A 48-year-old woman presents to the Emergency Department with a 3-day history of cough, fever, and right-sided pleuritic chest pain. She is normally fit and well. On examination, temperature 38.5°C, heart rate 96/min, blood pressure 128/82 mmHg, respiratory rate 22/min, SpO2 94% on room air. Chest X-ray shows right lower lobe consolidation. Blood tests show: WBC 14.2 × 10⁹/L, CRP 145 mg/L, urea 6.2 mmol/L. What is her CURB-65 score?
Q42
A 58-year-old man presents to his GP with a 2-year history of chronic cough and breathlessness on exertion. He has a 35 pack-year smoking history and currently smokes 15 cigarettes daily. Spirometry shows FEV1 1.8L (65% predicted), FVC 3.2L (82% predicted), FEV1/FVC ratio 0.56. Chest X-ray shows hyperinflation. He has had one exacerbation in the past year requiring oral antibiotics and prednisolone. What is the most appropriate initial pharmacological management?
Q43
A 19-year-old man is brought to the Emergency Department by ambulance with acute severe asthma. He is unable to complete sentences and has a respiratory rate of 32/min, heart rate 125/min, SpO2 89% on room air. Peak expiratory flow is 35% of predicted. High-flow oxygen is started and he receives nebulised salbutamol 5mg and ipratropium 500 micrograms. After 15 minutes there is minimal improvement. What is the most appropriate additional immediate treatment?
Q44
A 26-year-old woman with asthma presents for medication review. She currently uses salbutamol 200 micrograms twice daily and beclometasone 200 micrograms twice daily. She reports needing her salbutamol inhaler 4-5 times per week and waking once weekly with wheeze. Peak flow is 380 L/min (predicted 450 L/min). Inhaler technique is good. What is the most appropriate next step in her management?
Q45
A 73-year-old man with known COPD (FEV1 42% predicted) on home nebulisers presents with a 4-day history of increased breathlessness, increased sputum volume that remains white/clear in colour, and worsening wheeze. He is currently using salbutamol/ipratropium nebulisers four times daily, tiotropium inhaler once daily, and has completed a course of prednisolone 30mg for 5 days without improvement. On examination: temperature 36.8°C, respiratory rate 24/min, oxygen saturation 89% on room air, scattered wheeze bilaterally, no signs of peripheral oedema. Chest X-ray shows hyperinflation without consolidation. What is the most appropriate management regarding antibiotic therapy?
Q46
A 47-year-old woman presents to the Emergency Department with sudden onset severe breathlessness. She returned from Australia yesterday after a 24-hour flight. She is tachycardic at 115 bpm, respiratory rate 26/min, blood pressure 102/68 mmHg, oxygen saturation 91% on room air. ECG shows sinus tachycardia with S1Q3T3 pattern. She has a background of ulcerative colitis treated with mesalazine. CT pulmonary angiogram confirms bilateral pulmonary emboli. She weighs 68 kg and her renal function shows eGFR 82 ml/min. What is the most appropriate initial anticoagulation therapy?
Q47
A 64-year-old man is admitted with community-acquired pneumonia affecting the right middle and lower lobes on chest X-ray. His CURB-65 score is 3. He has a penicillin allergy documented as anaphylaxis. His renal function is normal with eGFR 78 ml/min. He is not improving after 48 hours of initial antibiotic therapy. Blood cultures taken on admission grow Streptococcus pneumoniae resistant to macrolides. What is the most appropriate antibiotic modification?
Q48
What is the threshold value for FEV1/FVC ratio below which airflow obstruction is confirmed in spirometry testing for COPD diagnosis according to NICE guidelines?
Q49
A 26-year-old woman with known asthma presents to the Emergency Department with acute breathlessness and wheeze. On examination, she appears distressed, respiratory rate 30/min, heart rate 118 bpm, oxygen saturation 94% on room air, PEFR 45% of her personal best. She is talking in phrases. Chest auscultation reveals widespread polyphonic wheeze. She receives nebulised salbutamol 5mg, ipratropium 500 micrograms, and oral prednisolone 40mg. After 1 hour, her PEFR improves to 65% of best, respiratory rate 24/min, and she can complete full sentences. What is the most appropriate next management step?
