RESP & ENT MCQs

Q-1 A. Inhaled corticosteroid

A 62-year-old man with a history of recurrent lower B. Heart-lung transplant
respiratory tract infections is diagnosed as having bilateral C. Pulmonary rehabilitation
bronchiectasis following a high resolution CT scan. Which D. Loop diuretic therapy
one of the following is most important in the long term E. Long-term oxygen therapy
control of his symptoms?
ANSWER:
A. Inhaled corticosteroids Long-term oxygen therapy
B. Prophylactic antibiotics
C. Surgery EXPLANATION:
D. Postural drainage After smoking cessation, long-term oxygen therapy i(LTOT) is
E. Mucolytic therapy one of the few interventions that has been shown to improve
survival in COPD.
ANSWER:
Postural drainage LTOT should be offered to patients with a pO2 of < 7.3 kPa or
to those with a pO2 of 7.3 - 8 kPa and one of the following:
EXPLANATION: • secondary polycythaemia
Symptom control in non-CF bronchiectasis - inspiratory • nocturnal hypoxaemia
muscle training + postural drainage • peripheral oedema
• pulmonary hypertension
BRONCHIECTASIS: MANAGEMENT
Bronchiectasis describes a permanent dilatation of the COPD: STABLE MANAGEMENT
airways secondary to chronic infection or inflammation. After
assessing for treatable causes (e.g. immune deficiency) NICE updated it's guidelines on the management of chronic
management is as follows: obstructive pulmonary disease (COPD) in 2010.
• physical training (e.g. inspiratory muscle training) - has a
good evidence base for patients with non-cystic fibrosis General management
bronchiectasis • smoking cessation advice
• postural drainage • annual influenza vaccination
• antibiotics for exacerbations + long-term rotating • one-off pneumococcal vaccination
antibiotics in severe cases
• bronchodilators in selected cases Bronchodilator therapy
• immunisations • a short-acting beta2-agonist (SABA) or short-acting
• surgery in selected cases (e.g. Localised disease) muscarinic antagonist (SAMA) is first-line treatment
• for patients who remain breathless or have exacerbations
Most common organisms isolated from patients with despite using short-acting bronchodilators the next step is
bronchiectasis: determined by the FEV1
• Haemophilus influenzae (most common)
• Pseudomonas aeruginosa FEV1 > 50%
• Klebsiella spp. • long-acting beta2-agonist (LABA), for example salmeterol,
• Streptococcus pneumoniae or:
• long-acting muscarinic antagonist (LAMA), for example
Q-2 tiotropium
You review a 67-year-old man who has chronic obstructive
pulmonary disease (COPD). On examination there is FEV1 < 50%
evidence of cor pulmonale with a significant degree of pedal • LABA + inhaled corticosteroid (ICS) in a combination
oedema. His FEV1 is 43%. During a recent hospital stay his inhaler, or:
pO2 on room air was 7.5 kPa. Which one of the following • LAMA
interventions is most likely to increase survival in this
patient? For patients with persistent exacerbations or breathlessness
• if taking a LABA then switch to a LABA + ICS combination
inhaler
• otherwise give a LAMA and a LABA + ICS combination
inhaler Criterion Marker
C Confusion (abbreviated mental test score <= 8/10)
Oral theophylline R Respiration rate >= 30/min
• NICE only recommends theophylline after trials of short B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60
and long-acting bronchodilators or to people who cannot mmHg
used inhaled therapy 65 Aged >= 65 years
• the dose should be reduced if macrolide or
fluoroquinolone antibiotics are co-prescribed Patients are stratified for risk of death as follows:
• 0: low risk (less than 1% mortality risk)
Mucolytics • 1 or 2: intermediate risk (1-10% mortality risk)
• should be 'considered' in patients with a chronic • 3 or 4: high risk (more than 10% mortality risk).
productive cough and continued if symptoms improve
NICE recommend, in conjunction with clinical judgement:
Cor pulmonale • home-based care for patients with a CRB65 score of 0
• features include peripheral oedema, raised jugular • hospital assessment for all other patients, particularly
venous pressure, systolic parasternal heave, loud P2 those with a CRB65 score of 2 or more.
• use a loop diuretic for oedema, consider long-term
oxygen therapy NICE also mention point-of-care CRP test. This is currently not
• ACE-inhibitors, calcium channel blockers and alpha widely available but they make the following recommendation
blockers are not recommended by NICE with reference to the use of antibiotic therapy:
• CRP < 20 mg/L - do not routinely offer antibiotic therapy
Factors which may improve survival in patients with stable • CRP 20 - 100 mg/L - consider a delayed antibiotic
COPD prescription
• smoking cessation - the single most important • CRP > 100 mg/L - offer antibiotic therapy
intervention in patients who are still smoking
• long term oxygen therapy in patients who fit criteria Secondary care setting
• lung volume reduction surgery in selected patients Note that in hospital, once blood tests are available the
CURB65, rather than the CRB65, can be used. This adds an
Q-3 extra criterion of urea > 7 mmol/L:
A 48-year-old salesman presents with a 5 day history of
cough and
pleuritic chest pain. He has no past medical history of note. Criterion Marker
On examination his temperature is 38.2ºC, blood pressure is C Confusion (abbreviated mental test score <= 8/10)
120/80 mmHg, respiratory rate 18/min and pulse 84/min. U urea > 7 mmol/L
Auscultation of the chest reveals bronchial breathing in the R Respiration rate >= 30/min
left base and the same area is dull to percussion. What is the B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60
most suitable management? mmHg
65 Aged >= 65 years
A. Oral amoxicillin
B. Oral co-amoxiclav NICE recommend, in conjunction with clinical judgement:
C. Oral amoxicillin + erythromycin • consider home-based care for patients with a CURB65
D. Oral erythromycin score of 0 or 1 - low risk (less than 3% mortality risk)
E. Admit • consider hospital-based care for patients with a CURB65
score of 2 or more - intermediate risk (3-15% mortality
ANSWER: risk)
Oral amoxicillin • consider intensive care assessment for patients with a
CURB65 score of 3 or more - high risk (more than 15%
EXPLANATION: mortality risk)
PNEUMONIA: ASSESSMENT AND MANAGEMENT
Investigations
Primary care setting • chest x-ray
NICE recommends that patients should initially be assessed in • in intermediate or high-risk patients NICE recommend
primary care using the CRB65 criteria: blood and sputum cultures, pneumococcal and legionella
urinary antigen tests
• CRP monitoring is recommend for admitted patients to
help determine response to treatment
Management of low-severity community acquired pneumonia ANSWER:
• amoxicillin is first-line Reduced frequency of exacerbations
• if penicillin allergic then use a macrolide or tetracycline
• NICE now recommend a 5 day course of antibiotics for EXPLANATION:
patients with low severity community acquired COPD - reason for using inhaled corticosteroids - reduced
pneumonia exacerbations

Management of moderate and high-severity community Please see Q-2 for COPD: Stable Management
acquired pneumonia
• dual antibiotic therapy is recommended with amoxicillin Q-5
and a macrolide A 19-year-old man presents as he is concerned he may be
• a 7-10 day course is recommended asthmatic. Which one of the following points in the history
• NICE recommend considering a beta-lactamase stable would make this diagnosis less likely?
penicillin such as co-amoxiclav, ceftriaxone or piperacillin
with tazobactam and a macrolide in high-severity A. Smoking since age of 16 years
community acquired pneumonia B. Peripheral tingling during episodes of dyspnoea
C. Peripheral blood eosinophilia
Discharge criteria and advice post-discharge D. Chest tightness whilst exercising
NICE recommend that patients are not routinely discharged if E. History of eczema
in the past 24 hours they have had 2 or more of the following
findings: ANSWER:
• temperature higher than 37.5°C Peripheral tingling during episodes of dyspnoea
• respiratory rate 24 breaths per minute or more
• heart rate over 100 beats per minute EXPLANATION:
The British Thoracic Society suggest peripheral tingling is one
• systolic blood pressure 90 mmHg or less
of the factors which makes a diagnosis of asthma less likely.
• oxygen saturation under 90% on room air
His smoking history does not preclude a diagnosis of asthma
• abnormal mental status
and COPD would be very unlikely given his age.
• inability to eat without assistance.
ASTHMA: DIAGNOSIS
They also recommend delaying discharge if the temperature is
higher than 37.5°C.
The British Thoracic Society (BTS) updated their asthma
guidelines in 2016 resulting in some significant changes in
NICE recommend that the following information is given to
how asthma is diagnosed and managed.
patients with pneumonia in terms of how quickly their
symptoms should symptoms should resolve:
The diagnosis of asthma remains clinical, based on a
combination of history, examination and investigation results.
Time Progress
There is no one definitive test and the combination of findings
1 week Fever should have resolved
results in a high, intermediate or low probability of asthma.
4 weeks Chest pain and sputum production should have substantially
reduced
There are a number of respiratory symptoms which should
6 weeks Cough and breathlessness should have substantially reduced
make you consider asthma as a diagnosis. The guidelines
3 months Most symptoms should have resolved but fatigue may still be
remind us that the predictive value of individual symptoms or
present
signs is poor.
6 months Most people will feel back to normal.
wheeze
cough
Q-4
breathlessness
A 54-year-old woman with chronic obstructive pulmonary
chest tightness
disease (COPD) is prescribed an inhaled corticosteroid. What
is the main therapeutic benefit of inhaled corticosteroids in
Once a diagnosis is being considered, a combination of
patients with COPD?
history, examination and investigation results should be used
to determine whether a patient has a high, intermediate or
A. Reduced severity of exacerbations
low probability of asthma. Factors which should be considered
B. Improved all cause mortality
include:
C. Reduced use of bronchodilators
recurrent episodes of symptoms: may be triggered by viral
D. Slows decline in FEV1
infection, allergen exposure, NSAIDs/beta-blockers and/or
E. Reduced frequency of exacerbations
exacerbated by exercise, cold air and emotion/laughter in Once a diagnosis of asthma has been made all patients (or
children parents/carers) should be offered self-management education
recorded observation of wheeze: due to varying use of including a written personalised asthma action plan
language this usually means wheeze documented by a in adults, these may be based on symptoms/peak flows
clinician whereas in children symptom-based plans are preferred
symptom variability: asthma is generally worse at night or
early in the morning *in the extended guidelines the BTS state some of the
personal history of atopy: e.g. eczema/allergic rhinitis symptoms/factors which may point to an alternative
absence of symptoms of alternative diagnosis: e.g. COPD, diagnosis. Please see the guidelines for the full list:
dysfunctional breathing or obesity*
historical record of variable peak flows or FEV1 Clinical clue Possible diagnosis
Predominant cough without lung Chronic cough syndromes;
At this point, the guidelines do not make specific function abnormalities pertussis
recommendations about who is considered to have a high, Prominent dizziness, light- Dysfunctional breathing
medium or low probability of asthma. It is now recommended headedness, peripheral tingling
that we make a clinical judgement about likelihood, which Recurrent severe asthma attacks Vocal cord dysfunction
probably better reflects day-to-day practice. without objective confirmatory
evidence
Predominant nasal symptoms without Rhinitis
If a patient has a high probability of asthma:
lung function abnormalities
treatment should be initiated (typically 6 weeks of inhaled
Postural and food-related symptoms, Gastro-oesophageal reflux
corticosteroid)
predominant cough
an assessment should be made about whether the patient has
Orthopnoea, paroxysmal nocturnal Cardiac failure
responded to treatment using either a validated scoring dyspnoea, peripheral oedema,
system or lung functions tests (FEV1 at clinic visits or by preexisting cardiac disease
domiciliary serial peak flows) Crackles on auscultation Pulmonary fibrosis
a good response to treatment is clearly supportive of an Significant smoking history (ie, >30 COPD
asthma diagnosis, a poor response should prompt tests for pack-years), age of onset >35 years
airway obstruction with spirometry and bronchodilator Chronic productive cough in the Bronchiectasis; inhaled foreign
reversibility absence of wheeze or breathlessness body; obliterative bronchioitis;
large airway stenosis
If a patient has a intermediate probability of asthma: New onset in smoker, systemic Lung cancer; sarcoidosis
tests for airway obstruction with spirometry and symptoms, weight loss, haemoptysis
bronchodilator reversibility should be undertaken
if a child is too young to perform spirometry the BTS Q-6
recommend we consider watchful waiting if the child is A 34-year-old steelworker presents complaining of episodic
asymptomatic, or offer a carefully monitored trial of shortness of breath. This is particularly noted whilst at work
treatment if the child is symptomatic where he describes feeling wheezy and having a tendency to
cough. A diagnosis of occupation asthma is suspected. Which
If a patient has a low probability of asthma: one of the following is the most appropriate diagnostic
investigations should continue looking for alternative causes investigation?
of the presenting symptoms
if other diagnoses considered unlikely then investigations for A. Patch testing
asthma should be arranged, including spirometry and B. High resolution computed tomography of thorax
bronchodilator reversibility C. Serial peak flow measurements at work and at home
D. Specific IgE measurements
Reasons for referring to secondary care include: E. Skin prick test
if the diagnosis remains unclear despite investigations
suspected occupational asthma ANSWER:
poor response to treatment Serial peak flow measurements at work and at home
a severe or life-threatening asthma attack
there are other 'red-flags' which may indicate more severe EXPLANATION:
disease or alternative diagnosis such as systemic features ASTHMA: OCCUPATIONAL
(weight loss, fever etc), failure to thrive in children, focal Patients may either present with concerns that chemicals at
signs, chronic sputum production etc. Please see the work are worsening their asthma or you may notice in the
guidelines for the full list history that symptoms seem better at weekends / when away
from work.
Exposure to the following chemicals is associated with
occupational asthma: A no antibiotic prescribing or delayed antibiotic prescribing
• isocyanates - the most common cause. Example approach is generally recommended for patients with acute
occupations include spray painting and foam moulding otitis media, acute sore throat/acute pharyngitis/acute
using adhesives tonsillitis, common cold, acute rhinosinusitis or acute
• platinum salts cough/acute bronchitis.
• soldering flux resin
• glutaraldehyde However, an immediate antibiotic prescribing approach may
• flour be considered for:
• epoxy resins • children younger than 2 years with bilateral acute otitis
• proteolytic enzymes media
• children with otorrhoea who have acute otitis media
Serial measurements of peak expiratory flow are • patients with acute sore throat/acute pharyngitis/acute
recommended at work and away from work. tonsillitis when 3 or more Centor criteria are present

