40, pulse of 120, blood pressure is 100 systolic, saturating 85% on air. A bedside echocardiogram shows evidence of right ventricular strain.His ECG shows an incomplete right bundle brach block, troponin is 120 ng/l and his pro-BNP is 1500 pg/ml. An urgent CTPA confirms the presence of a large saddle embolus in the right main pulmonary artery. Instead of giving systemic thrombolysis, the man is referred to the cathlab for an urgent catheter directed thrombolysis (CTD).

What is the major advantage of CTD compared to systemic thrombolysis?

A 70 year old man with a background of severe COPD with an FEV1 of 20% is being discharged from the ward today following a week long admission with severe infective exacerbation of COPD requiring a period of non-invasive ventilation.

Which of the following index will best predict his hospital readmission in the next 3 months?

A 70 year old woman with known COPD is admitted to hospital with a two day history of worsening reathlessness, cough and sputum production. Clinically she is tachypneic with a RR of 40 and saturating 89% on 2L/min of oxygen. Her arterial blood gas shows acute respiratory acidosis with a pH of 7.20 and a pCO2 of 100.

Which of the following intervention is most likely to reduce her risk of intubation and ventilation?

In the management of community acquired pneumonia, which of the following clinical tool has the highest accuracy of predicting patients who will require intensive respiratory and ventilatory support (IRVS)?

What is the antibiotic of choice for severe community acquired pneumonia in patients living in a non-tropical region in Australia?

Which of the following primary lung cancer has the most favourable prognosis?

Glycopyrronium bromide is an inhaled long-acting muscarinic antagonist (LAMA) that is used as a maintenance bronchodilator treatment to relieve symptoms in adults with chronic obstructive pulmonary disease (COPD).

What is the most common side effect of this medication?

With regards to Positron Emission Tomography (PET) scanning, which of the following statement below is not correct?

In individuals with persistent symptoms of asthma, treatment with an inhaled corticosteroid will improve the following except?

Which of the following malignancies has the highest mortality rate in Australia?

A 35-year-old man presents with fever, malaise, a red indurated rash on his lower leg and marked painful swelling of both ankles. His chest X-ray is shown below:

What is the most likely diagnosis?

A 37 year old man from Wellington, previously fit and well, presents with two months history of general unwellness with increased lethargy, abdominal pain and headache. He is a current smoker of 10 pack years. Examination is unremarkable. His serum sodium, potassium and creatinine are all within normal limits.

However he does have a raised serum corrected calcium of 3.5mmol/L and a suppressed serum PTH of 0.6 pmol/L. His chest X-ray shows prominent bilateral hilar lymphadenopathy.

What is the most likely explanation for his hypercalcemia?

A 66-year-old man with a 50-pack-year smoking history presents for assessment of disabling dyspnoea and reduced exercise tolerance. Physical examination reveals poor chest expansion with increased percussion note and vesicular but globally reduced breath sounds. There is no evidence of cardiac failure.
His pulmonary function tests show a forced expiratory volume in 1 second (FEV1) of 0.89 L (predicted 2.95 L) and a forced vital capacity (FVC) of 2.10 L (predicted 3.65 L). After bronchodilator, FEV1 increased to 1.1 L and FVC to 3.0 L. Residual volume was 185% predicted, carbon monoxide diffusing capacity was 50% predicted and his resting SaO2 was 95% on room air. You decide to refer him to the pulmonary rehabilitation programme.

Which one of the following is least likely to improve after completion of a pulmonary rehabilitation program?

The following are potential biomarkers for a guarded prognosis from COVID-19 pneumonia except?