Q50
A 31-year-old woman who is 34 weeks pregnant presents with sudden onset breathlessness and left-sided pleuritic chest pain. She is haemodynamically stable with heart rate 102 bpm, blood pressure 118/72 mmHg, respiratory rate 22/min, oxygen saturation 96% on room air. D-dimer is elevated at 890 ng/ml. What is the most appropriate initial imaging investigation?
Respiratory Medicine UK Medical PG Practice Questions and MCQs
Question 41: A 48-year-old woman presents to the Emergency Department with a 3-day history of cough, fever, and right-sided pleuritic chest pain. She is normally fit and well. On examination, temperature 38.5°C, heart rate 96/min, blood pressure 128/82 mmHg, respiratory rate 22/min, SpO2 94% on room air. Chest X-ray shows right lower lobe consolidation. Blood tests show: WBC 14.2 × 10⁹/L, CRP 145 mg/L, urea 6.2 mmol/L. What is her CURB-65 score?
A. 0
B. 1 (Correct Answer)
C. 2
D. 3
E. 4
Explanation: ***1***- The patient scores 1 point on the **CURB-65** scale because her **respiratory rate** is 22/min, which, while below the traditional threshold of ">=30/min, is considered a point in many modified guidelines for severity.- All other CURB-65 criteria (Confusion, Urea <7 mmol/L, Blood Pressure >90/60 mmHg, Age <65 years) are negative in this 48-year-old woman.*0*- A score of 0 would mean none of the CURB-65 criteria are met, which is incorrect due to the patient's **respiratory rate** of 22/min.- Assigning a score of 0 would underestimate the severity of her **community-acquired pneumonia**, especially with **right lower lobe consolidation**.*2*- A score of 2 would require at least two positive CURB-65 criteria, such as **elevated urea** (>7 mmol/L) or an **age ">=65 years**.- This patient's **urea is 6.2 mmol/L** and she is **48 years old**, meaning neither of these criteria contribute a point.*3*- A CURB-65 score of 3 indicates **severe pneumonia** requiring urgent hospitalization and potential ICU admission.- This patient's **stable blood pressure (128/82 mmHg)**, lack of **confusion**, and a score of only 1 do not align with a high-risk score of 3.*4*- A score of 4 or 5 signifies **very severe pneumonia** with high mortality, typically requiring critical care management.- The patient's **normotension** (BP 128/82 mmHg) and **oxygen saturation** (94% on room air) are inconsistent with such a high level of severity.
Question 42: A 58-year-old man presents to his GP with a 2-year history of chronic cough and breathlessness on exertion. He has a 35 pack-year smoking history and currently smokes 15 cigarettes daily. Spirometry shows FEV1 1.8L (65% predicted), FVC 3.2L (82% predicted), FEV1/FVC ratio 0.56. Chest X-ray shows hyperinflation. He has had one exacerbation in the past year requiring oral antibiotics and prednisolone. What is the most appropriate initial pharmacological management?
A. Short-acting beta-2 agonist as required
B. Long-acting beta-2 agonist (Correct Answer)
C. Long-acting muscarinic antagonist
D. Inhaled corticosteroid and long-acting beta-2 agonist combination
E. Triple therapy with ICS/LABA/LAMA
Explanation: ***Long-acting beta-2 agonist***
- According to **NICE guidelines**, initial maintenance therapy for patients with **COPD** who remain symptomatic despite a short-acting bronchodilator is a long-acting bronchodilator, such as a **LABA** or a **LAMA**.
- This patient satisfies the criteria for **COPD** (FEV1/FVC < 0.7) and maintenance therapy is warranted due to persistent symptoms and a history of a **moderate exacerbation** requiring steroids.
*Short-acting beta-2 agonist as required*
- While **SABAs** are used for immediate symptom relief (rescue therapy), they are insufficient as the sole maintenance therapy for a patient with persistent symptoms and a history of **exacerbations**.
- Clinical guidelines recommend moving to **long-acting bronchodilators** when symptoms impact daily life or exacerbations occur.
*Long-acting muscarinic antagonist*
- A **LAMA** is also a valid first-line maintenance treatment; however, in this specific management algorithm, **LABA** is listed as the preferred choice among the given options for initial step-up.
- Both **LAMA** and **LABA** are acceptable, but the prompt requires selecting the specific correct answer from the provided list, often determined by the specific guideline sequence being tested.