Referral should be made to a respiratory specialist for patients The Centor criteria* are as follows:
with suspected occupational asthma. • presence of tonsillar exudate
• tender anterior cervical lymphadenopathy or
Q-7 lymphadenitis
A 20-month-old boy presents with mild unilateral earache • history of fever
since yesterday. He keeps pulling at his right ear. There is no • absence of cough
discharge. He does not have any rashes and is still eating and
drinking well. He has not had any fevers. If the patient is deemed at risk of developing complications,
an immediate antibiotic prescribing policy is recommended
On examination, his temperature is 36.8ºC and his pulse is • are systemically very unwell
110 beats per minute. He looks well. His ears both look • have symptoms and signs suggestive of serious illness
normal. and/or complications (particularly pneumonia,
mastoiditis, peritonsillar abscess, peritonsillar
What is the most appropriate management option? cellulitis, intraorbital or intracranial complications)
• are at high risk of serious complications because of
A. Acetic acid spray pre-existing comorbidity. This includes patients with
B. Amoxicillin significant heart, lung, renal, liver or neuromuscular
C. Dexamethasone, neomycin and acetic acid spray disease, immunosuppression, cystic fibrosis, and
D. Flucloxacillin young children who were born prematurely
E. Monitor symptoms • are older than 65 years with acute cough and two or
more of the following, or older than 80 years with
ANSWER: acute cough and one or more of the following:
Monitor symptoms - hospitalisation in previous year
- type 1 or type 2 diabetes
EXPLANATION: - history of congestive heart failure
This young boy has had a 24 hour history of unilateral - current use of oral glucocorticoids
earache. The rest of the history is reassuring and there is no
evidence of any infection on examination at this time. The guidelines also suggest that patients should be advised
Management at this stage should be advice of using how long respiratory tract infections may last:
analgesia (paracetamol and ibuprofen) for symptomatic • acute otitis media: 4 days
relief and monitoring symptoms. Acetic acid spray and • acute sore throat/acute pharyngitis/acute tonsillitis: 1
flucloxacillin can be used for otitis externa. Amoxicillin can week
be used for bilateral otitis media that is ongoing for at least • common cold: 1 1/2 weeks
4 days. Dexamethasone, neomycin and acetic acid spray can • acute rhinosinusitis: 2 1/2 weeks
be used in children over 2 years of age according to the • acute cough/acute bronchitis: 3 weeks
British National Formulary.
*if 3 or more of the criteria are present there is a 40-60%
RESPIRATORY TRACT INFECTIONS: NICE GUIDELINES chance the sore throat is caused by Group A beta-haemolytic
NICE issued guidance in 2008 on the management of Streptococcus
respiratory tract infection, focusing on the prescribing of
antibiotics for self-limiting respiratory tract infections in adults
and children in primary care
Q-8 of psychiatric illness should be monitored closely while
You are reviewing a patient with chronic obstructive taking varenicline.
pulmonary disease (COPD) who remains breathless despite
using a salbutamol inhaler as required. Their FEV1 is 60%. In the current BNF:
What are the two main options?
Cautions
A. Long-acting beta2-agonist (LABA) or inhaled Cautions
corticosteroid risk of relapse, irritability, depression, and insomnia on
B. Long-acting muscarinic antagonist (LAMA) + inhaled discontinuation (consider dose tapering on completion of 12-
corticosteroid (ICS) in a combination inhaler or long- week course); history of psychiatric illness (may exacerbate
acting beta2-agonist (LABA) underlying illness including depression); predisposition to
C. Long-acting beta2-agonist (LABA) or LABA + inhaled seizures, including conditions that may lower seizure
corticosteroid (ICS) in a combination inhaler threshold; history of cardiovascular disease
D. Long-acting beta2-agonist (LABA) or regular combined
short-acting beta2-agonist + muscarinic antagonist (e.g. SMOKING CESSATION
Combivent) NICE released guidance in 2008 on the management of
E. Long-acting beta2-agonist (LABA) or long-acting smoking cessation. General points include:
muscarinic antagonist (LAMA) patients should be offered nicotine replacement therapy
(NRT), varenicline or bupropion - NICE state that clinicians
ANSWER: should not favour one medication over another
Long-acting beta2-agonist (LABA) or long-acting muscarinic NRT, varenicline or bupropion should normally be prescribed
antagonist (LAMA) as part of a commitment to stop smoking on or before a
particular date (target stop date)
EXPLANATION: prescription of NRT, varenicline or bupropion should be
COPD - still breathless despite using inhalers as required? sufficient to last only until 2 weeks after the target stop date.
FEV1 > 50%: LABA or LAMA Normally, this will be after 2 weeks of NRT therapy, and 3-4
FEV1 < 50%: LABA + ICS or LAMA weeks for varenicline and bupropion, to allow for the different
methods of administration and mode of action. Further
Please see Q-2 for COPD: Stable management prescriptions should be given only to people who have
demonstrated that their quit attempt is continuing
Q-9 if unsuccessful using NRT, varenicline or bupropion, do not
You are considering prescribing varenicline to a 45-year-old offer a repeat prescription within 6 months unless special
man who is trying to stop smoking. Which one of the circumstances have intervened
following conditions is most likely to contradict the do not offer NRT, varenicline or bupropion in any combination
prescription of varenicline?
Nicotine replacement therapy
A. Previous or current central nervous system tumour • adverse effects include nausea & vomiting, headaches
B. Past history of deliberate self-harm and flu-like symptoms
C. Hypertension • NICE recommend offering a combination of nicotine
D. Myasthenia gravis patches and another form of NRT (such as gum, inhalator,
E. Obesity lozenge or nasal spray) to people who show a high level
of dependence on nicotine or who have found single
ANSWER: forms of NRT inadequate in the past
Past history of deliberate self-harm
Varenicline
EXPLANATION: • a nicotinic receptor partial agonist
Varenicline should be used with caution in patients with a • should be started 1 week before the patients target date
history of depression. There are ongoing studies looking at to stop
the risk of suicidal behaviour in patients taking varenicline. • the recommended course of treatment is 12 weeks (but
patients should be monitored regularly and treatment
The current MHRA/CHM advice is: only continued if not smoking)
• has been shown in studies to be more effective than
Suicidal behaviour and varenicline bupropion
Patients should be advised to discontinue treatment and • nausea is the most common adverse effect. Other
seek prompt medical advice if they develop agitation, common problems include headache, insomnia, abnormal
depressed mood, or suicidal thoughts. Patients with a history dreams
• varenicline should be used with caution in patients with a Q-11
history of depression or self-harm. There are ongoing Following the 2014 National Review of Asthma Deaths, what
studies looking at the risk of suicidal behaviour in patients number of courses of oral or intravenous steroids in the past
taking varenicline 12 months should prompt referral to secondary care for
• contraindicated in pregnancy and breast feeding optimisation of asthma treatment?

Bupropion More than 1

• a norepinephrine and dopamine reuptake inhibitor, and More than 2
nicotinic antagonist More than 3
• should be started 1 to 2 weeks before the patients target More than 4
date to stop More than 5
• small risk of seizures (1 in 1,000)
• contraindicated in epilepsy, pregnancy and breast ANSWER:
feeding. Having an eating disorder is a relative More than 2
contraindication
EXPLANATION:
Pregnant women ASTHMA: NATIONAL REVIEW OF ASTHMA DEATHS
NICE recommended in 2010 that all pregnant women should In 2014 the Royal College of Physicians (RCP) published a
be tested for smoking using carbon monoxide detectors, review, 'Why asthma still kills: The National Review of Asthma
partly because 'some women find it difficult to say that they Deaths (NRAD)', which received widespread media coverage.
smoke because the pressure not to smoke during pregnancy is This detailed review looked at 195 asthma deaths which
so intense.'. All women who smoke, or have stopped smoking occurred over a 12 month period. Much of this media focus
within the last 2 weeks, or those with a CO reading of 7 ppm was angled at poor GP management of patients with asthma.
or above should be referred to NHS Stop Smoking Services. The following is a selected set of findings and
recommendations. Please see the full report for a complete
Interventions list - a link is provided.
• the first-line interventions in pregnancy should be
cognitive behaviour therapy, motivational interviewing or Key findings of the report included:
structured self-help and support from NHS Stop Smoking • personal asthma action plans, acknowledged to improve
Services asthma care, were known to be provided to only 44 (23%)
• the evidence for the use of NRT in pregnancy is mixed but of the 195 people who died from asthma
it is often used if the above measures failure. There is no • there was no evidence that an asthma review had taken
evidence that it affects the child's birthweight. Pregnant place in general practice in the last year before death for
women should remove the patches before going to bed 84 (43%) of the 195 people who died
• as mentioned above, varenicline and bupropion are • the expert panels identified factors that could have
contraindicated avoided death in relation to the health professionals
implementation of asthma guidelines in 89 (46%) of the
Q-10 195 deaths, including lack of specific asthma expertise in
A 47-year-old man is reviewed in the smoking cessation 34 (17%) and lack of knowledge of the UK asthma
clinic. Which one of the following conditions would guidelines in 48 (25%)
contraindicate the prescription of bupropion? • inappropriate prescribing of long-acting beta agonist
(LABA) bronchodilator inhalers. 27 (14%) of those who
A. History of supraventricular tachycardia died were prescribed a single-component LABA
B. Previous episodes of acute pancreatitis bronchodilator at the time of death. At least five (3%)
C. Epilepsy patients were on LABA monotherapy without inhaled
D. Depression corticosteroid preventer treatment
E. Hypertension
Selected recommendations include:
ANSWER: • referral to secondary care should be made if patients
Epilepsy have required more than two courses of systemic
corticosteroids, oral or injected, in the previous 12
EXPLANATION: months or require management using British Thoracic
Bupropion: contraindicated in epilepsy Society (BTS) stepwise treatment 4 or 5 to achieve control
• all patients who have been prescribed more than 12
Please see Q-9 for Smoking Cessation reliever inhalers in the past 12 months should be invited
for urgent review of their asthma control
• an assessment of inhaler technique should be routinely 3. Maintain control by increasing treatment as necessary and
undertaken and formally documented at annual review decreasing treatment when control is good
• non-adherence to inhaled corticosteroids is associated
with increased risk of poor asthma control and should be The previous steps 1-5 of asthma management have been
continually monitored abandoned. Previously 'Step 1' of asthma management was
• the use of combination inhalers should be encouraged. the use of a short-acting beta agonist (SABA) as required. This
Where long-acting beta agonist (LABA) bronchodilators is no longer suggested as the initial first step. Instead, all
are prescribed for people with asthma, they should be patients from the 'diagnosis and assessment' onwards should
prescribed with an inhaled corticosteroid in a single use a SABA as required. Having to use a SABA more than 3
combination inhaler times per week is considered a sign that further add-on
therapy is needed.
Q-12
A 29-year-old woman who is 14 weeks pregnant presents to Initial step
the Emergency Department with an exacerbation of asthma. It is now recommended that a low-dose inhaled corticosteroid
She quickly settles with nebulised salbutamol and you are (ICS) is started in all patients with a diagnosis, or suspected
asked to review her prior to discharge. She currently only diagnosis, of asthma, right from the 'diagnosis and
uses a salbutamol inhaler (100mcg) as required and thinks assessment' period prior to a formal diagnosis being made.
that the most common trigger is grass pollen. Her peak flow The first step of asthma management is now a low-dose
is now 380 l/min (predicted 440 l/min) and inhaler technique inhaled corticosteroid in combination with a short-acting beta
is good. What is the most appropriate course of action? agonist.

A. Add inhaled ipratropium bromide 500 mcg qds Next step.

B. Suggest she uses the salbutamol 100 mcq qds The a long-acting beta agonist (LABA). This should ideally be in
C. Arrange a course of pollen desensitisation injections the form of a combination inhaler.
D. Add inhaled salmeterol 50 mcg bd
E. Add inhaled beclomethasone 200 mcg bd Next step..
If poor control remains the next step depends on the
ANSWER: response to the LABA:
Add inhaled beclomethasone 200 mcg bd • no response to LABA - stop LABA and increase dose of ICS
to medium-dose
EXPLANATION: • response to LABA - continue LABA and increase ICS to
The British Thoracic Society (BTS) guidelines make it clear medium-dose. An alternative to this is to continue on the
that short-acting /long-acting beta 2-agonists, inhaled and current treatment but consider a trial of a leukotriene
oral corticosteroids should all be used as normal during receptor antagonist, SR theophylline or a long-acting
pregnancy. muscarinic antagonist (LAMA)

ASTHMA: MANAGEMENT IN ADULTS Next step...

The British Thoracic Society (BTS) updated their asthma Consider trials of either:
guidelines in 2016 resulting in some significant changes in • increasing the ICS to high-dose, OR
how asthma is diagnosed and managed. In terms of • the addition of a fourth drug (e.g. a leukotriene receptor
management, some of the key changes include: antagonist, SR theophylline, a LAMA or an oral beta-
• the previous numbered steps have been abandoned agonist tablet)
• all patients should receive an inhaled corticosteroid, right • patient should be referred to specialist care at this point
from the point of assessment in patients with suspected
asthma Next step....
• a combined inhaled corticosteroid/long-acting beta The consideration of regular oral steroids at the lowest dose
agonist (ICS/LABA) is recommended instead of separate providing adequate daily control.
inhalers to increase compliance
• a long-acting muscarinic antagonist (LAMA) is an options
for patient who haven't responded to a combined
ICS/LABA inhaler

In terms of management, the BTS suggest the following

approach:
1. Start treatment at the level most appropriate to initial
severity
2. Achieve early control
 D. Long-acting beta2-agonist (LABA) or regular combined
short-acting beta2-agonist + muscarinic antagonist (e.g.
Combivent)
E. Long-acting muscarinic antagonist (LAMA) + inhaled
corticosteroid (ICS) in a combination inhaler or long-
acting beta2-agonist (LABA)

ANSWER:
Long-acting muscarinic antagonist (LAMA) or LABA + inhaled
corticosteroid (ICS) in a combination inhaler

EXPLANATION:
COPD - still breathless despite using inhalers as required?
FEV1 > 50%: LABA or LAMA
FEV1 < 50%: LABA + ICS or LAMA

Please see Q-2 for COPD: stable management

Q-14
A 30 year-old lady with a diagnosis of asthma is reviewed in
general practice. She is currently taking a salbutamol inhaler
as required along with inhaled corticosteroid 200micrograms
twice a day.

After a recent review she had been prescribed salmeterol

2016 British Thoracic Society asthma algorithm for adults 100µg twice a day. There was some improvement with this
but she is currently continuing to require her salbutamol
Table showing examples of inhaled corticosteroid doses inhaler 2-6 times/day.
Low Medium High
Beclometasone Beclometasone Beclometasone
Which of the following medication adjustments is the most
dipropionate dipropionate dipropionate appropriate?

