A 28-year-old woman has felt unwell for the last 4 days with coryzal symptoms and

worsening breathlessness. She is asthmatic and has used her inhalers without any relief
for the last hour.
On arrival in the Emergency Department, She is confused and cannot respond to
questions, and her peak expiratory flow rate (PEFR) is 32 % of predicted.

HR 125 bpm, RR 30/min. Her lips appear blue, her neck muscles are being used to assist
breathing.

Q1- How would you assess the severity of this acute asthmatic attack? (3 marks)

Q2- How would you investigate this lady? (3 marks)

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 Q3- Mention the drugs that could be used to treat this acute attack. (3 marks)
Corticosteroids
(albuterol)

Q4- Among these drugs there is a significant shared side effect which may affect the
respiratory muscles movement. Mention this side effect and the drugs that could cause it.
(3 marks)

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 A
1) A 30-year-old woman has had an acute severe episode of asthma. This is her first acute
episode for over 10 years and she is recovering in hospital. She has a salbutamol 100
micrograms inhaler that she uses occasionally and a beclometasone 200 micrograms
inhaler that is prescribed for use twice daily. Which single measure is most likely to
improve this woman’s long-term asthma control?

a) Add montelukast 10mg PO once daily

b) Add salmeterol 50 micrograms inhaler (INH) twice daily
c) Ensure up-to-date spirometry and lung function tests
d) Organize a review by an asthma specialist in 3 months’ time
e) Write a plan of how and when to take the inhalers

2) A 52-year-old woman is severely short of breath. She is confused and cannot respond
to questions. There is no one accompanying her to shed light on her medical history.

T 37.1°C, HR 120bpm, BP 105/65mmHg, RR 26/min.

Her lips appear blue, her neck muscles are being used to assist breathing, and there is
a generalized wheeze on her chest. She is put on high-flow oxygen. Which is the single
most appropriate course of immediate management?

a) Aminophylline 300mg IV
b) Epinephrine (adrenaline) 0.5mg IM
c) Hydrocortisone 100mg IV
d) Magnesium sulphate 1.2g IV
e) Salbutamol 5mg nebulized (NEB)

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 3) A 69-year-old man has had a cough, myalgia, and felt feverish for the last 7 days. He is
wheezy and is finding it particularly difficult to breathe. He has asthma and is using his
usual inhalers every half an hour but feels that they are not having any effect on his
symptoms.

Which single finding is most consistent with a severe attack of asthma?

a) BP 90/60mmHg
b) Inability to complete sentences
c) Inaudible air entry bilaterally
d) Peak expiratory flow rate (PEFR) <33% of predicted
e) SaO2 <75% on air

4) A 32-year-old woman has asthma and is increasingly short of breath in the mornings.
She describes her chest feeling tight and says it is hard for her to catch her breath. As
a result, she is taking two puffs of her salbutamol 100 micrograms inhaler at least three
times before midday. Peak expiratory flow rate: 310 L/min.

Which is the single most appropriate next step in her management?

a) Beclometasone 200 micrograms INH twice daily

b) Prednisolone 40mg PO once daily for 5 days
c) Salbutamol 200 micrograms INH four times daily
d) Salmeterol 50 micrograms INH twice daily
e) Seretide® 100/50 micrograms INH twice daily

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 5) A 68-year-old man becomes suddenly short of breath with left-sided chest discomfort.
He has chronic obstructive pulmonary disease (COPD) and is on home oxygen, regular
nebulizers, and maintenance oral steroids.

T 37.1°C, HR 100 bpm, RR 24/min, SaO2 86% on 2L O2.

A CT pulmonary angiogram rules out a pulmonary embolus. Which single examination

finding is most likely to support the diagnosis?

a) Left-sided bronchial breath sounds

b) Left-sided hyperresonant percussion note
c) Left-sided hyporesonant percussion note
d) Left-sided increased vocal resonance
e) Left-sided stony dull percussion note

6) A 32-year-old woman has been unwell for 3 weeks, initially with a headache and
myalgia and latterly with a dry cough. She is a non-smoker and has no past medical
history of note. She has reduced air entry bilaterally and symmetrical erythematous
skin lesions that blister centrally on her arms and legs. Which is the single most likely
causative organism?

a) Chlamydia pneumoniae
b) Klebsiella pneumoniae
c) Legionella pneumophila
d) Mycoplasma pneumoniae
e) Streptococcus pneumoniae

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 7) A 72-year-old man has had a dry cough and increasing right-sided chest pain for 10
days. This is despite having just completed a 7 day course of amoxicillin 500 mg PO
three times daily.