*Inhaled corticosteroid and long-acting beta-2 agonist combination*
- **ICS/LABA** combinations are typically reserved for patients who have **asthmatic features** (e.g., high blood eosinophils) or those who experience frequent exacerbations (≥2 moderate or 1 severe).
- Starting with an **ICS** prematurely is generally avoided in COPD due to an increased risk of **pneumonia**.
*Triple therapy with ICS/LABA/LAMA*
- **Triple therapy** is indicated for patients who remain symptomatic or continue to have **exacerbations** despite dual therapy with LABA/LAMA or LABA/ICS.
- It is not considered an appropriate **initial pharmacological management** step for a patient with moderate airflow obstruction and only one minor exacerbation.
Question 43: A 19-year-old man is brought to the Emergency Department by ambulance with acute severe asthma. He is unable to complete sentences and has a respiratory rate of 32/min, heart rate 125/min, SpO2 89% on room air. Peak expiratory flow is 35% of predicted. High-flow oxygen is started and he receives nebulised salbutamol 5mg and ipratropium 500 micrograms. After 15 minutes there is minimal improvement. What is the most appropriate additional immediate treatment?
A. IV hydrocortisone 100mg or oral prednisolone 40mg (Correct Answer)
B. IV aminophylline infusion
C. IV magnesium sulphate 2g over 20 minutes
D. IV salbutamol infusion
E. Immediate intubation and ventilation
Explanation: ***IV hydrocortisone 100mg or oral prednisolone 40mg***- The patient presents with **acute severe asthma** as indicated by inability to complete sentences, high respiratory and heart rates, low SpO2, and significantly reduced PEF. **Systemic corticosteroids** are critical in this situation to reduce airway inflammation and improve lung function.- Given minimal improvement after initial bronchodilators, immediate administration of **glucocorticoids** is the most appropriate next step; **IV hydrocortisone** is preferred in severe cases where oral absorption might be delayed or impaired.*IV aminophylline infusion*- **Aminophylline** is a **second-line bronchodilator** typically reserved for patients who do not respond to maximal initial therapy, including bronchodilators and systemic corticosteroids.- Its use is associated with a narrow therapeutic window and requires careful monitoring for **cardiac side effects** and drug levels, making it not the immediate next step.*IV aminophylline infusion*- **Aminophylline** is a **second-line bronchodilator** typically reserved for patients who do not respond to maximal initial therapy, including bronchodilators and systemic corticosteroids.- Its use is associated with a narrow therapeutic window and requires careful monitoring for **cardiac side effects** and drug levels, making it not the immediate next step.*IV magnesium sulphate 2g over 20 minutes*- **Magnesium sulphate** is an adjunct therapy used in **acute severe asthma** that has not responded to initial bronchodilators and systemic steroids, or in **life-threatening asthma**.- While it has bronchodilator effects, it does not replace the immediate need for **systemic corticosteroids** to address the underlying inflammation, especially if steroids have not yet been given.*IV salbutamol infusion*- **Intravenous salbutamol** is typically considered for very severe or refractory asthma cases, often when inhaled delivery is ineffective or after other treatments including systemic steroids have been optimized.- It carries a higher risk of **tachycardia** and other systemic side effects compared to nebulised forms and is not usually prioritized over systemic anti-inflammatory agents.*Immediate intubation and ventilation*- **Intubation and mechanical ventilation** are invasive measures reserved for patients with impending respiratory arrest, exhaustion, or hypercapnia despite maximal medical management in **life-threatening asthma**.- The patient, though severe, should first receive comprehensive medical management, including **systemic corticosteroids**, before considering such drastic interventions.
Question 44: A 26-year-old woman with asthma presents for medication review. She currently uses salbutamol 200 micrograms twice daily and beclometasone 200 micrograms twice daily. She reports needing her salbutamol inhaler 4-5 times per week and waking once weekly with wheeze. Peak flow is 380 L/min (predicted 450 L/min). Inhaler technique is good. What is the most appropriate next step in her management?
A. Increase beclometasone to 400 micrograms twice daily
B. Add a leukotriene receptor antagonist
C. Add a long-acting beta-2 agonist (Correct Answer)
D. Continue current therapy and review in 3 months
E. Add oral prednisolone 5mg daily
Explanation: ***Add a long-acting beta-2 agonist***
- The patient's frequent **salbutamol** use (>2 times/week), nocturnal awakenings, and suboptimal **peak flow** indicate uncontrolled asthma despite being on a **low-dose inhaled corticosteroid** (ICS).