• Clenil - 100 mcg • Clenil - 200 mcg • Clenil - 250 mcg

A. Add regular oral prednisolone
two puffs bd two puffs bd two-four puffs bd B. Add regular oral modified release theophylline
• Qvar - 50 mcg two • Qvar - 100 mcg • Qvar - 100 mcg C. Add regular oral leukotriene receptor antagonist
puffs bd two puffs bd four puffs bd D. Increase regular inhaled steroid dose
E. Add regular inhaled ipratropium
Fluticasone propionate Fluticasone propionate Fluticasone propionate
ANSWER:
• Flixotide - 50 mcg • Flixotide - 125 • Flixotide - 250 Increase regular inhaled steroid dose
two puffs bd mcg two puffs bd mcg two puffs bd
EXPLANATION:
There was some improvement but control remained poor.
Q-13 The next step would therefore be to increase the dose of
You are reviewing a patient with chronic obstructive inhaled steroid.
pulmonary disease (COPD) who remains breathless despite Q-15
using an ipratropium bromide inhaler as required. Her FEV1 One of your patients who has COPD is to start long-term
is 40%. What are the two main options? oxygen therapy. What is the most appropriate way to supply
this oxygen?
A. Long-acting beta2-agonist (LABA) or inhaled
corticosteroid A. Oxygen cylinders supplied via Home Oxygen Order Form
B. Long-acting muscarinic antagonist (LAMA) or LABA + B. Oxygen concentrator arranged following self-referral to
inhaled corticosteroid (ICS) in a combination inhaler local pharmacy
C. Long-acting beta2-agonist (LABA) or long-acting C. Oxygen cylinders supplied via FP10
muscarinic antagonist (LAMA) D. Oxygen concentrator supplied via Home Oxygen Order
Form
E. Oxygen concentrator supplied via FP10
 A. 2 days
ANSWER: B. 4 days
Oxygen concentrator supplied via Home Oxygen Order Form C. 7 days
D. 10 days
EXPLANATION: E. 2 1/2 weeks
The Home Oxygen Order Form has replaced the FP10 for F. 4 weeks
oxygen prescription. The actually supply of the oxygen is now G. 5 weeks
from private companies rather than the local pharmacy.
For each one of the following respiratory tract infections
COPD: LONG-TERM OXYGEN THERAPY select the average total illness length:
The 2010 NICE guidelines on COPD clearly define which
patients should be assessed for and offered long-term oxygen Q-17
therapy (LTOT). Patients who receive LTOT should breathe Acute tonsillitis
supplementary oxygen for at least 15 hours a day. Oxygen
concentrators are used to provide a fixed supply for LTOT. ANSWER:
7 days
Assess patients if any of the following:
• very severe airflow obstruction (FEV1 < 30% predicted). Q-18
Assessment should be 'considered' for patients with Acute rhinosinusitis
severe airflow obstruction (FEV1 30-49% predicted)
• cyanosis ANSWER:
• polycythaemia 2-1/2 weeks
• peripheral oedema
• raised jugular venous pressure Q-19
• oxygen saturations less than or equal to 92% on room air Common Cold

Assessment is done by measuring arterial blood gases on 2 ANSWER:

occasions at least 3 weeks apart in patients with stable COPD 10 days
on optimal management.
EXPLANATION Q-17 THROUGH 19:
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with Please see Q-7 for Respiratory Tract Infections: NICE
a pO2 of 7.3 - 8 kPa and one of the following: GUIDELINES
• secondary polycythaemia
• nocturnal hypoxaemia Q-20
• peripheral oedema A 27-year-old man presents for review. Around six months
he started work at a garage which specialises in the spray
• pulmonary hypertension
painting of cars. Over the past few weeks he has been having
increasing problems with a cough and wheeze during the
Q-16
daytime. He wonders if it may be related to his work as his
You are reviewing a patient with chronic obstructive
symptoms improved following a recent two week holiday to
pulmonary disease. Which one of the following best
Greece. You give him a peak flow meter. An average of the
describes the vaccinations they should receive?
results are shown below:
A. Annual influenza + annual pneumococcal
Average peak flow
B. Annual influenza + one-off pneumococcal + one-off Hib
booster Days at work 510 l/min

C. Annual influenza + one-off pneumococcal Days not at work 630 l/min

D. Annual influenza + pneumococcal every 5 years
E. Annual influenza What is the most appropriate course of action?

ANSWER: A. Prescribe a corticosteroid inhaler + a salbutamol inhaler

Annual influenza + one-off pneumococcal B. Prescribe a salbutamol inhaler for work days
C. Arrange spirometry
EXPLANATION: D. Advise him to quit his job
Please see Q-2 for COPD: Stable Management E. Refer to respiratory
Q-17 THROUGH 19
Theme: Respiratory tract infections: NICE guidelines ANSWER:
Refer to respiratory
 Which one of the following statements regarding the use of
EXPLANATION: long-term oxygen (LTOT) therapy in patients with chronic
Patients with suspected occupational asthma should be obstructive pulmonary disease (COPD) is correct?
referred to a respiratory specialist
A. All patients with severe COPD (FEV1 30-49% predicted)
Please see Q-6 for Asthma: Occupational should be offered LTOT
B. LTOT is associated with a slight increase in mortality but
Q-21 a decrease in morbidity
Your next patient is a 34-year-old accountant who has come C. Smoking is an absolute contraindication
for their annual review. Until around two years ago they D. Oxygen cylinders should be used to provide LTOT
used just a salbutamol inhaler as required. At this point he E. Patients receiving LTOT should breathe supplemental
managed to stop smoking. Following a series of oxygen for at least 15 hours a day
exacerbations he was started on a corticosteroid inhaler and
currently takes Clenil (beclometasone dipropionate) 400mcg ANSWER:
bd. The patient reports that his asthma control has been Patients receiving LTOT should breathe supplemental oxygen
'good' for the past six months or so. He has had to use his for at least 15 hours a day
asthma inhaler twice over the past six months, both times
after going for a long jog. His peak flow today is 520 l/min EXPLANATION:
which is 90% of the best value recorded 5 years ago but up Interestingly, NICE do not view smoking as an absolute
from the 510 l/min recorded 12 months ago. His inhaler contraindication to LTOT, despite the obvious safety issues. It
technique is good. What is the most appropriate next step in states 'If they smoke, warn them about the risk of fire and
management? explosion'.

A. Make no changes Please see Q-15 for COPD: Long-term oxygen therapy
B. Stop the Clenil inhaler
C. Decrease the Clenil dose to 200 mcg bd Q-23
D. Add salmeterol A 19-year-old woman presents with a night-time cough and a
E. Perform a chest x-ray wheezy sensation after exercising. She has a past history of
eczema. She is a non-smoker. Her mother is a known
ANSWER: asthmatic. Examination of her chest today is unremarkable.
Decrease the Clenil dose to 200 mcg bd
You arrange spirometry which is reported as normal, with a
EXPLANATION: FEV1/FVC of 0.72.
Good asthma control? Consider stepping down treatment
The British Thoracic Society guidelines encourage us to 'step- What is the most appropriate next step?
down' the treatment for asthmatic patients who are well
controlled. A. Trial of a salbutamol inhaler + inhaled corticosteroid
B. Arrange an ECG
ASTHMA: STEPPING DOWN TREATMENT C. Perform a full blood count to check for eosinophilia
The British Thoracic Society (BTS) guidelines recommend that D. Arrange a chest x-ray
we should consider stepping down treatment every 3 months E. Refer to the respiratory clinic
or so. The guidelines don't advocate a strict move from say
step 3 to step 2 but advise us to take into account duration of ANSWER:
treatment, side-effects and patient preference. Trial of a salbutamol inhaler + inhaled corticosteroid

When reducing the dose of inhaled steroids the BTS advise us EXPLANATION:
to do this by 25-50% at a time. This patient has a high probability of asthma - they should,
therefore, be given a trial of treatment.
Clearly patients with stable asthma may only have a formal
review on an annual basis but it is likely that if a patient has Please see Q-5 for Asthma: Diagnosis
recently had an escalation of asthma treatment they would be
reviewed on a more frequent basis. Q-24
You are working in the out-patient respiratory clinic where a
62 year old female patient attends for follow-up. She has a
Q-22 diagnosis of COPD (FEV1/FVC= 0.68, FEV1=46% predicted)
and currently smokes 30 cigarettes per day. She has noted
progressive ankle swelling over last year but has not suffered
any exacerbations in this time. She currently takes a Please look at the image below:
tiotropium inhaler as well as a combination inhaler of
salmetarol/fluticasone with a salbutamol inhaler when
required, her inhaler technique has been assessed as good.
In clinic her arterial blood gas results on air give a pO2 of 7.3
kPa and 7.8 kPa respectively from today and from clinic two
months ago.

The patient would like to be considered for home oxygen

therapy. According to current NICE guidelines what advice
should you give her?

A. She does not qualify for home oxygen as her oxygen

levels are too high
B. Home oxygen is contraindicated as she is a current
Which one of the following conditions is associated with
smoker
these changes?
C. No proven survival benefit of long term oxygen has been
demonstrated in COPD patients
A. Ventricular septal defect
D. Agree to arrange home oxygen but warn of the risk of
B. Hypothyroidism
fire or explosion
C. Mesothelioma
E. Advise a trial of maintenance oral steroids in the first
D. Hepatic cancer
instance
E. Chronic obstructive pulmonary disease
ANSWER:
ANSWER:
Agree to arrange home oxygen but warn of the risk of fire or
Mesothelioma
explosion
EXPLANATION:
EXPLANATION:
CLUBBING
This question essentially tests the candidates’ knowledge of
The causes of clubbing may be divided into cardiac,
the indications for long term oxygen therapy (LTOT) in COPD
respiratory and other
patients.
Cardiac causes
Generally speaking, LTOT is indicated for COPD patients with
PaO2<7.3 kPa when stable. However this cut-off is extended • cyanotic congenital heart disease (Fallot's, TGA)
to <8kPa when one or more of the following is present; • bacterial endocarditis
secondary polycythaemia, pulmonary hypertension, • atrial myxoma
nocturnal hypoxaemia, or as is the case in this question,
peripheral oedema. Assessment of arterial oxygen Respiratory causes
concentration should be performed when stable and with • lung cancer
two readings at least three weeks apart. Supplementary • pyogenic conditions: cystic fibrosis, bronchiectasis,
oxygen should be used for a minimum of 15 hours per day, abscess, empyema
but effect is greater if used for more than 20 hours per day. • tuberculosis
• asbestosis, mesothelioma
Maintenance oral corticosteroid use is not routinely • fibrosing alveolitis
recommended and is only generally indicated when unable
to fully wean steroids between exacerbations. Other causes
• Crohn's, to a lesser extent UC
Perhaps surprisingly, in reference to smoking and LTOT, • cirrhosis, primary biliary cirrhosis
current NICE guidance states 'patients should be warned of • Graves' disease (thyroid acropachy)
the risk of fire or explosion if they continue to smoke when • rare: Whipple's disease
prescribed oxygen'. A better answer would be to offer
smoking cessation in the first instance and to reinforce this Q-26
aggressively, but this option is not given. Following the 2014 National Review of Asthma Deaths, what
is the minimum number of salbutamol prescriptions in the
Please see Q-15 for COPD: Long-term oxygen therapy past 12 months that should prompt an urgent review of a
patient's asthma control?
Q-25
A. 4 Which one of the following interventions is most likely to
B. 8 increase survival in patients with COPD?
C. 12
D. 16 A. Home nebulisers
E. 20 B. Tiotropium inhaler
C. Long-term steroid therapy
ANSWER: D. Smoking cessation
12 E. Long-term oxygen therapy

EXPLANATION: ANSWER:
The Royal College of Physicians make the following Smoking cessation
recommendation in the report:
EXPLANATION:
All asthma patients who have been prescribed more than 12 Whilst long-term oxygen therapy may increase survival in
short-acting reliever inhalers in the previous 12 months hypoxic patients, smoking cessation is the single most
should be invited for urgent review of their asthma control, important intervention in patients with COPD
with the aim of improving their asthma through education
and change of treatment if required Please see Q-2 for COPD: stable management

Please see Q-11 for Asthma: National Review of Asthma Q-29 THROUGH 31
Deaths Theme: Asthma: stepwise management in adults

Q-27 A. Short-acting beta agonist

You review a 26-year-old woman. She has a history of B. Inhaled corticosteroid
asthma and is prescribed salbutamol 100mcg 2 puffs prn, C. Short-acting beta agonist + inhaled corticosteroid
beclometasone dipropionate 400mcg bd and salmeterol D. Long-acting beta agonist
50mcg bd. Last week she found out she was pregnant and E. Leukotriene receptor antagonist
stopped the beclometasone and salmeterol inhalers as she F. Short-acting muscarinic antagonist
was concerned about potential harm to the pregnancy. What G. Long-acting muscarinic antagonist
is the most appropriate action? H. Omalizumab

A. Reduce beclometasone to 200 mcg bd and continue The diagram below is based on the 2016 British Thoracic
salmeterol at the same dose Society guidelines on the management of asthma in adults:
B. Stop beclometasone and salmeterol inhalers + refer to a
respiratory physician
C. Reduce beclometasone to 200 mcg bd and stop
salmeterol
D. Restart beclomethasone at same dose and stop
salmeterol
E. Reassure + restart beclometasone and salmeterol
inhalers

ANSWER:
Reassure + restart beclometasone and salmeterol inhalers

EXPLANATION:
Both the BNF and British Thoracic Society guidelines stress
the need for good control of asthma during pregnancy. The
BNF advises that 'inhaled drugs, theophylline and
prednisolone can be taken as normal during pregnancy and
breast-feeding'.

Please see Q-12 for Asthma: Management in Adults

Q-28
For each one of the number gaps above, please select one
option from the list. EXPLANATION:
The British Thoracic Society (BTS) recommend adding a long-
Q-29 acting B2 agonist if there is an inadequate response to the
Gap (1) addition of inhaled steroid. The inhaled steroid dose should
be increased if there is an inadequate response to the long-
ANSWER: acting B2 agonist.
Short-acting beta agonist + inhaled corticosteroid
In the 2016 BTS guidelines an initial 'low-dose' for adults is
EXPLANATION: beclometasone dipropionate 200mcg bd, a common clinical
The first step of asthma management is now a low-dose example being Clenil.
inhaled corticosteroid in combination with a short-acting beta Please see Q-12 for Asthma: Management in Adults
agonist
Q-33
Q-30 A 23-year-old woman is on the combined oral contraceptive
Gap (2) pill and has just returned from holiday in Japan. She reports
that she is feeling very short of breath. You suspect a
ANSWER: pulmonary embolism and perform an ECG.
Long-acting beta agonist 63%
Which one of the following is the most common ECG finding
EXPLANATION: in pulmonary embolism?
The guidelines recommend that the long-acting beta agonist is
given as a combination inhaler with the inhaled corticosteroid, A. S1, Q3, T3 pattern
as this can improve compliance. B. Tall, tented T waves
C. Prolonged QT interval
Q-31 D. Sinus tachycardia
Gap (3) E. Sinus bradycardia

ANSWER: ANSWER:
Long-acting muscarinic antagonist Sinus tachycardia

EXPLANATION: EXPLANATION:
Long-acting muscarinic antagonists have been used in the The most common ECG finding in patients with pulmonary
management of COPD for many years. The 2016 British embolism is sinus tachycardia. The S1, Q3, T3 pattern is often
Thoracic Society guidelines advocated their use in asthma for quoted in textbooks but is rarely seen.
the first time.
The October 2014 AKT feedback stated
EXPLANATION Q-29 THROUGH 31:
Please see Q-12 for Asthma: Management in Adults Some candidates found interpretation of ECGs difficult. This
is an area in which we will continue to test regularly. ECGs
Q-32 are increasingly performed routinely in practice (eg in
A 24-year-old female comes for review. She was diagnosed relation to blood pressure management or QT interval
with asthma two years ago and is currently using a issues).
salbutamol inhaler 100mcg prn combined with
beclometasone dipropionate inhaler 200mcg bd. Despite this PULMONARY EMBOLISM: INVESTIGATION
her asthma is not well controlled. On examination her chest We know from experience that few patients (around 10%)
is clear and she has a good inhaler technique. What is the present with the medical student textbook triad of pleuritic
most appropriate next step in management? chest pain, dyspnoea and haemoptysis. Pulmonary embolism
can be difficult to diagnose as it can present with virtually any
A. Increase beclometasone dipropionate to 400mcg bd cardiorespiratory symptom/sign depending on it's location
B. Switch steroid to fluticasone propionate and size.
C. Trial of leukotriene receptor antagonist
D. Add salmeterol So which features make pulmonary embolism more likely?
E. Add tiotropium
The PIOPED study1 in 2007 looked at the frequency of
ANSWER: different symptoms and signs in patients who were diagnosed
Add salmeterol with pulmonary embolism.
 include speed, easier to perform out-of-hours, a reduced
The relative frequency of common clinical signs is shown need for further imaging and the possibility of providing
below: an alternative diagnosis if PE is excluded
• Tachypnea (respiratory rate >16/min) - 96% • if the CTPA is negative then patients do not need further
• Crackles - 58% investigations or treatment for PE
• Tachycardia (heart rate >100/min) - 44% • ventilation-perfusion scanning may be used initially if
• Fever (temperature >37.8°C) - 43% appropriate facilities exist, the chest x-ray is normal, and
there is no significant symptomatic concurrent
It is interesting to note that the Well's criteria for diagnosing a cardiopulmonary disease
PE use tachycardia rather than tachypnoea.