T 37.5°C, BP 85/55 mmHg, HR 100 bpm, SaO2 94% on air, RR 34/min.

Chest—decreased air entry in the right upper zone.
AMTS (abbreviated mental test score)—10/10

Which is the single most appropriate next step in management?

a) Amoxicillin 500mg PO three times daily

b) Amoxicillin 500mg PO three times daily + clarithromycin 500mg twice daily
c) Ciprofloxacin 500mg IV twice daily
d) Co-amoxiclav 1.2g IV three times daily + clarithromycin 500mg twice daily
e) Doxycycline 100mg PO once daily

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 8) A 55-year-old woman has been increasingly short of breath for 2 weeks. She has felt
feverish and has been coughing up green coloured sputum for the past 5 days. She
smokes ten cigarettes a day and drinks 20 units of alcohol a week.

T 38.8°C, HR 115 bpm, BP 110/65 mmHg, RR 22/min, SaO2 91% on air.

Percussion of the chest reveals stony dullness up to the mid-zone on the right. Her
chest X-ray is shown below.

Which single pathological process is the most likely cause?

a) Decreased colloid osmotic pressure

b) Elevated hydrostatic pressure
c) Impaired lymphatic drainage of the pleural space
d) Increased capillary permeability
e) Passage of peritoneal fluid through spaces in the diaphragm

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 9) A 58-year-old man is admitted with bacterial pneumonia following influenza. He
initially improved but subsequently developed a cough productive of purulent blood-
stained sputum and swinging fevers.
On examination he is pyrexial 38.4°C, has a BP of 110/70 mmHg and a pulse of 105.
You can hear coarse crackles throughout both lung fields, decreased air entry and a
stony dull percussion note at the right base.
Investigations reveal:
White cell count 13.1 x109/L (4-10)
Creatinine 145 µmol/L (60-120)
CXR Bilateral basal consolidation, right-sided pleural effusion

Which of the following is the next appropriate investigation?

a) Sputum cultures
b) CT thorax
c) Diagnostic pleural fluid sampling
d) MRI thorax
e) Ultrasound thorax

10) A 34-year-old woman with severe asthma comes to the clinic for review. She is
currently taking 800 mcg per day of inhaled beclomethasone, yet still feels significantly
short of breath and is coughing at night nearly every night.
On examination her PEFR is 340, compared to 500 predicted. She has extensive wheeze
on auscultation of both lung fields.

Which of the following is the most appropriate next intervention?

a) Add salmeterol 50 mg/day

b) Change to fluticasone 400 mcg/day
c) Increase beclomethasone to 1600 mcg/day
d) Start montelukast 10 mg/day
e) Start prednisolone 5 mg/day

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 11) A 47-year-old woman with a history of asthma is referred with deteriorating
symptoms from a lower respiratory tract infection.
She has been laid up in bed for the whole of the previous week with influenza, but most
recently, as her upper respiratory symptoms have improved, she has begun to develop
a cough productive of purulent blood stained sputum and has severe right lower
pleuritic chest pain.
On examination she is pyrexial 38.2°C, her BP is 105/65 mmHg, and her pulse is 108.
There is right-sided consolidation.
Chest x ray shows extensive right lower lobe consolidation with cavitation
Investigations show:
WCC 15.2 x 109/L (4-10)
CRP 210 mg/L (<10)

Which of the following is the most likely infective organism?

a) Chlamydia
b) Klebsiella
c) Legionella
d) Staphylococus
e) Streptococcus

12) A 65-year-old woman, a heavy smoker for many year, has had worsening dyspnoea
for the past five years, without a significant cough. A chest x ray shows increased lung
size along with flattening of the diaphragm, consistent with emphysema. Over the next
several years she develops worsening peripheral oedema. Her BP is 115/70 mmHg.