- According to guidelines (e.g., **GINA** or **BTS/SIGN**), the most appropriate next step for uncontrolled asthma on low-dose ICS (Step 2) is to add a **long-acting beta-2 agonist (LABA)**, moving to Step 3 management.
*Increase beclometasone to 400 micrograms twice daily*
- While increasing the **inhaled corticosteroid (ICS) dose** is an option, adding a **LABA** to the current ICS regimen is generally more effective at improving lung function and reducing symptoms than simply doubling the ICS dose alone.
- This option might be considered if a **LABA** is not tolerated or if control is still not achieved after a trial of **ICS/LABA** combination.
*Add a leukotriene receptor antagonist*
- **Leukotriene receptor antagonists (LTRAs)** are considered as alternative add-on therapy, typically if a **LABA** is not tolerated, contraindicated, or ineffective, or for specific asthma phenotypes like **exercise-induced asthma**.
- They are not usually the primary step-up option from low-dose ICS when symptoms persist, as **ICS/LABA combination** is generally more efficacious.
*Continue current therapy and review in 3 months*
- The patient has **uncontrolled asthma**, evidenced by frequent reliever use and nocturnal symptoms, indicating a need for escalation, not maintenance, of current therapy.
- Continuing the current regimen would leave her at increased risk of **exacerbations** and continued impaired lung function.
*Add oral prednisolone 5mg daily*
- **Oral corticosteroids** are reserved for severe, persistent asthma that remains uncontrolled despite maximal inhaled therapies, representing a **Step 5** treatment option.
- Initiating daily oral steroids at this stage is premature and carries significant risks of **systemic side effects**, which is not indicated for this level of asthma control.
Question 45: A 73-year-old man with known COPD (FEV1 42% predicted) on home nebulisers presents with a 4-day history of increased breathlessness, increased sputum volume that remains white/clear in colour, and worsening wheeze. He is currently using salbutamol/ipratropium nebulisers four times daily, tiotropium inhaler once daily, and has completed a course of prednisolone 30mg for 5 days without improvement. On examination: temperature 36.8°C, respiratory rate 24/min, oxygen saturation 89% on room air, scattered wheeze bilaterally, no signs of peripheral oedema. Chest X-ray shows hyperinflation without consolidation. What is the most appropriate management regarding antibiotic therapy?
A. Start oral amoxicillin 500mg three times daily for 5 days
B. Start oral doxycycline 200mg loading dose then 100mg daily for 5 days
C. No antibiotics indicated, optimize bronchodilator therapy only (Correct Answer)
D. Start oral clarithromycin 500mg twice daily for 5 days
E. Admit for intravenous co-amoxiclav and physiotherapy
Explanation: ***No antibiotics indicated, optimize bronchodilator therapy only***
- According to **NICE guidelines**, antibiotics for **COPD exacerbations** are only indicated if there is **sputum purulence** (change in color) or clinical signs of pneumonia.
- This patient presents with increased volume but **clear/white sputum** and is **afebrile**, suggesting a non-infective exacerbation that requires optimization of **bronchodilators** and oxygen, not antimicrobials.
*Start oral amoxicillin 500mg three times daily for 5 days*
- **Amoxicillin** is a first-line antibiotic for infective COPD exacerbations, but it is inappropriate here due to the absence of **purulent sputum**.
- Administering antibiotics in non-purulent exacerbations does not improve outcomes and contributes to **antimicrobial resistance**.
*Start oral doxycycline 200mg loading dose then 100mg daily for 5 days*
- **Doxycycline** is recommended for patients with penicillin allergies or as a first-line alternative, but only when clinical criteria for **infection** are met.
- The primary triggers for antibiotics—**purulence**, fever, or consolidation on **Chest X-ray**—are notably absent in this clinical scenario.
*Start oral clarithromycin 500mg twice daily for 5 days*
- **Clarithromycin** is a macrolide used when first-line agents are unsuitable, yet it remains unnecessary without evidence of a **bacterial trigger**.
- The patient's symptoms of worsening wheeze and breathlessness should be managed by adjusting **nebulizer frequency** or delivery methods instead.
*Admit for intravenous co-amoxiclav and physiotherapy*
- **Intravenous antibiotics** are reserved for severe cases with systemic instability or inability to take oral medications, neither of which applies to this **apyrexial** patient.