2012 NICE guidelines

All patients with symptoms or signs suggestive of a PE should

have a history taken, examination performed and a chest x-
ray to exclude other pathology.

If a PE is still suspected a two-level PE Wells score should be

performed:

Clinical feature Points

Clinical signs and symptoms of DVT (minimum of leg swelling and 3
pain with palpation of the deep veins)
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 1.5
weeks
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or 1
palliative)

Clinical probability simplified scores

• PE likely - more than 4 points
• PE unlikely - 4 points or less

If a PE is 'likely' (more than 4 points) arrange an immediate

computed tomography pulmonary angiogram (CTPA). If there
is a delay in getting the CTPA then give low-molecular weight
heparin until the scan is performed.

If a PE is 'unlikely' (4 points or less) arranged a D-dimer test. If

this is positive arrange an immediate computed tomography Some other points
pulmonary angiogram (CTPA). If there is a delay in getting the
CTPA then give low-molecular weight heparin until the scan is D-dimers
performed. sensitivity = 95-98%, but poor specificity

If the patient has an allergy to contrast media or renal ECG

impairment a V/Q scan should be used instead of a CTPA. the classic ECG changes seen in PE are a large S wave in lead I,
a large Q wave in lead III and an inverted T wave in lead III -
CTPA or V/Q scan? 'S1Q3T3'. However this change is seen in no more than 20% of
patients
The consensus view from the British Thoracic Society and NICE right bundle branch block and right axis deviation are also
guidelines is as follows: associated with PE
• computed tomographic pulmonary angiography (CTPA) is sinus tachycardia may also be seen
now the recommended initial lung-imaging modality for
non-massive PE. Advantages compared to V/Q scans
 EXPLANATION:
PULMONARY FUNCTION TESTS
Pulmonary function tests can be used to determine whether a
respiratory disease is obstructive or restrictive. The table
below summarises the main findings and gives some example
conditions:

ECG from a patient with a PE. Shows a sinus tachycardia and a partial S1Q3T3 - Obstructive lung disease Restrictive lung disease
the S wave is not particularly convincing.
FEV1 - significantly reduced FEV1 - reduced
FVC - reduced or normal FVC - significantly reduced
FEV1% (FEV1/FVC) - reduced FEV1% (FEV1/FVC) - normal or
increased
Asthma Pulmonary fibrosis
COPD Asbestosis
Bronchiectasis Sarcoidosis
Bronchiolitis obliterans Acute respiratory distress
syndrome
Infant respiratory distress
syndrome
Kyphoscoliosis
Neuromuscular disorders

ECG of a patient with a PE. It shows some of the ECG features that may be
Q-35
associated with PE (sinus tachycardia, S1, T3 and T wave inversion in the precordial
leads). Other features such as the left axis deviation are atypical. A 61-year-old female is reviewed in the rheumatology clinic
with increasing shortness of breath. She has been on long-
V/Q scan term drug therapy to control her rheumatoid arthritis. Her
• sensitivity = 98%; specificity = 40% - high negative oxygen saturations on room air are on 89%. Investigations
predictive value, i.e. if normal virtually excludes PE reveal the following:
• other causes of mismatch in V/Q include old pulmonary
embolisms, AV malformations, vasculitis, previous Chest x-ray Bilateral interstitial shadowing
radiotherapy
• COPD gives matched defects Which drug is most likely to be responsible for her
symptoms?
CTPA
• peripheral emboli affecting subsegmental arteries may be A. Infliximab
missed B. Hydroxychloroquine
C. Sulphasalazine
Pulmonary angiography D. Azathioprine
• the gold standard E. Methotrexate
• significant complication rate compared to other
investigations ANSWER:
Methotrexate
Q-34
A 72-year-old woman is investigated for shortness of breath. EXPLANATION:
Auscultation of the lungs reveals fine bibasal crackles. Which RHEUMATOID ARTHRITIS: RESPIRATORY MANIFESTATIONS
one of the following set of results would be most consistent
with a diagnosis of pulmonary fibrosis? A variety of respiratory problems may be seen in patients with
rheumatoid arthritis:
A. FEV1 - reduced, FEV1/FVC - reduced • pulmonary fibrosis
B. FEV1 - increased, FEV1/FVC - reduced • pleural effusion
C. FVC - increased, FEV1/FVC - increased • pulmonary nodules
D. FEV1 - normal, FEV1/FVC - reduced • bronchiolitis obliterans
E. FVC - reduced, FEV1/FVC – normal • complications of drug therapy e.g. methotrexate
pneumonitis
ANSWER: • pleurisy
FVC - reduced, FEV1/FVC – normal • Caplan's syndrome - massive fibrotic nodules with
occupational coal dust exposure
• infection (possibly atypical) secondary to Q-38
immunosuppression A 71-year-old woman presents with dyspnoea and
haemoptysis for the past two weeks. Clinical examination
Q-36 reveals a loud first heart sound, a diastolic murmur and new-
A 60-year-old woman who has recently been diagnosed with onset atrial fibrillation
chronic obstructive pulmonary disease (COPD) presents for
review. She is still occasionally breathless despite using a ANSWER:
short-acting muscarinic antagonist (SAMA) as required. Her Mitral Stenosis
FEV1 is 45% of predicted and she has managed to stop
smoking. Of the following options, which one is the most Q-39
appropriate next step in management? A 62-year-old woman who is being investigated for renal
impairment presents with haemoptysis. On examination she
A. Switch to a combined short-acting beta2-agonist and has a flat nose
muscarinic antagonist inhaler (e.g. Combivent)
B. Long-acting beta2-agonist ANSWER:
C. Long-acting beta2-agonist + inhaled corticosteroid (ICS) Granulomatosis with polyangitis
in a combination inhaler
D. Inhaled corticosteroid EXPLANATION:
E. Use the SAMA regularly (e.g. 2 puffs qds) HAEMOPTYSIS
The table below lists the main characteristics of the most
ANSWER: important causes of haemoptysis:
Long-acting beta2-agonist + inhaled corticosteroid (ICS) in a
combination inhaler Diagnosis Notes
Lung cancer History of smoking
EXPLANATION: Symptoms of malignancy: weight loss,
Another option here is a long-acting muscarinic antagonist anorexia
(LAMA), for example tiotropium. Please see the 2010 NICE Pulmonary oedema Dyspnoea
Bibasal crackles and S3 are the most reliable
guidelines for more details.
signs
Tuberculosis Fever, night sweats, anorexia, weight loss
Please see Q-2 for COPD: Stable Management
Pulmonary embolism Pleuritic chest pain
Tachycardia, tachypnoea
Q-37 THROUGH 39
Lower respiratory tract Usually acute history of purulent cough
Theme: Haemoptysis infection
Bronchiectasis Usually long history of cough and daily
A. Lung cancer purulent sputum production
B. Pulmonary embolism Mitral stenosis Dyspnoea
C. Goodpasture's syndrome Atrial fibrillation
D. Tuberculosis Malar flush on cheeks
E. Aortic regurgitation Mid-diastolic murmur
F. Mitral stenosis Aspergilloma Often past history of tuberculosis.
G. Coccidiomycosis Haemoptysis may be severe
H. Aspergilloma Chest x-ray shows rounded opacity
I. Granulomatosis with polyangiitis Granulomatosis with Upper respiratory tract: epistaxis, sinusitis,
polyangiitis nasal crusting
J. Bronchiectasis
Lower respiratory tract: dyspnoea,
haemoptysis
Glomerulonephritis
For each of the following scenarios select the most likely Saddle-shape nose deformity
diagnosis: Goodpasture's Haemoptysis
syndrome Systemically unwell: fever, nausea
Q-37 Glomerulonephritis
A 52-year-old man who was born in India presents with
episodic haemoptysis. His only history is tuberculosis as an
adolescent. Chest x-ray shows a rounded opacity in the right Q-40
upper zone surrounded by a rim of air You are assisting a 28-year-old female with smoking
cessation. She has a significant past medical history and is on
ANSWER: several medications for these conditions. Which of the
Aspergilloma
following co-morbidities would not be a contraindication to A. Two arterial blood gases measurements with pO2 < 6.3
prescribing bupropion (Zyban)? kPa
B. One arterial blood gas measurement with pO2 < 7.7 kPa
A past history of anorexia nervosa C. One arterial blood gas measurement with pO2 < 8.3 kPa
Stable angina D. One arterial blood gas measurement with pO2 < 8.0 kPa
Pregnancy E. Two arterial blood gases measurements with pO2 < 7.3
A history of bipolar disorder kPa
Well controlled epilepsy
ANSWER:
ANSWER: Two arterial blood gases measurements with pO2 < 7.3 kPa
Stable angina
EXPLANATION:
EXPLANATION: Please see Q-15 for COPD: Long-term oxygen therapy
Bupropion should be avoided in pregnancy although there is
no information available to substantiate this Q-43
contraindication. Which one of the following markers is most useful for
monitoring the progression of patients with chronic
The BNF lists acute alcohol or benzodiazepine withdrawal; obstructive pulmonary disease?
severe hepatic cirrhosis, CNS tumour; history of seizures,
eating disorders, or bipolar disorder as contraindications to A. FEV1/FVC ratio
bupropion. B. Lifestyle questionnaire
C. Oxygen saturations
Feedback on the January 2016 MRCGP Applied Knowledge D. FEV1
Test (AKT 26) states 'we regularly feed back on issues E. Number of exacerbations per year
concerning safe prescribing, particularly where the clinical
situation is complex, although we had noted an ANSWER:
improvement in AKT 25' FEV1

Please see Q-9 for Smoking Cessation EXPLANATION:

COPD: INVESTIGATION AND DIAGNOSIS
Q-41 NICE recommend considering a diagnosis of COPD in patients
Which one of the following statements regarding smoking over 35 years of age who are smokers or ex-smokers and have
cessation is incorrect? symptoms such as exertional breathlessness, chronic cough or
regular sputum production.
A. Clinicians should not favour one method over another
B. A repeat treatment course should not normally be The following investigations are recommended in patients
offered within 6 months with suspected COPD:
C. Nicotine replacement therapy and varenicline may be • post-bronchodilator spirometry to demonstrate airflow
combined if patients have failed monotherapy obstruction: FEV1/FVC ratio less than 70%
D. Varenicline should be started 1 week before stopping • chest x-ray: hyperinflation, bullae, flat hemidiaphragm.
smoking Also important to exclude lung cancer
E. Flu-like symptoms is a recognised adverse effect of • full blood count: exclude secondary polycythaemia
nicotine replacement therapy • body mass index (BMI) calculation

ANSWER: The severity of COPD is categorized using the FEV1*:

Nicotine replacement therapy and varenicline may be
combined if patients have failed monotherapy Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity
< 0.7 > 80% Stage 1 -
EXPLANATION: Mild**
Please see Q-9 for Smoking Cessation < 0.7 50-79% Stage 2 -
Moderate
Q-42 < 0.7 30-49% Stage 3 -
Which one of the following is the main criteria for Severe
determining whether a patient with chronic obstructive < 0.7 < 30% Stage 4 -
pulmonary disease (COPD) should be offered long-term Very severe
oxygen therapy?
Measuring peak expiratory flow is of limited value in COPD, as corticosteroids, long-acting beta agonists, leukotriene receptor
it may underestimate the degree of airflow obstruction. antagonists, theophyllines, oral corticosteroids, and smoking
cessation if clinically appropriate.
*note that the grading system has changed following the 2010
NICE guidelines. If the FEV1 is greater than 80% predicted but Adverse effects
the post-bronchodilator FEV1/FVC is < 0.7 then this is • abdominal pain
classified as Stage 1 - mild • headache
• fever
**symptoms should be present to diagnose COPD in these • Churg-Strauss syndrome: may present with eosinophilia,
patients vasculitic rash, worsening respiratory symptoms and
peripheral neuropathy
Q-44
One of your patients with difficult to control asthma has Q-45
been started on omalizumab by the respiratory clinic. A 24-year-old man comes to the surgery as he is planning an
expedition to the Andes. He asks for advice on preventing
Which one of the following statements regarding acute mountain sickness (AMS), other than gradual ascent.
omalizumab is correct? What is the most appropriate advice?

A. It causes weight gain in around 10% of patients A. Acetazolamide (Diamox)

B. It is given as an intravenous infusion every 2 months B. Non-steroid anti-inflammatories
C. It can be used in patients aged 6 years and older C. Ensure maximal physical fitness prior to trip
D. Leukotriene receptor antagonists and oral theophyllines D. Dexamethasone starting 2 days prior to arrival
should be stopped once omalizumab is commenced E. There is no evidence of any effective intervention to
E. It is classed as an ultra-long acting bronchodilator prevent AMS

ANSWER: ANSWER:
It can be used in patients aged 6 years and older Acetazolamide (Diamox)

EXPLANATION: EXPLANATION:
Omalizumab is given as a subcutaneous injection every 2 to 4 Acetazolamide, a carbonic anhydrase inhibitor, has an
weeks. It is licensed for patients aged 6 years and older evidence to support its use in preventing AMS. Interestingly,
there actually appears to be a positive correlation between
OMALIZUMAB physical fitness and the risk of developing AMS
Omalizumab is a new drug that is available for the
management of severe asthma. As it's name suggests it's a ALTITUDE RELATED DISORDERS
monoclonal antibody that specifically binds to free human There are three main types of altitude related disorders: acute
immunoglobulin E (IgE). mountain sickness (AMS), which may progress to high altitude
pulmonary edema (HAPE) or high altitude cerebral edema
Omalizumab is given as a subcutaneous injection every 2 to 4 (HACE). All three conditions are due to the chronic hypobaric
weeks. hypoxia which develops at high altitudes