Which of the following cardiac findings is most likely to be present?

a) Constrictive pericarditis
b) Left ventricular aneurysm
c) Mitral valve stenosis
d) Non-bacterial thrombotic endocarditis
e) Right ventricular hypertrophy

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 13) A 21-year-old woman presents to the Emergency department with a one hour history
of shortness of breath, and chest tightness.
The symptoms occurred acutely, and she has suffered identical attacks previously
which are increasing in frequency. Her GP has treated her with a salbutamol inhaler,
although she has not had any formal pulmonary function testing. Usage of her
salbutamol inhaler has not helped her shortness of breath.
On examination she is distressed and chest examination shows vesicular breath sounds
with an elevated respiratory rate. Oxygen saturation is 98% on air which is sustained
on exertion.
Chest x ray is normal and arterial blood gas analysis shows:
pH 7.52 (7.35-7.45)
pCO2 2.2 kPa (4.7-7.45)
PO2 18 kPa (increased from 15) (10.0-13.0)
HCO3 25 (22.0 - 30.0)

Which of the following would be your diagnosis?

a) Acute asthma attack (mild)

b) Hyperventilation (psychogenic)
c) Pulmonary embolism
d) Respiratory muscle disease
e) Volume depletion

14) A 61-year-old smoker presents with a three week history of worsening

breathlessness. A chest X-ray shows a large left-sided pleural effusion.
He has a small amount of the effusion aspirated and sent off for examination. Which
of the following laboratory results would point to this effusion being an exudate rather
than a transudate?
(LDH = lactate dehydrogenase)

a) Pleural fluid LDH / Serum LDH < 0.6

b) Effusion LDH level greater than 2/3rds the upper limit of serum LDH
c) Pleural fluid protein / Serum protein < 0.5
d) Pleural fluid glucose/ Serum glucose > 0.4
e) Effusion LDH level greater than 1/3rd the upper limit of serum LDH

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 15) A 53-year-old dental secretary presents with a four month history of dry cough. She
has never smoked. She denies haemoptysis, weight loss and dyspnoea. There is no post
nasal drip.
Her medical history consists only of hypertension for one year. She is on ramipril 2.5
mg, bendroflumethiazide 2.5 mg and amlodipine 10 mg.
On examination her JVP is not raised and her chest is clear. A CXR was requested.

What would be the most likely cause of her cough?

a) Allergic rhinitis
b) Bronchiectasis
c) Drug induced
d) Interstitial lung disease
e) Lung cancer

16) A 21-year-old woman presents to the Emergency department with an hour history of
chest tightness, dyspnoea, tingling in her hands and light-headedness. She has neither
past medical history nor family history of note.
Examination is unremarkable aside from an elevated respiratory rate. Her pulse
oximetry shows saturations of 96% on air, which do fall when she walks across the
room. A chest x ray is also normal. An arterial blood gas sample (on air and at rest) is
obtained and the results are as follows:
pH 7.52 (7.36 - 7.44)
pCO2 2.2 kPa (4.7 - 6.0)
p02 9.1 kPa (11.3 -12.6)
HCO3 25 mmol/L (20 - 28)
What is the most likely diagnosis?

a) Acute asthma attack

b) Hyperventilation (psychogenic)
c) Pulmonary embolism
d) Respiratory muscle disease
e) Volume Depletion

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 17) Which one of the following interventions is most likely to increase survival in patients
with COPD?

a) Home nebulisers
b) Tiotropium inhaler
c) Long-term steroid therapy
d) Smoking cessation
e) Long-term oxygen therapy

18) A 22-year-old male is admitted wheezing with a respiratory rate of 35/min, a pulse of
120 beats per min, blood pressure 110/70 mmHg, peak expiratory flow rate <50%
predicted.
The emergency medical services have administered salbutamol 5 mg (twice),
ipratroprium 0.5 mg and face mask oxygen. He has been given hydrocortisone 100 mg
IV. The intensive care team are aware of the patient.
His arterial blood gas (done on high-flow oxygen) reveals:
pH 7.42 (7.36-7.44)
PaCO2 5.0 kPa (4.7-6.0)
PaO2 22 kPa (11.3-12.6)
SpO2 98

Which therapy should be implemented next?

a) Intubation and ventilation

b) Ipratropium nebuliser
c) Magnesium 1-2 g IV
d) Non-invasive ventilation
e) Repeat nebulisers

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