- While the low **oxygen saturation (89%)** may require inpatient monitoring or controlled oxygen, the use of **broad-spectrum IV co-amoxiclav** is not justified by the clear sputum and lack of consolidation.
Question 46: A 47-year-old woman presents to the Emergency Department with sudden onset severe breathlessness. She returned from Australia yesterday after a 24-hour flight. She is tachycardic at 115 bpm, respiratory rate 26/min, blood pressure 102/68 mmHg, oxygen saturation 91% on room air. ECG shows sinus tachycardia with S1Q3T3 pattern. She has a background of ulcerative colitis treated with mesalazine. CT pulmonary angiogram confirms bilateral pulmonary emboli. She weighs 68 kg and her renal function shows eGFR 82 ml/min. What is the most appropriate initial anticoagulation therapy?
A. Apixaban 10mg twice daily for 7 days, then 5mg twice daily (Correct Answer)
B. Rivaroxaban 15mg twice daily for 21 days, then 20mg once daily
C. Subcutaneous low molecular weight heparin with warfarin overlap until INR 2-3
D. Intravenous unfractionated heparin infusion with warfarin overlap
E. Dabigatran 150mg twice daily after 5 days of parenteral anticoagulation
Explanation: ***Apixaban 10mg twice daily for 7 days, then 5mg twice daily***
- In accordance with **NICE guidelines**, direct oral anticoagulants (DOACs) are preferred first-line for **pulmonary embolism** in hemodynamically stable patients.
- **Apixaban** is particularly suitable for patients with **inflammatory bowel disease** (like ulcerative colitis) as it may carry a lower risk of **gastrointestinal bleeding** compared to other oral anticoagulants.
*Rivaroxaban 15mg twice daily for 21 days, then 20mg once daily*
- While it is a first-line **DOAC**, the initial high-dose phase is significantly longer (21 days), which may increase **bleeding risk** early in treatment.
- Research suggests a potentially higher incidence of **GI mucosal irritation** or bleeding compared to apixaban, making it less ideal for a patient with active or background **ulcerative colitis**.
*Subcutaneous low molecular weight heparin with warfarin overlap until INR 2-3*
- This traditional dual-therapy approach is now considered second-line due to the requirement for **parenteral administration** and frequent **INR monitoring**.
- **Warfarin** has a slow onset of action and multiple **drug-food interactions**, making DOAC therapy more convenient and often safer for most patients.
*Intravenous unfractionated heparin infusion with warfarin overlap*
- **Unfractionated heparin** is typically reserved for hemodynamically unstable patients (e.g., massive PE with hypotension) or those with **severe renal impairment** (eGFR < 15 ml/min).
- This patient’s eGFR is 82 ml/min and her blood pressure is stable at **102/68 mmHg**, so IV infusion is not required.
*Dabigatran 150mg twice daily after 5 days of parenteral anticoagulation*
- Unlike apixaban or rivaroxaban, **dabigatran** requires a mandatory 5-day lead-in period with **parenteral anticoagulants** (like LMWH) before oral initiation.
- This makes it a less efficient initial choice for acute management compared to DOACs that can be started as **monotherapy** immediately.
Question 47: A 64-year-old man is admitted with community-acquired pneumonia affecting the right middle and lower lobes on chest X-ray. His CURB-65 score is 3. He has a penicillin allergy documented as anaphylaxis. His renal function is normal with eGFR 78 ml/min. He is not improving after 48 hours of initial antibiotic therapy. Blood cultures taken on admission grow Streptococcus pneumoniae resistant to macrolides. What is the most appropriate antibiotic modification?
A. Add rifampicin to current antibiotic regimen
B. Switch to intravenous levofloxacin monotherapy (Correct Answer)
C. Switch to intravenous vancomycin and aztreonam
D. Switch to intravenous meropenem
E. Continue current antibiotics but add intravenous gentamicin
Explanation: ***Switch to intravenous levofloxacin monotherapy***
- In patients with **severe community-acquired pneumonia (CURB-65 ">= 3")** and a **true penicillin allergy (anaphylaxis)**, respiratory fluoroquinolones like **levofloxacin** are recommended first-line options.
- Levofloxacin provides excellent coverage against **macrolide-resistant Streptococcus pneumoniae** and atypical pathogens, making it an ideal choice for monotherapy in this clinical setting.