Where does omalizumab fit into current management? Acute mountain sickness is generally a self-limiting condition.
Features of AMS start to occur above 2,500 - 3,000m,
NICE updated their technology appraisal of omalizumab in developing gradually over 6-12 hours and potentially last a
2013. A copy of the criteria is given below. The emphasis in number of days:
bold has been added. • headache
• nausea
Omalizumab is recommended as an option for treating severe • fatigue
persistent confirmed allergic IgE-mediated asthma as an add
on to optimised standard therapy in people aged 6 years and Prevention and treatment of AMS
older: • the risk of AMS may actually be positively correlated to
who need continuous or frequent treatment with oral physical fitness
corticosteroids (defined as 4 or more courses in the previous • gain altitude at no more than 500 m per day
year)
• acetazolamide (a carbonic anhydrase inhibitor) is widely
used to prevent AMS and has a supporting evidence base
Optimised standard therapy is defined as a full trial of and, if
• treatment: descent
tolerated, documented compliance with inhaled high-dose
A minority of people above 4,000m go onto develop high Note that preparations of nicotine replacement therapy are
altitude pulmonary oedema (HAPE) or high altitude cerebral licensed for children over 12 years and there is no
oedema (HACE), potentially fatal conditions contraindication with E-cigarettes.
• HAPE presents with classical pulmonary oedema features
• HACE presents with headache, ataxia, papilloedema Feedback on the April 2015 MRCGP Applied Knowledge Test
(AKT) states that candidates appear to be unfamiliar with
Management of HACE some aspects around substance misuse. They recommend
• descent that if the management of drug abuse does not occur in their
• dexamethasone daily practice, then candidates are encouraged to gain some
experience and knowledge, particularly concerning
Management of HAPE prescribing, to equip them for working in practice.
• descent
• nifedipine, dexamethasone, acetazolamide, Please see Q-9 for Smoking Cessation
phosphodiesterase type V inhibitors*
• oxygen if available Q-47
A 45-year-old man is prescribed bupropion to help him quit
*the relative merits of these different treatments has only smoking. What is the mechanism of action of bupropion?
been studied in small trials. All seem to work by reducing
systolic pulmonary artery pressure A. Nicotinic receptor partial agonist
B. Selective serotonin reuptake inhibitor
Q-46 C. Norepinephrine and dopamine reuptake inhibitor, and
A 15-year-old male is attempting to stop smoking. He nicotinic antagonist
recently smoked 15 cigarettes a day but has managed to cut D. Dopamine agonist
down to 8 cigarettes a day by using an E-cigarette (electronic E. Dopamine antagonist
cigarette). He is also keen to try NRT (nicotine replacement
therapy) to reduce his smoking even further. He asks what ANSWER:
you think about E-cigarettes to aid smoking cessation. Norepinephrine and dopamine reuptake inhibitor, and
Which of the following is likely to be included in your nicotinic antagonist
discussion with him?
EXPLANATION:
A. The short-term data shows no harm with E-cigarettes
but you would update him if evidence of long-term harm Please see Q-9 for Smoking Cessation
starts to emerge
B. The use of NRT (nicotine replacement therapy) is Q-48
contraindicated along with the use of E-cigarettes A 33-year-old man is seen in the asthma clinic. He was
C. Teenagers should actually be encouraged to use E- referred with poorly control asthma and has recently had
cigarettes even if they don't smoke as this reduces the salmeterol added in addition to beclometasone dipropionate
chance of them taking up smoking regular cigarettes inhaler 200mcg bd and salbutamol prn. There has
D. You would advise him to revert back to regular unfortunately been no response to adding the salmeterol.
cigarettes as there is no long-term safety data about E- What is the most appropriate action?
cigarettes
E. It is probably preferable to use E-cigarettes than normal A. Stop salmeterol + trial of leukotriene receptor
cigarettes as the harm is likely to be less antagonist
B. Continue salmeterol + increase beclometasone
ANSWER: dipropionate inhaler to 400 mcg bd
It is probably preferable to use E-cigarettes than normal C. Continue salmeterol + trial of leukotriene receptor
cigarettes as the harm is likely to be less antagonist
D. Stop salmeterol + trial of oral theophylline
EXPLANATION: E. Stop salmeterol + increase beclometasone dipropionate
A recent Cochrane review showed E-cigarettes help smoking inhaler to 400 mcg bd
cessation but there is evidence of harm with short-term use.
Long-term data is still awaited. ANSWER:
Stop salmeterol + increase beclometasone dipropionate
There is emerging concern that teenagers who start with E- inhaler to 400 mcg bd
cigarettes are at risk of going on to smoke regular cigarettes.
EXPLANATION:
Please see Q-12 for Asthma: Management in Adults
Q-49
A 62-year-old woman with recently diagnosed chronic A. Salmeterol inhaler
obstructive pulmonary disease (COPD) presents for review. B. Combined salmeterol + fluticasone inhaler
Her FEV1 is 65% of the predicted value. She has managed to C. Long term oxygen therapy
give up smoking and was prescribed a salbutamol inhaler to D. Betamethasone inhaler
use as required. Despite this she is still symptomatic and E. Oral aminophylline
complains of wheeze and shortness of breath. What is the
most appropriate next step? ANSWER:
Combined salmeterol + fluticasone inhaler
A. Add an inhaled corticosteroid
B. Add a long-acting muscarinic antagonist inhaler EXPLANATION:
C. Refer for consideration of long-term oxygen therapy Following the 2010 NICE guidelines the next step in
D. Add oral theophylline management would be a combined long-acting beta2-
E. Add a combination long-acting beta2-agonist and agonist (LABA) with an inhaled corticosteroid (ICS).
corticosteroid inhaler
Please see Q-2 for COPD: Stable Management
ANSWER:
Add a long-acting muscarinic antagonist inhaler Q-52
You are doing the annual review of a 72-year-old man with
EXPLANATION: chronic obstructive pulmonary disease (COPD). Last year he
Following the 2010 NICE guidelines a long-acting beta2- had three exacerbations of his COPD, one of which resulted
agonist (LABA) would be an alternative option. in him being hospitalised. Today his chest is clear and his
oxygen saturations are 94% on room air. According to NICE
Please see Q-2 for COPD: Stable Management guidelines, what treatment should you offer him?

Q-50 A. A home supply of prednisolone and an antibiotic

A 25-year-old woman with no past medical history of note B. A home supply of prednisolone
attends her 10 week antenatal appointment. She describes C. A home supply of an antibiotic
herself as a 'light smoker' and the carbon monoxide reading D. A home nebuliser
is 12 ppm. Which one of the following interventions that E. Home oxygen
may be offered to pregnant women is most efficacious?
ANSWER:
A. Nicotine replacement therapy A home supply of prednisolone and an antibiotic
B. Fluoxetine
C. Bupropion EXPLANATION:
D. Varenicline In the 2010 NICE guidelines there is a recommendation that
E. Cognitive behavioural therapy patients who have frequency exacerbations of COPD should
be given a home supply of corticosteroids and antbiotics. It is
ANSWER: of course good practice to ask the patient to contact you if
Cognitive behavioural therapy they are required to use them, at least to ensure that no
further action is required. An antibiotic should be only be
EXPLANATION: taken if the patient is coughing up purulent sputum.
Smoking cessation in pregnancy
check all women with a carbon monoxide monitor Please see Q-2 for COPD: Stable Management
CBT/motivational interviewing before NRT
Q-53
Please see Q-9 for Smoking Cessation A 21-year-old man comes for review. Over the past six
months he has experienced a night-time cough and a 'tight-
Q-51 chest' when he tries to exercise. He has a history of hayfever
You review a 60-year-old woman in the COPD clinic. She was and eczema and is a non-smoker.
diagnosed with COPD four years ago and is currently
maintained on a salbutamol inhaler as required and a His symptoms have got progressively and now occur on a
tiotropium inhaler regularly. She has recently managed to daily basis. He is also woken around twice a week due to his
give up smoking and her latest FEV1 was 42% of predicted. breathing.
Despite her current therapy she is have frequent
exacerbations. What is the most appropriate next step in her Spirometry shows FEV1/FVC of 0.65 with a FEV1 72% of
management? predicted.
 C. Nebulised ipratropium bromide
What is the most appropriate course of action? D. Prednisolone 20mg
E. Up to 10 puffs of salbutamol
A. Trial of a salbutamol inhaler + a corticosteroid inhaler
B. Refer to the respiratory clinic ANSWER:
C. Trial of a salbutamol inhaler Up to 10 puffs of salbutamol
D. Ask him to keep a diary of peak flow readings
E. Arrange a chest x-ray EXPLANATION:
There is no need for admission in this case. Up to 10 puffs of
ANSWER: salbutamol would be the first-line option here. Oxygen is not
Trial of a salbutamol inhaler + a corticosteroid inhaler required because his oxygen levels are satisfactory. There is
no need to increase his inhaled steroids during the acute
EXPLANATION: exacerbation. However oral steroids should be given at a
This patient has a 'high' probability of asthma so treatment higher dose of 40mg daily (not 20mg). Nebulised ipratropium
should be started. bromide if he does not respond to the salbutamol.

Please see Q-5 for Asthma: Diagnosis ASTHMA: ASSESSMENT AND MANAGEMENT IN PRIMARY
CARE
Q-54 Patients with acute asthma are stratified into moderate,
A 54-year-old woman with a 30-pack-year history of smoking severe or life-threatening
presents due to increasing breathlessness. A diagnosis of
chronic obstructive pulmonary disease (COPD) is suspected. Moderate Severe Life-threatening
Which of the following diagnostic criteria should be used • PEFR > 50% best or • PEFR 33 - 50% best • PEFR < 33% best or
when assessing a patient with suspected COPD? predicted or predicted predicted
• Speech normal • Can't complete • Oxygen sats < 92%
A. FEV1 > 70% of predicted value + FEV1/FVC < 60% • RR < 25 / min sentences • Silent chest, cyanosis or
• Pulse < 110 bpm • RR > 25/min feeble respiratory effort
B. FEV1/FVC < 70% + symptoms suggestive of COPD
• Pulse > 110 bpm • Bradycardia, dysrhythmia
C. FEV1 < 70% of predicted value + FEV1/FVC < 70% or hypotension
D. FEV1 < 80% of predicted value + FEV1/FVC < 60% • Exhaustion, confusion or
E. FEV1 < 70% of predicted value + FEV1/FVC > 70% coma

ANSWER: Management of moderate asthma

FEV1/FVC < 70% + symptoms suggestive of COPD • beta 2 agonists such as salbutamol, either nebulised or
via a spacer (4-6 puffs, given one at a time and inhaled
EXPLANATION: separately, repeated at intervals of 10-20 minutes)
Please see the 2010 NICE guidelines for further details. • if PEFR between 50-75% then prednisolone 40-50 mg
Patients can now be diagnosed with 'mild' COPD if their FEV1
predicted is > 80% if they have symptoms suggestive of Management of severe asthma
COPD. • consider admission
• oxygen to hypoxaemic patients to maintain a SpO2 of 94-
Please see Q-43 for COPD: investigations and diagnosis 98%
• beta 2 agonists such as salbutamol, either nebulised or
Q-55 via a spacer (4-6 puffs, given one at a time and inhaled
You see a 18-year-old boy who has an exacerbation of his separately, repeated at intervals of 10-20 minutes)
asthma. He usually takes 400 micrograms of Clenil and • prednisolone 40-50 mg
salbutamol as required. • if no response then admit
On examination, his oxygen saturations are 94% in air. His Management of life-threatening asthma
pulse is 84 beats per minute. His chest sounds mildly wheezy
• arrange immediate admission (999 call)
but there are no crackles. He is able to talk in full sentences.
• oxygen to hypoxaemic patients to maintain a SpO2 of 94-
Peak flow measurement is 75% of his predicted.
98%
• nebulised beta 2 agonists (e.g. Salbutamol) + ipratropium
Which of the following options would be most appropriate?
• prednisolone 40-50mg or IV hydrocortisone 100mg
A. Gives 100% oxygen
B. Increase the clenil to 800 micrograms during the acute
exacerbation
Q-56 pneumothorax in healthy smoking men is around 10%
A 26-year-old female presents to the surgery due to an compared with around 0.1% in non-smoking men.
exacerbation of her asthma. On examination her peak flow is
300 l/min (usual 450 l/min) and she can complete sentences. With respect to 'Fitness to fly' rules the CAA suggest patients
Pulse is 90 bpm and the respiratory rate is 18 / min. may travel 2 weeks after successful drainage if there is no
Examination of the chest reveals a bilateral expiratory residual air. The British Thoracic Society used to recommend
wheeze but is otherwise unremarkable. What is the most not travelling by air for a period of 6 weeks but this has now
appropriate management? been changed to 1 week post check x-ray

A. Oxygen + nebulised salbutamol + allow home if settles PNEUMOTHORAX

with follow-up review The British Thoracic Society (BTS) published updated
B. Oxygen + nebulised salbutamol + advise to double guidelines for the management of spontaneous
inhaled steroids + allow home if settles with follow-up pneumothorax in 2010. A pneumothorax is termed primary if
review there is no underlying lung disease and secondary if there is
C. Nebulised salbutamol + prednisolone + allow home if
settles with follow-up review Primary pneumothorax
D. Oxygen + nebulised salbutamol + prednisolone + Recommendations include:
immediate admission • if the rim of air is < 2cm and the patient is not short of
E. Nebulised salbutamol + advise to double inhaled breath then discharge should be considered
steroids + allow home if settles with follow-up review • otherwise aspiration should be attempted
• if this fails (defined as > 2 cm or still short of breath) then
ANSWER: a chest drain should be inserted
Nebulised salbutamol + prednisolone + allow home if settles • patients should be advised to avoid smoking to reduce
with follow-up review the risk of further episodes - the lifetime risk of
developing a pneumothorax in healthy smoking men is
EXPLANATION: around 10% compared with around 0.1% in non-smoking
The British Thoracic Society gives specific recommendations men
on dealing with acute asthma in primary care
Secondary pneumothorax
Please see Q-55 for Asthma: Assessment and Management in Recommendations include:
Primary Care • if the patient is > 50 years old and the rim of air is > 2cm
and/or the patient is short of breath then a chest drain
Q-57 should be inserted.
A 29-year-old man is admitted with sudden onset dyspnoea • otherwise aspiration should be attempted if the rim of air
and pleuritic chest pain. He is a smoker but has no history of is between 1-2cm. If aspiration fails (i.e. pneumothorax is
respiratory disease. He considers himself healthy and still greater then 1cm) a chest drain should be inserted.
regularly plays rugby. On admission he has a chest x-ray that All patients should be admitted for at least 24 hours
shows a pneumothorax with a 3cm rim of air. Aspiration is • if the pneumothorax is less the 1cm then the BTS
successful and he is discharged. A follow-up chest x-ray two guidelines suggest giving oxygen and admitting for 24
weeks later shows a complete resolution. What is the single hours
most important piece of advice to reduce his risk of further • regarding scuba diving, the BTS guidelines state: 'Diving
pneumothoraces? should be permanently avoided unless the patient has
undergone bilateral surgical pleurectomy and has normal
A. Avoid flying for 12 months lung function and chest CT scan postoperatively.'
B. Avoid contact sports for 12 months
C. Stop smoking Iatrogenic pneumothorax
D. Arrange a course of respiratory physiotherapy Recommendations include:
E. Seek prompt medical advice for potential respiratory • less likelihood of recurrence than spontaneous
infections pneumothorax
• majority will resolve with observation, if treatment is
ANSWER:
required then aspiration should be used
Stop smoking
• ventilated patients need chest drains, as may some
patients with COPD
EXPLANATION:
All patients should be advised to avoid smoking to reduce
the risk of further episodes - the lifetime risk of developing a
Q-58
A woman who is 10 weeks pregnant is reviewed in the Q-60
antenatal clinic for her first appointment. On the computer With respect to the NICE Chronic Obstructive Pulmonary
records she is listed as being an 'ex-smoker'. Following Disease guidelines (COPD), what criteria should be used to
recent NICE guidelines, what is the most appropriate way to determine whether patients who are having an excerbation
assess her smoking status? of COPD require antibiotics?