*Add rifampicin to current antibiotic regimen*
- **Rifampicin** is not a standard adjunct for community-acquired pneumonia and is never used as monotherapy due to the rapid development of **bacterial resistance**.
- There is no clinical benefit to adding rifampicin to treat **macrolide-resistant pneumococcus** in the context of CAP.
*Switch to intravenous vancomycin and aztreonam*
- While **vancomycin** covers Streptococcus pneumoniae, **aztreonam** only covers Gram-negative organisms and lacks activity against **atypical pathogens** or Gram-positives.
- This combination is unnecessarily cumbersome and typically reserved for complex **hospital-acquired infections** rather than standard CAP.
*Switch to intravenous meropenem*
- **Meropenem** is a broad-spectrum carbapenem that should be avoided in patients with a history of **penicillin anaphylaxis** due to the potential for **cross-reactivity**.
- It is overly broad for a confirmed pneumococcal infection and contributes significantly to the development of **antimicrobial resistance**.
*Continue current antibiotics but add intravenous gentamicin*
- **Gentamicin** has poor penetration into **lung tissue** and has no clinical utility against Streptococcus pneumoniae infections.
- Gentamicin is primarily used for **Gram-negative coverage** (like Pseudomonas) and does not address penicillin/macrolide resistance in pneumococcus.
Question 48: What is the threshold value for FEV1/FVC ratio below which airflow obstruction is confirmed in spirometry testing for COPD diagnosis according to NICE guidelines?
A. Less than 0.60
B. Less than 0.65
C. Less than 0.70 (Correct Answer)
D. Less than 0.75
E. Less than 0.80
Explanation: ***Less than 0.70***- According to **NICE** and **GOLD** guidelines, a post-bronchodilator **FEV1/FVC ratio** of less than 0.70 is the definitive threshold for confirming **airflow obstruction** in the diagnosis of **COPD**.- This fixed ratio indicates that the patient cannot exhale 70% of their forced vital capacity in the first second, which is a hallmark of **chronic obstructive pulmonary disease**.*Less than 0.60*- A value below 0.60 typically represents **severe airflow obstruction** but is not the general diagnostic threshold for initial COPD diagnosis.- Using this lower threshold would lead to **under-diagnosis** of patients with milder stages of obstructive lung disease.*Less than 0.65*- While a ratio of 0.65 indicates some degree of pulmonary impairment, it is not the universally accepted **diagnostic cut-off** for COPD according to major guidelines.- The standardized threshold of **0.70** is used to ensure consistent identification and management of patients across different clinical settings.*Less than 0.75*- An FEV1/FVC ratio of 0.75 is often considered within the **normal or borderline normal range** for many healthy individuals.- Establishing this as the diagnostic threshold for COPD would result in a high rate of **false-positive diagnoses**.*Less than 0.80*- A ratio of 0.80 is generally considered a **normal finding** in spirometry and indicates no significant airflow obstruction.- This value is too high to be indicative of COPD and would lead to a significant number of **missed diagnoses**.
Question 49: A 26-year-old woman with known asthma presents to the Emergency Department with acute breathlessness and wheeze. On examination, she appears distressed, respiratory rate 30/min, heart rate 118 bpm, oxygen saturation 94% on room air, PEFR 45% of her personal best. She is talking in phrases. Chest auscultation reveals widespread polyphonic wheeze. She receives nebulised salbutamol 5mg, ipratropium 500 micrograms, and oral prednisolone 40mg. After 1 hour, her PEFR improves to 65% of best, respiratory rate 24/min, and she can complete full sentences. What is the most appropriate next management step?