A. Use a 'NHS Smoking Exposure in Pregnancy' A. Those with moderate or severe COPD
questionnaire B. Those who are > 65 years of age or patients with
B. Use a carbon monoxide detector, explaining that all significant comorbidities
women are checked regardless of their declared C. Those with purulent sputum or clinical signs of
smoking status pneumonia
C. Do not enquire any further to prevent causing undue D. All patients
distress to the women E. Those who have had a positive sputum culture
D. Ask the women 'do you or anybody in your household
smoke, and if so how many per day?' ANSWER:
E. Ask the women 'do you or anybody in your household Those with purulent sputum or clinical signs of pneumonia
smoke, and if so how many per day?' + examine fingers
for tar-staining EXPLANATION:
COPD: MANAGEMENT OF ACUTE EXACERBATIONS
ANSWER: The most common bacterial organisms that cause infective
Use a carbon monoxide detector, explaining that all women exacerbations of COPD are:
are checked regardless of their declared smoking status • Haemophilus influenzae (most common cause)
• Streptococcus pneumoniae
EXPLANATION: • Moraxella catarrhalis
Smoking cessation in pregnancy
check all women with a carbon monoxide monitor Respiratory viruses account for around 30% of exacerbations,
CBT/motivational interviewing before NRT with the human rhinovirus being the most important
pathogen.
Please see Q-9 for Smoking Cessation
NICE guidelines from 2010 recommend the following:
Q-59 increase frequency of bronchodilator use and consider giving
A 51-year-old man is noticed to have the following hand via a nebuliser
abnormality: • give prednisolone 30 mg daily for 7-14 days
• it is common practice for all patients with an
exacerbation of COPD to receive antibiotics. NICE do not
support this approach. They recommend giving oral
antibiotics 'if sputum is purulent or there are clinical signs
of pneumonia

Q-61
A 19-year-old who is normally fit and well presents with a
sore throat. A decision is made not to prescribe antibiotics.
How long should he be advised that his illness will last on
Which one of the following is least likely to be responsible? average?

A. Bacterial endocarditis A. 2 days

B. Empyema B. 4 days
C. Fibrosing alveolitis C. 1 week
D. Bullous emphysema D. 10 days
E. Lung cancer E. 2 weeks

ANSWER: ANSWER:
Bullous emphysema 1 week

EXPLANATION:
EXPLANATION:
Please see Q-7 for Respiratory Tract Infections: NICE
Please see Q-25 for Clubbing
Guidelines
Q-62
Which one of the following statements regarding the use of EXPLANATION:
nicotine replacement therapy (NRT) in pregnancy is true? This may be occupational asthma. He should be asked to
complete a peak flow diary and referred to a specialist as per
A. Most studies suggest that NRT reduces birth weight BTS guidelines.
B. Should not be used in women with a history of epilepsy
C. NRT patches should be removed before going to bed Q-65
D. Should be started 2 weeks before a women is planning A 23-year-old woman comes for review. Despite using
to stop smoking beclometasone 200 mcg bd she is regularly having to use her
E. Should not be used in women with a personal or family salbutamol inhaler. Her inhaler technique is good.
history of neural tube defects
ANSWER:
ANSWER: Add inhaled long-acting B2 agonist
NRT patches should be removed before going to bed
EXPLANATION Q-63 THROUGH 65:
EXPLANATION: Please see Q-12 for Asthma: Management in Adults

Please see Q-9 for Smoking Cessation Q-66

A 38-year-old man is reviewed in the respiratory clinic
Q-63 THROUGH 65 complaining of episodic wheezing whilst playing rugby.
Theme: Asthma: stepwise management in adults There is no history of cough, atopy or smoking. He is
generally fit and well and has no past medical history of
A. Add inhaled steroid at 400 mcg/day note. Clinical examination is unremarkable. Following history
B. Increase inhaled steroid to 800 mcg/day and examination it is thought he has an intermediate
C. Increase inhaled steroid to 2000 mcg/day probability of asthma. Which one of the following is the
D. Course of prednisolone for 5 days most appropriate next investigation?
E. Double inhaled steroids until symptoms resolve
F. Add inhaled long-acting B2 agonist A. Spirometry + bronchodilator reversibility test
G. Trial of leukotriene receptor antagonist B. Chest x-ray
H. Refer to specialist C. Histamine stimulation test
I. Admit to hospital D. Methacholine stimulation test
E. A trial of inhaled corticosteroids with FEV1
For each of the following scenarios select the most measurements before and after
appropriate action:
ANSWER:
Q-63 Spirometry + bronchodilator reversibility test
A 30-year-old man who has asthma presents with a 5 day
history of cough and wheeze. He currently takes salbutamol EXPLANATION:
prn and beclometasone 200 mcg bd. His peak flow is 70% of Asthma - intermediate probability - do spirometry first-line
normal The 2016 British Thoracic Society suggest that a combination
of history and examination findings are used to determine
ANSWER: whether a patient has a high, intermediate or low
Course of prednisolone for 5 days probability of asthma. If the patient is determined to have an
intermediate possibility of asthma then a test for airway
EXPLANATION: obstruction should be carried out, such spirometry +
The BTS guidelines advise doctors to 'Give steroids in bronchodilator reversibility. Another option could be serial
adequate doses in all cases of acute asthma.' peak flow measurements.

Q-64 If the FEV1/FVC < 0.7 then a trial of treatment is appropriate.

A 45-year-old man with a five year history of asthma comes Otherwise further investigations should be performed
for review. He currently uses salbutamol prn and a combined
beclometasone + salmeterol inhaler regularly. He mentions Please see Q-5 for Asthma: Diagnosis
that he never gets symptoms at the weekend or whilst on
holiday

ANSWER:
Refer to specialist
Q-67
A 28-year-old woman presents with a persistent cough and Bronchoscopy
feeling of wheeziness after exercising. Which one of the • this allows a biopsy to be taken to obtain a histological
following would make a diagnosis of asthma more likely? diagnosis sometimes aided by endobronchial ultrasound

A. Only gets symptoms after having a viral upper PET scanning

respiratory tract infection • is typically done in non-small cell lung cancer to establish
B. Peripheral pins and needles during an episode eligibility for curative treatment
C. Symptoms worsen after taking aspirin • uses 18-fluorodeoxygenase which is preferentially taken
D. Unexplained neutrophilia on the full blood count up by neoplastic tissue
E. Cough productive of small amounts of clear sputum • has been shown to improve diagnostic sensitivity of both
local and distant metastasis spread in non-small cell lung
ANSWER: cancer
Symptoms worsen after taking aspirin
Q-69
EXPLANATION: A 33-year-old woman is prescribed varenicline to help her
Having a cough productive of sputum, only having symptoms quit smoking. What is the mechanism of action of
after an URTI and peripheral pins and needles all make a varenicline?
diagnosis of asthma less likely.
A. Norepinephrine and dopamine reuptake inhibitor, and
Please see Q-5 for Asthma: Diagnosis nicotinic antagonist
B. Dopamine agonist
Q-68 C. Dopamine antagonist
A 55-year-old man presents to clinic with a persistent cough D. Selective serotonin reuptake inhibitor
and occasional haemoptysis. He has a 40 pack-year history of E. Nicotinic receptor partial agonist
smoking. An urgent chest x-ray is reported as being normal.
In patients who are subsequently diagnosed with lung ANSWER:
cancer, what percentage of recent chest x-rays were Nicotinic receptor partial agonist
reported as normal?
EXPLANATION:
A. 2%
B. 5% Please see Q-9 for Smoking Cessation
C. 10%
D. 20% Q-70
E. 35% A 62-year-old heavy smoker presents with shortness of
breath and a morning cough. A chest x-ray shows
ANSWER: hyperinflated lung fields. Spirometry is organized. Which one
10% of the following set of results would be most consistent with
a diagnosis of chronic obstructive pulmonary disease?
EXPLANATION:
In around 10% of patients subsequently diagnosed with lung FEV1: forced expiratory volume in 1 second
cancer the chest x-ray was reported as normal FVC: forced vital capacity
It is important not to get false reassurance from a normal
chest x-ray report in patients with worrying symptoms A. FEV1 - reduced, FEV1/FVC - normal
(smoker with haemoptysis). This patient should have a CT B. FEV1 - increased, FEV1/FVC - reduced
scan to exclude a lung cancer. C. FEV1 - reduced, FEV1/FVC - reduced
D. FEV1 - normal, FEV1/FVC - reduced
LUNG CANCER: INVESTIGATION E. FEV1 - reduced, FEV1/FVC - increased
Chest x-ray
• this is often the first investigation done in patients with ANSWER:
suspected lung cancer FEV1 - reduced, FEV1/FVC - reduced
• in around 10% of patients subsequently diagnosed with
lung cancer the chest x-ray was reported as normal EXPLANATION:
The history is highly suggestive of chronic obstructive
CT pulmonary disease (COPD), which results in an obstructive
• is the investigation of choice to investigate suspected pattern on spirometry.
lung cancer
Airflow obstruction is defined as a ratio of FEV1/FVC of less Q-73
than 0.7. A 19-year-old with 'brittle asthma' is seen in clinic. Three
weeks ago she started taking prednisolone 15mg od as her
NICE uses the FEV1 (compared to the predicted for asthma was poorly controlled on beclometasone
age/height/gender) to categorise the severity of COPD. dipropionate 800 mcg bd, salmeterol, oral montelukast and
salbutamol as required. She is still having to use her
Please see Q-34 for Pulmonary Function Tests salbutamol inhaler at least twice a day. What should happen
with regards to inhaled steroids?
Q-71
You are reviewing the management of a number of patients A. Continue beclometasone dipropionate 800 mcg bd
with chronic obstructive pulmonary disease (COPD). Which B. Stop inhaled steroids
one of the following factors should prompt an assessment C. Increase beclometasone dipropionate to 1000 mcg bd
for long-term oxygen therapy? D. Decrease beclometasone dipropionate to 400 mcg bd
E. Use beclometasone dipropionate 200 mcg on an 'as
A. Failure to respond to inhaled and/or oral corticosteroids required' basis with salbutamol
B. FEV1/FVC of 0.47
C. Haemoglobin of 10.1 g/dl ANSWER:
D. Anxiety relating to chronic shortness-of-breath Increase beclometasone dipropionate to 1000 mcg bd
E. Ankle oedema
EXPLANATION:
ANSWER: Even when patients are on oral prednisolone they should be
Ankle oedema using high-dose inhaled corticosteroids. This patient should,
of course, be under the care of a respiratory specialist given
EXPLANATION: the severity of her condition.

Please see Q-15 for COPD: Long-term oxygen therapy Please see Q-12 for Asthma: Management in Adults

Q-72 Q-74
A 40-year-old man is investigated for increasing shortness of According to recent NICE guidelines on the management of
breath. He has smoked for the past 25 years. Pulmonary respiratory tract infections, which one of the following
function tests are performed and are reported as follows: patients should not be considered for immediate antibiotic
prescribing:
FEV1 1.4 L (predicted 3.8 L)
A. A 12-year-old who has acute sinusitis and a temperature
FVC 1.7 L (predicted 4.5 L)
of 37.6ºC
FEV1/FVC 82% (normal > 75%)
B. A 23-year-old woman who has acute tonsillitis. Her temp
is 37.8ºC, tonsillar exudate is seen and there is tender
Which one of the following disorders is most consistent with lymph nodes
these results? C. A 5-year-old who has acute otitis media associated with
otorrhoea
A. Asthma D. A 7-month old who has bilateral otitis media and is
B. Bronchiectasis apyrexial
C. Neuromuscular disorder E. An 18-month old who has bilateral otitis media and a
D. Chronic obstructive pulmonary disease temperature of 38.1ºC
E. Laryngeal malignancy
ANSWER:
ANSWER: A 12-year-old who has acute sinusitis and a temperature of
Neuromuscular disorder 37.6ºC

EXPLANATION: EXPLANATION:
These results show a restrictive picture, which may result Antibiotics are not recommended for uncomplicated sinusitis.
from a number of conditions including a neuromuscular
disorder. The other answers cause an obstructive picture. Please see Q-7 for Respiratory Tract Infections: NICE
GUIDELINES
Please see Q-34 for Pulmonary Function Tests
Q-75
A 59-year-old woman presents for review. Around six weeks Consider an urgent chest x-ray (to be performed within 2
ago she was diagnosed with pneumonia after presenting weeks) to assess for lung cancer in people aged 40 and over
with a productive cough and flu-like symptoms. She has no with any of the following:
history of asthma and gave up smoking around three years • persistent or recurrent chest infection
ago after being diagnosed with hypertension. A chest x-ray • finger clubbing
was obtained which was reported as follows: • supraclavicular lymphadenopathy or persistent cervical
lymphadenopathy
Consolidation is seen in the left lower zone. • chest signs consistent with lung cancer
Normal mediastinal outline. No pleural effusion.
Normal heart size
• thrombocytosis

Q-76
She was treated with a 7 day course of amoxicillin which
You are reviewing the management of a number of patients
improved her symptoms. A routine follow-up x-ray is
with chronic obstructive pulmonary disease (COPD). Which
repeated 6 weeks later:
one of the following factors should prompt an assessment
for long-term oxygen therapy?
Consolidation has improved but not resolved in the left lower zone
No suspicious lesion seen.
Normal mediastinal outline. A. FEV1 54% of predicted
B. Haemoglobin of 18.4 g/dl
Her cough is now '80% better' and is now non-productive. C. Body mass index 18.8 kg / m^2
There is no history of haemoptysis and her weight is stable. D. Oxygen saturations of 93% on room air
What is the most appropriate course of action? E. FEV1/FVC of 0.47

A. Repeat the chest x-ray in 6 weeks ANSWER:

B. Give a course of clarithromycin Haemoglobin of 18.4 g/dl
C. Give a course of flucloxacillin + amoxicillin
D. Urgent referral to the chest clinic EXPLANATION:
E. Check serum ACE levels Please see Q-15 for COPD: Long-term Oxygen Therapy

ANSWER: Q-77 THROUGH 79

Urgent referral to the chest clinic Theme: Respiratory tract infections: NICE guidelines

EXPLANATION: A. 2 days
This lady, who is an ex-smoker, has slowly resolving B. 4 days
consolidation and a persistent cough. She should be referred C. 7 days
under the 2 week wait rule to exclude lung cancer. D. 10 days
E. 2 weeks
LUNG CANCER: REFERRAL F. 3 weeks
The 2015 NICE cancer referral guidelines gave the following G. 4 weeks
advice: H. 5 weeks

Refer people using a suspected cancer pathway referral (for For each one of the following respiratory tract infections
an appointment within 2 weeks) for lung cancer if they: select the average total illness length:
• have chest x-ray findings that suggest lung cancer
• are aged 40 and over with unexplained haemoptysis Q-77
Acute otitis media
Offer an urgent chest x-ray (to be performed within 2 weeks)
to assess for lung cancer in people aged 40 and over if they ANSWER:
have 2 or more of the following unexplained symptoms, or if 4 days
they have ever smoked and have 1 or more of the following
unexplained symptoms: Q-78
• cough Acute sore throat
• fatigue
ANSWER:
• shortness of breath
7 days
• chest pain
• weight loss
• appetite loss
Q-79
Acute bronchitis ANSWER:
Morphine sulphate modified release 10 mg twice daily
ANSWER:
3 weeks EXPLANATION:
The patient has end-stage COPD and has himself indicated
EXPLANATION Q-77 THROUGH 79: that control of symptoms is his priority. As such,
Please see Q-7 for Respiratory Tract Infections: NICE consideration of use of opioid or benzodiazepine medications
GUIDELINES for symptomatic relief of breathlessness is appropriate. A
recent prospective study demonstrated that lower dose
Q-80 opioid use (< 30 mg daily oral morphine equivalent) does not
A 72-year-old man was admitted to hospital with an increase risk of hospitalisation or increase mortality in
exacerbation of his longstanding chronic obstructive airways patients with COPD on long-term oxygen therapy. The low
disease. The patient's regular treatment for COPD included dose of modified release morphine sulphate is therefore the
home oxygen, home bronchodilator nebulisers and high- correct answer in this question.
dose inhaled steroids. Normal exercise tolerance was very
limited with the patient becoming profoundly breathless Benzodiazepines were shown to not increase admission rates
after mobilising only short distances around his house. but did increase mortality. The patients packed cell volume is
Following an admission to the intensive care unit for normal; therefore venesection has no role in this case
respiratory support the previous winter the patient had
expressed a wish that he would not want non-invasive Please see Q-2 for COPD: Stable Management
ventilation or intubation in the future and stated that
control of his symptoms was his priority. Q-81
A 58-year-old man is investigated for a chronic cough and is
Treatment with prednisolone, nebulised bronchodilators and found to have lung cancer. He enquires whether it may be
antibiotics was started on admission. Having been work related. Which one of the following is most likely to
profoundly dyspneoic at rest at admission the patient's increase his risk of developing lung cancer?
symptoms improved gradually over the next week until the
patient returned to his baseline of dyspnoea on minimal A. Isocyanates
physical exertion. He again requests if there is any other B. Soldering flux resin
treatments that can ameliorate his symptoms. C. Passive smoking
Recent investigations are summarized below. D. Coal dust
E. Polyvinyl chloride
Forced vital capacity: 115 % predicted
Forced expiratory volume (1s): 34 % predicted ANSWER:
FEV1 / FVC: 30 % predicted Passive smoking