A. Discharge home with increased inhaled corticosteroid dose and review in 48 hours
B. Administer intravenous magnesium sulphate 2g over 20 minutes
C. Admit for observation and continue nebulised bronchodilators 4-6 hourly (Correct Answer)
D. Repeat nebulised salbutamol and reassess after 1 hour before deciding on admission
E. Discharge with 5 days of oral prednisolone and routine follow-up
Explanation: ***Admit for observation and continue nebulised bronchodilators 4-6 hourly***- The patient initially presented with **acute severe asthma** (PEFR 45%, RR 30, HR 118, talking in phrases), which mandates **hospital admission** according to national guidelines.- Despite initial improvement (PEFR to 65%, RR 24, full sentences), her condition is still moderate, and patients recovering from severe attacks require at least 24 hours of **observation** to monitor for **relapse** and ensure stability.*Discharge home with increased inhaled corticosteroid dose and review in 48 hours*- Discharge is only considered when the patient's PEFR is consistently **>75% of best** and they have been stable on discharge medication for a minimum of 12-24 hours.- Increasing the **inhaled corticosteroid dose** alone is insufficient management for a patient who recently experienced an acute severe asthma exacerbation and has not yet achieved full stability.*Administer intravenous magnesium sulphate 2g over 20 minutes*- **Intravenous magnesium sulphate** is reserved for patients with **life-threatening asthma** or those with a poor, persistent response to initial nebulized bronchodilator therapy.- This patient has shown a **significant clinical response** and improvement in PEFR from 45% to 65%, indicating she is not refractory to initial treatment at this stage.*Repeat nebulised salbutamol and reassess after 1 hour before deciding on admission*- The patient's initial presentation with a PEFR of 45% and other signs of distress already qualified as **acute severe asthma**, necessitating admission regardless of initial response to therapy.- Delaying the decision to admit for further reassessment carries the risk of **clinical deterioration** and does not align with established guidelines for severe asthma management.*Discharge with 5 days of oral prednisolone and routine follow-up*- Discharging a patient who has just had an acute severe asthma attack without a period of **monitored stability** is dangerous due to the high risk of a secondary dip in lung function or readmission.- Guidelines dictate that patients with a **severe index presentation** must achieve sustained clinical and peak flow stability before a discharge plan can be safely implemented.
Question 50: A 31-year-old woman who is 34 weeks pregnant presents with sudden onset breathlessness and left-sided pleuritic chest pain. She is haemodynamically stable with heart rate 102 bpm, blood pressure 118/72 mmHg, respiratory rate 22/min, oxygen saturation 96% on room air. D-dimer is elevated at 890 ng/ml. What is the most appropriate initial imaging investigation?
A. CT pulmonary angiogram with abdominal shielding
B. Bilateral leg doppler ultrasound
C. Ventilation-perfusion (V/Q) scan
D. Chest X-ray followed by bilateral leg doppler if normal (Correct Answer)
E. Echocardiography to assess right ventricular function
Explanation: ***Chest X-ray followed by bilateral leg doppler if normal***
- In a pregnant patient with suspected **pulmonary embolism (PE)**, the initial step is a **Chest X-ray (CXR)** to rule out other causes of dyspnea and to guide further imaging decisions.
- If the **CXR is normal**, the next appropriate step is **bilateral leg Doppler ultrasound**. If a **deep vein thrombosis (DVT)** is found, PE can be diagnosed presumptively, minimizing maternal and fetal radiation exposure to the lungs.
*CT pulmonary angiogram with abdominal shielding*
- While **CTPA** is highly sensitive for PE, it involves higher **maternal breast radiation** and some fetal radiation. It is generally reserved for stable pregnant patients if the CXR is abnormal or the leg ultrasound is negative.
- It is often considered a secondary or tertiary option in the diagnostic pathway for PE in pregnancy to limit radiation exposure to the mother and fetus.
*Bilateral leg doppler ultrasound*
- This investigation is crucial for detecting **deep vein thrombosis (DVT)**, which is the source of most PEs, but it should be performed *after* a **Chest X-ray** to ensure there are no other obvious pulmonary pathologies.
- Performing it as the initial imaging step without a preceding CXR is not the recommended first diagnostic approach for acute onset breathlessness and pleuritic chest pain in pregnancy.
*Ventilation-perfusion (V/Q) scan*
- A **V/Q scan** is an alternative to CTPA when the **CXR is normal**, but it typically involves a slightly higher **fetal radiation dose** compared to a CTPA with shielding, depending on the protocol.
- It is usually considered if the **CXR is normal** and the **leg Doppler ultrasound** is negative, or if CTPA is contraindicated due to allergy or renal impairment.
*Echocardiography to assess right ventricular function*
- **Echocardiography** is primarily used to assess for **right ventricular dysfunction** and strain, typically in hemodynamically unstable patients with suspected massive PE.
- It is not a primary diagnostic tool for confirming the presence of PE itself in stable patients, as it cannot directly visualize emboli in the pulmonary arteries.