Haemoglobin 170 g / dL EXPLANATION:

Whilst many chemicals have been implicated in the
White cell count 15.8 * 109/l
development of lung cancer passive smoking is the most
Platelets 167 * 109/l
likely cause. Up to 15% of lung cancers in patients who do
Urea 6.7 mmol / L not smoke are thought to be caused by passive smoking
Creatinine 98 micromol / L
LUNG CANCER: RISK FACTORS
Sodium 140 mmol / L

Potassium 4.1 mmol / L Smoking

Packed cell volume 0.42 • increases risk of lung CA by a factor of 10

What treatment is the best choice for relief of dyspnoea in Other factors
this patient? • asbestos - increases risk of lung ca by a factor of 5
• arsenic
A. Morphine sulphate modified release 10 mg twice daily • radon
B. Venesection • nickel
C. Diazepam 2 mg four times daily • chromate
D. Temazepam 10 mg at night • aromatic hydrocarbon
E. Morphine sulphate liquid preparation 20 mg four times • cryptogenic fibrosing alveolitis
daily
Factors that are NOT related fine bibasal crackles. Finger clubbing is noted. Investigations
• coal dust show the following:

Smoking and asbestos are synergistic, i.e. a smoker with B-type natriuretic peptide 88 pg/ml (< 100pg/ml)
asbestos exposure has a 10 * 5 = 50 times increased risk
ECG: sinus rhythm, 72/min
Q-82
A 65-year-old woman is investigated for a 6 week history of Spirometry
worsening shortness of breath, lethargy and weight loss. Her
past medical history includes chronic obstructive pulmonary FEV1 1.57 L (50% of predicted)
disease, hypertension and she is an ex-smoker. Clinical
FVC 1.63 L (39% of predicted)
examination is unremarkable. Investigation results are as
follows: FEV1/FVC 96%

Chest x-ray What is the most likely diagnosis?

Hyperinflated lung fields, normal heart size

A. Primary pulmonary hypertension

Bloods B. Heart failure
Sodium 131 mmol/l C. Chronic obstructive pulmonary disease
Potassium 3.4 mmol/l
D. Idiopathic pulmonary fibrosis
E. Lung cancer
Urea 7.2 mmol/l

Creatinine 101 µmol/l ANSWER:

Hb 10.4 g/dl
Idiopathic pulmonary fibrosis
MCV 91 fl
EXPLANATION:
Plt 452 * 109/l This is a typical history of idiopathic pulmonary fibrosis: a
WBC 3.7 * 109/l male patient aged 50-70 years presenting with progressive
exertional dyspnoea associated with clubbing and a
What is the most appropriate management? restrictive picture on spirometry,

A. Screen for depression The normal B-type natriuretic peptide makes heart failure
B. Short synacthen test extremely unlikely.
C. Urgent referral to the chest clinic
D. Stop bendroflumethiazide IDIOPATHIC PULMONARY FIBROSIS
E. Urgent gastroscopy Idiopathic pulmonary fibrosis (IPF, previously termed
cryptogenic fibrosing alveolitis) is a chronic lung condition
ANSWER: characterised by progressive fibrosis of the interstitium of the
Urgent referral to the chest clinic lungs. Whilst there are many causes of lung fibrosis (e.g.
medications, connective tissue disease, asbestos) the term IPF
EXPLANATION: is reserved when no underlying cause exists.
Despite a normal chest x-ray an ex-smoker with shortness of
breath, weight loss and hyponatraemia should be IPF is typically seen in patients aged 50-70 years and is twice
investigated on an urgent basis for lung cancer. This as common in men.
approach is supported by current NICE guidelines. Whilst
gastrointestinal cancer is a possibility the normal MCV is not Features
entirely consistent with chronic blood loss • progressive exertional dyspnoea
• bibasal crackles on auscultation
Please see Q-75 for Lung cancer: referral • dry cough
• clubbing
Q-83
A 67-year-old man presents with progressive exertional Diagnosis
dyspnoea. These symptoms have been getting progressively • spirometry: classically a restrictive picture (FEV1
worse over the past nine months and are associated with a normal/decreased, FVC decreased, FEV1/FVC increased)
dry cough. He gave up smoking 20 cigarettes/day around 30 • impaired gas exchange: reduced transfer factor (TLCO)
years ago. On examination his oxygen saturations are 97% • imaging: bilateral interstitial shadowing (typically small,
on room air, respiratory rate is 14/min and there are some irregular, peripheral opacities - 'ground-glass' - later
 progressing to 'honeycombing') may be seen on a chest x-
ray but high-resolution CT scanning is the investigation of
choice and required to make a diagnosis of IPF
• ANA positive in 30%, rheumatoid factor positive in 10%
but this does not necessarily mean that the fibrosis is
secondary to a connective tissue disease. Titres are
usually low

Management
• pulmonary rehabilitation
• very few medications have been shown to give any
benefit in IPF. There is some evidence that pirfenidone
(an antifibrotic agent) may be useful in selected patients
(see NICE guidelines) Chest X-ray and CT scan from a patient who presented with dyspnoea. The x-ray
• many patients will require supplementary oxygen and shows reitcular opacities predominantly in the bases. In addition the CT
eventually a lung transplant demonstrates honeycombing and traction bronchiectasis

Prognosis
• poor, average life expectancy is around 3-4 years

CT scan showing advanced pulmonary fibrosis including 'honeycombing'

Q-84
What type of spirometry is recommended by NICE when
investigating a patient with suspected chronic obstructive
pulmonary disease (COPD)?
Chest X-ray shows sub-pleural reticular opacities that increase from the apex to
the bases of the lungs A. Post-bronchodilator spirometry
B. Spirometry following mild-moderate exertion
C. Spirometry after not smoking for 48 hours
D. Pre-bronchodilator spirometry
E. Spirometry with reversibility
ANSWER:
Post-bronchodilator spirometry
EXPLANATION:
Please see the NICE guidelines for more details.
Please see Q-43 for COPD: Investigations and Diagnosis
Q-85
A 24-year-old female presents with episodic wheezing and
shortness of breath for the past 4 months. She has smoked
for the past 8 years and has a history of eczema. Examination
of her chest is unremarkable. Spirometry is arranged and is
reported as normal. What is the most appropriate
management of her symptoms?
A. Peak flow diary The BTS say there is little evidence to separate the different
B. Trial of lansoprazole options available. They do however suggest that leukotriene
C. Baseline FEV1 repeated following inhaled corticosteroids receptor antagonists are least likely to cause side-effects.
D. Arrange a chest x-ray Monitoring of serum concentrations may also be required for
E. Trial of a salbutamol inhaler and low-dose inhaled theophyllines. Given this ladies history of poor attendance
corticosteroid and request for a tablet with the fewest side-effects it seems
reasonable to give her a trial of a leukotriene receptor
ANSWER: antagonist.
Trial of a salbutamol inhaler and low-dose inhaled
corticosteroid Please see Q-12 for Asthma: Management in Adults

EXPLANATION: Q-87
Asthma diagnosis - if high probability of asthma - start A 45-year-old woman who is a known asthmatic comes for
treatment review. In the past two years she has had around six
The new British Thoracic Society guidelines take a more exacerbations of asthma requiring oral steroids. Her current
practical approach to diagnosing asthma. If a patient has medication includes salbutamol 2 puffs prn, salmeterol
typical symptoms of asthma a trial of treatment is 50mcg bd and beclometasone 200 mcg 1 puff bd. You note
recommended. Normal spirometry when the patient is well from the records that her BMI is 31 kg/m^2, she is a non-
does not exclude a diagnosis of asthma. The smoking history smoker and has a good inhaler technique. What is the most
is unlikely to be relevant at her age. appropriate next step in management?

Please see Q-5 for Asthma: Diagnosis A. Increase beclometasone to 200 mcg 2 puffs bd
B. Referral to a dietician
Q-86 C. Add oral theophylline
A 29-year-old woman with a history of asthma presents for D. Add oral montelukast
review. She has recently been discharged from hospital E. Add inhaled tiotropium
following an acute exacerbation and reports generally poor
control with a persistent night time cough and exertional ANSWER:
wheeze. Increase beclometasone to 200 mcg 2 puffs bd

Her current asthma therapy is: EXPLANATION:

salbutamol inhaler 100mcg prn
Clenil (beclometasone dipropionate) inhaler 800mcg bd Please see Q-12 for Asthma: Management in Adults
salmeterol 50mcg bd
Q-88
She has a history of missing appointments and requests a A 65-year-old life-long smoker with a significant past history
medication with as few side-effects as possible. What is the of asbestos exposure is investigated for lung cancer. Given
most appropriate next step in management? his history of both smoking and asbestos exposure, what is
his increased risk of lung cancer?
A. Ipratropium inhaler
B. Low-dose prednisolone A. 5
C. Leukotriene receptor antagonist B. 10
D. Modified-release theophylline C. 50
E. Omalizumab D. 500
E. 1,000
ANSWER:
Leukotriene receptor antagonist ANSWER:
50
EXPLANATION:
This patient is already taking a 'high' dose of inhaled EXPLANATION:
corticosteroid as defined in the guidelines. The British Please see Q-81 for Lung Cancer: Risk Factors
Thoracic Society (BTS) recommend one of 4 options:
leukotriene receptor antagonist
theophylline
B2 agonist tablet
long-acting muscarinic antagonist
Q-89 THROUGH 91 Seen invariably in smokers
Theme: Shortness of breath Chronic obstructive Chronic productive cough is typical
pulmonary disease Features of right heart failure may be seen
A. Heart failure Orthopnoea and paroxysmal nocturnal
B. Recurrent pulmonary emboli dyspnoea are characteristic
Bibasal crackles and a third heart sound (S3)
C. Lung cancer
are the most reliable features of left-sided
D. Obesity failure
E. Pulmonary fibrosis Right heart failure causes peripheral oedema
F. Anaemia and a raised JVP
G. Asthma Asthma Cough, wheeze and shortness of breath are
H. Chronic obstructive pulmonary disease typical
I. Bronchiectasis Symptoms are often worse at night and may be
J. Aortic stenosis precipitated by cold weather or exercise
Associated with hay fever and eczema
Aortic stenosis Chest pain, SOB and syncope seen in
For each one of the following scenarios please select the
symptomatic patients
most likely diagnosis: An ejection systolic murmur radiating to the
neck and narrow pulse pressure are found on
Q-89 examination
A 54-year-old obese woman presents with shortness of Recurrent pulmonary There may be a history of predisposing factors
breath. She currently uses HRT and smokes 20 per day. Chest emboli e.g. Malignancy
auscultation is unremarkable. Spirometry shows an Pleuritic chest pain and haemoptysis may be
obstructive pattern with no reversibility to bronchodilators. seen but symptoms are often vague
Tachycardia and tachypnoea are common in
the acute situation
ANSWER: Symptoms of right heart failure may develop in
Chronic obstructive pulmonary disease severe cases
Lung cancer Normally seen in smokers
EXPLANATION: Haemoptysis, chronic cough or unresolving
The lack of reversibility in response to bronchodilator therapy infection are common presentations
suggests a diagnosis of COPD rather than asthma. Systemic symptoms e.g. Weight loss and
anorexia
Q-90 Pulmonary fibrosis Progressive shortness of breath may be the
only symptom
A 62-year-old man who is currently being treated for
Fine bibasal crackles are typical
colorectal cancer presents with progressive shortness of Spirometry shows a restrictive pattern
breath over the past 2 months. Respiratory examination is
Bronchiectasis Affected patients may produce large amounts
unremarkable other than a respiratory rate of 24 / min. He is of purulent sputum
also noted to have a raised JVP and a pulse rate of 96 / min. Patients may have a history of previous
infections (e.g. Tuberculosis, measles), bronchial
ANSWER: obstruction or ciliary dyskinetic syndromes e.g.
Recurrent pulmonary emboli Kartagener's syndrome
Anaemia There may be a history of gastrointestinal
Q-91 symptoms
Pallor may be seen on examination
A 67-year-old man presents with increasing shortness of
Obesity Obese patients tend to be more SOB due to
breath. His symptoms are worse at night. A third heart
the increased work of activity
sound is noted on examination.
Q-92
ANSWER:
A 42-year-old woman presents with pyrexia and a productive
Heart failure
cough. Around 10 days ago she developed symptoms
consistent with a flu-like illness. For around 4-5 days she was
EXPLANATION Q-89 THROUGH 91:
in bed with myalgia, fever and lethargy. Initially there was an
SHORTNESS OF BREATH: CHRONIC
improvement in her condition but over the past three days
The table below gives characteristic features for conditions
she has developed a cough productive of thick pink-yellow
causing chronic shortness of breath (SOB):
sputum. On examination there are scattered crackles in the
right base. Her symptoms are not severe enough to warrant
Seen invariably in smokers
Chronic obstructive Chronic productive cough is typical
admission and oral amoxicillin is prescribed. Which other
pulmonary disease Features of right heart failure may be seen medication should also be given?
Heart failure A history of ischaemic heart disease or
hypertension may be present
A. Aciclovir
B. Ciprofloxacin Please see Q-7 for Respiratory Tract Infections: NICE
C. Oseltamivir GUIDELINES
D. Flucloxacillin
E. Penicillin V Q-95
You are doing a new patient medical for a 66-year-old man.
ANSWER: He has a history of chronic obstructive pulmonary disease
Flucloxacillin (COPD) which was diagnosed 5 years ago. His only current
medication is a tiotropium inhaler. Despite good
EXPLANATION: concordance with this medication he remains short-of-
There is a high incidence of Staphylococcus aureus breath on minimal exertion. A recent chest x-ray showed no
pneumonia in patients following influenza. As a result the worrying features and his last FEV1 was 58%. What is the
BNF advises the co-prescription of flucloxacillin in such a most appropriate next step in management?
situation.
A. Add a long-acting beta2-agonist (LABA) + inhaled
Please see Q-3 for Pneumonia: Assessment and Management corticosteroid (ICS) inhaler
B. Add a short-acting beta2-agonist (SABA)
Q-93 C. Switch to a long-acting beta2-agonist (LABA)
A 69-year-old woman who has a long history of COPD D. Add a short-acting muscarinic antagonist (SAMA)
phones for advice. For the past two days she has felt more E. Add an inhaled corticosteroid (ICS) inhaler
short-of-breath and is using her inhalers more. She is
coughing up clear sputum. There is no fever, haemoptysis or ANSWER:
chest pain. She is unsure whether to take her 'rescue' Add a long-acting beta2-agonist (LABA) + inhaled
medications. What is the most appropriate advice? corticosteroid (ICS) inhaler

A. Hold-off the rescue medications for now, review in 24 EXPLANATION:

hours If you follow the NICE COPD treatment algorithm it is not
B. Take a course of prednisolone uncommon for patients to be only taking a LAMA such as
C. Take a course of prednisolone + the antibiotic tiotropium as it is recommended to stop the SAMA after
D. Arrange a 7 day loan of a home nebuliser commencing a LAMA. The next step for patients on LAMA
E. Take the antibiotic monotherapy would be to add a long-acting beta2-agonist
(LABA) + inhaled corticosteroid (ICS) inhaler, regardless of
ANSWER: the FEV1.
Take a course of prednisolone
Please see Q-2 for COPD: Stable Management
EXPLANATION:
NICE only recommend adding in an antibiotic if the sputum is Q-96
purulent. An 18-month-old boy is brought to the surgery by his Mum.
He has previously been prone to recurrent otitis media and
Please see Q-2 for COPD: Stable Management has been touching his left ear a lot over the last 3 days.
Q-94 Overnight he was unsettled, febrile and has developed an
A 34-year-old man complains of a sore throat. Which one of erythematous boggy swelling behind his left ear which is
the following is not part of the Centor criteria used to assess protruding more than on the right. On examination, the child
the likelihood of a bacterial cause? is miserable, his temperature is 39.2ºC, heart rate is 170
beats/minute and respiratory rate is 28 breaths/minute. You
A. Fever struggle to examine his ears due to distress but the right ear,
B. Tender anterior cervical lymphadenopathy canal and tympanic membrane are normal. From what you
C. Duration > 5 days can see on the left, the ear canal and tympanic membrane
D. Absence of cough are red. What is the most likely diagnosis?
E. Presence of tonsillar exudate
A. Lymphadenitis
ANSWER: B. Acute otitis media
Duration > 5 days C. Mastoiditis
D. Trauma
EXPLANATION: E. Parotid swelling
If 3 or more of the 4 Centor criteria are present there is a 40-
60% chance the sore throat is caused by Group A beta- ANSWER:
haemolytic Streptococcus Mastoiditis
EXPLANATION: EXPLANATION:
Mastoiditis is a serious bacterial infection. It mainly affects This patient has a community acquired pneumonia which is a
children and often occurs secondary to prolonged otitis common presentation on the acute medical take (Incidence:
media. The infection may cause the porous bone to break 5-11/1000). Patients typically present with a productive
down; severe infection may require intravenous antibiotics cough, fevers, shortness of breath, anorexia, rigors and may
and surgery. Acute otitis media is an infection of the inner report pleuritic chest pain and haemoptysis. Community
ear and does not usually present with swelling, however, acquired pneumonia may be primary or secondary to
mastoiditis can result from otitis media. In this patient, there underlying disease.
is no history of trauma to cause the swelling described,
which is also in the incorrect location to be a parotid Please see Q-3 for Pneumonia: Assessment and Management
swelling. Lymphadenitis may result in an erythematous
swelling, usually described as soft, fluctuant and tender Q-98
which may be found post auricularly but not over the You are seeing a patient whom you suspect may have
mastoid process. (AKT report October 2016) chronic obstructive pulmonary disease (COPD). Which one of
the following points/investigation is least relevant?
Please see Q-7 for Respiratory Tract Infections: NICE
GUIDELINES A. Smoking history
B. Chest x-ray
Q-97 C. Full blood count
A 67 year old gentleman presents with a three day history of D. Peak expiratory flow
a productive cough. He complains that over the last two days E. Spirometry
he has been progressively more short of breath, He
complains of feeling very weak and lethargic and on further ANSWER:
questioning reports fevers and rigors. His wife brought him Peak expiratory flow
to the community Emergency Medical Unit (EMU) as she was
concerned as he appeared to be deteriorating rapidly. EXPLANATION:
Peak expiratory flow is of no value in the diagnosis of COPD
Observations are: heart rate 125 beats per minute,
respiratory rate 32 breaths per minute, Sa02 90% on room Please see Q-43 for COPD: investigations and diagnosis
air, temperature 38.9º, blood pressure is 130/84 mmHg.
Q-99 THROUGH 101
He appears distressed but is not confused. Theme: Shortness of breath

Initial investigations show: A. Heart failure

B. Recurrent pulmonary emboli
Hb 134 g/l C. Lung cancer
D. Obesity
Platelets 550 * 109/l
E. Pulmonary fibrosis
WBC 18 * 109/l
F. Anaemia
G. Asthma
Na+ 141 mmol/l H. Chronic obstructive pulmonary disease
I. Bronchiectasis
K+ 3.7 mmol/l
J. Aortic stenosis
Urea 9.2 mmol/l

Creatinine 130 µmol/l For each one of the following scenarios please select the
CXR shows left lower zone consolidation. most likely diagnosis:

From the above information what is his CURB-65 score? Q-99

A 42-year-old smoker presents with chronic cough and
A. 1 shortness of breath. He describes bringing up copious
B. 2 amounts of sputum each morning. Chest x-ray shows
C. 3 numerous parallel line shadows.
D. 4
E. 5 ANSWER:
Bronchiectasis
ANSWER:
3
EXPLANATION: Please see Q-55 for Asthma: Assessment and Management in
Parallel line shadows (often called tram-lines) are common in Primary Care
bronchiectasis and indicate dilated bronchi due to
peribronchial inflammation and fibrosis. Q-103
You are asked to interpret the post-bronchodilator
Q-100 spirometry results of a 56-year-old woman who has been
A 71-year-old man who is being investigated for recurrent complaining of progressive shortness-of-breath.
collapse presents with progressive shortness of breath. His
pulse is 84 / min and blood pressure 110/90 mmHg. FEV1/FVC 0.60

FEV1% predicted 60%

ANSWER:
Aortic stenosis
What is the most appropriate interpretation of these
Q-101 results?
A 73-year-old man presents with shortness of breath. He
smokes 20 / day but is otherwise well. Spirometry shows a A. Poor technique - repeat spirometry
restrictive picture. B. Asthma
C. COPD (stage 1 - mild)
ANSWER: D. COPD (stage 2 - moderate)
Pulmonary fibrosis E. Pulmonary fibrosis

EXPLANATION Q-99 THROUGH 101: ANSWER:

Please see Q-91 for Shortness of Breath: Chronic COPD (stage 2 - moderate)

Q-102 EXPLANATION:
A 24-year-old female with a history of asthma presents to Please see Q-43 for COPD: investigation and diagnosis
the surgery complaining of being 'tight-chested'. On
examination breath sounds are quiet bilaterally and oxygen Q-104
saturations are 91%. The pulse is 90 bpm and her respiratory A 66 year-old gentleman with a diagnosis of chronic
rate is 18 / min. She doesn't want to do a peak flow as she obstructive pulmonary disease (COPD) is reviewed in
says it makes her feel more short of breath. What is the most respiratory clinic. He complains of persistent breathlessness
appropriate management? on exertion. There is no significant history of cough.

A. Nebulised salbutamol + prednisolone + allow home if Pulmonary function testing reveals:

settles with follow-up review
B. Oxygen + nebulised salbutamol + advise to double SpO2 90%

inhaled steroids + allow home if settles with follow-up FVC 2.8L

review FEV1 1.47 (40% predicted)
C. Nebulised salbutamol + advise to double inhaled
FEV1/FVC ratio 53%
steroids + allow home if settles with follow-up review
D. Oxygen + nebulised salbutamol + allow home if settles
with follow-up review The patient is currently prescribed a short-acting beta-2
E. Oxygen + nebulised salbutamol + prednisolone arrange agonist along with a combination inhaler containing a long-
immediate admission to A&E via ambulance acting beta-2 agonist and corticosteroid. What is the most
appropriate additional medication?
ANSWER:
Oxygen + nebulised salbutamol + prednisolone arrange A. Inhaled tiotropium
immediate admission to A&E via ambulance B. Oral modified-release aminophylline
C. Short-acting muscarinic agonist
EXPLANATION: D. Oral prednisolone
A quiet chest and hypoxia are signs of life-threatening E. Oral roflumilast
asthma. The British Thoracic Society give specific
recommendations on dealing with acute asthma in primary ANSWER:
care - please see the link Inhaled tiotropium

Remember that the pulse and respiratory may actually drop EXPLANATION:
in life-threatening asthma This question highlights the stepwise approach to the
management of stable COPD.
 Q-107
After a short-acting beta 2 agonist (SABA) (or short acting Which one of the following medications is most useful for
muscarinic antagonist (SAMA)): helping to prevent attacks of Ménière’s disease?
If FEV1 is >50% predicted offer either a long-acting
antimuscarinic bronchodilator (LAMA) or a long-acting beta- A. Promethazine
2 agonist (LABA) B. Prochlorperazine
If FEV1 is <50% predicted offer either a long-acting C. Betahistine
antimuscarinic bronchodilator (LAMA) or a combination D. Chlorphenamine
inhaler containing long-acting beta-2 agonist (LABA) and E. Cinnarizine
corticosteroid
(discontinue SAMA if a LAMA is started) ANSWER:
Betahistine
Any patient that remains breathless or continues to have
exacerbations should be offered triple therapy with a EXPLANATION:
combination inhaler containing LABA and corticosteroid plus MÉNIÈRE’S DISEASE
a LAMA (e.g. tiotropium) Ménière’s disease is a disorder of the inner ear of unknown
cause. It is characterised by excessive pressure and
Please see Q-2 for COPD: Stable Management progressive dilation of the endolymphatic system. It is more
common in middle-aged adults but may be seen at any age.
Q-105 Ménière’s disease has a similar prevalence in both men and
A 60-year-old man is diagnosed with idiopathic pulmonary women.
fibrosis after presenting with an 18 month history of
progressive dyspnoea. His latest FVC is 60% of predicted. Features
What is the average life expectancy for such a patient? • recurrent episodes of vertigo, tinnitus and hearing loss
(sensorineural). Vertigo is usually the prominent
A. 3-6 months symptom
B. 6-12 months • a sensation of aural fullness or pressure is now
C. 12-18 months recognised as being common
D. 3-4 years • other features include nystagmus and a positive Romberg
E. 8-12 years test
• episodes last minutes to hours
ANSWER: • typically symptoms are unilateral but bilateral symptoms
3-4 years may develop after a number of years

EXPLANATION: Natural history

Please see Q-83 for Idiopathic Pulmonary Fibrosis • symptoms resolve in the majority of patients after 5-10
years
Q-106 • the majority of patients will be left with a degree of
A 23-year-old female is commenced on varenicline to help hearing loss
her stop smoking. Which one of the following adverse effects • psychological distress is common
is most likely to occur?
Management
A. Vivid dreams • ENT assessment is required to confirm the diagnosis
B. Nausea
• patients should inform the DVLA. The current advice is to
C. Constipation
cease driving until satisfactory control of symptoms is
D. Insomnia
achieved
E. Drug-induced lupus
• acute attacks: buccal or intramuscular prochlorperazine.
Admission is sometimes required
ANSWER:
• prevention: betahistine and vestibular rehabilitation
Nausea
exercises may be of benefit
EXPLANATION:
Q-108
Whilst all of the above adverse effects may occur nausea is
A 37 year old man presents to your clinic with otalgia. He
the most common
was seen in the emergency department 2 days previously
but was discharged with advice only. He has now had otalgia
Please see Q-9 for Smoking Cessation
for 5 days.
On examination, he has a temperature of 38.5ºC, and he has Q-109
a red bulging ear drum on the right. How should you manage You see a 40-year-old man with reduced hearing on the right
this gentleman? side. You examine his ears and note the right ear canal is
blocked with wax but the left ear is clear. What would be the
A. Advise on regular paracetamol and return if no better expected findings on testing Rinne and Weber?
B. Start erythromycin
C. Start penicillin V A. Weber: sound localises to the left; Rinne: negative on
D. Start amoxicillin the right and positive on the left
E. Start co-amoxiclav B. Weber: sound localises to the right; Rinne: negative on
the right and positive on the left
ANSWER: C. Weber: sound localises to the right; Rinne: positive on
Start amoxicillin the right and positive on the left
D. Weber: sound localises to the left; Rinne: positive on the
EXPLANATION: right and positive on the left
This is a case of otitis media. Although 50% of these cases E. Weber: sound is heard centrally; Rinne: negative on the
are viral, and 60% improve without antibiotics, guidelines right and positive on the left
would advocate treatment after a delay of 2-3 days if there
is no improvement in symptoms. Especially in this case,
where the gentleman has a temperature and therefore ANSWER:
evidence of systemic involvement. Therefore, advising Weber: sound localises to the right; Rinne: negative on the
regular paracetamol is not correct in this case. right and positive on the left

Erythromycin is a useful alternative to patients who are EXPLANATION:

penicillin allergic, and especially as a syrup in children (as it The Rinne and Weber tests are used to distinguish conductive
costs less that some alternatives!) but would not be first line from sensorineural hearing loss.
in someone who can take penicillin.
This gentleman has wax blocking the right ear canal, so you
Penicillin V is the first line antibiotic for tonsillitis due to would expect to find a conductive hearing loss on the right
amoxicillin having the potential to cause a rash in cases of side.
glandular fever. However, it is not generally used in otitis
media. When performing the Weber test, the patient should localise
the sound to the side of a conductive hearing loss, as bone
Amoxicillin is the correct first line medication for treating conduction is increased. The sound will localise away from a
otitis media at 500mg TDS for 7 days. sensorineural hearing loss.

Co-amoxiclav is used as a second line agent if amoxicillin The Rinne test is negative if there is a conductive hearing
doesn't work, but wouldn't be used first line according to loss, as bone conduction is better than air conduction. It is
current guidelines. positive if air conduction is better than bone conduction,
which can be the case for mild-moderate sensorineural
OTITIS MEDIA hearing loss or if there is normal hearing.
Antibiotics should be prescribed immediately if:
• Symptoms lasting more than 4 days or not improving In this case, the wax causes a conductive hearing loss on the
• Systemically unwell but not requiring admission right side, so when performing the Weber test sound should
• Immunocompromise or high risk of complications localise to the right, and Rinne should be negative on the
secondary to significant heart, lung, kidney, liver, or right side and positive on the left.
neuromuscular disease
• Younger than 2 years with bilateral otitis media RINNE'S AND WEBER'S TEST
• Otitis media with perforation and/or discharge in the Performing both Rinne's and Weber's test allows
canal differentiation of conductive and sensorineural deafness.

If an antibiotic is given, a 5-day course of amoxicillin is first Rinne's test

line. In patients with penicillin allergy, erythromycin or • tuning fork is placed over the mastoid process until the
clarithromycin should be given. sound is no longer heard, followed by repositioning just
over external acoustic meatus
• air conduction (AC) is normally better than bone
conduction (BC)
• if BC > AC then conductive deafness
 Q-111 THROUGH 113
Weber's test Theme: Vertigo
• tuning fork is placed in the middle of the forehead
equidistant from the patient's ears A. Acoustic neuroma
• the patient is then asked which side is loudest B. Viral labyrinthitis
• in unilateral sensorineural deafness, sound is localised to C. Ménière’s disease
the unaffected side D. Multiple sclerosis
• in unilateral conductive deafness, sound is localised to E. Vertebrobasilar ischaemia
the affected side F. Ramsey-Hunt syndrome
G. Benign paroxysmal positional vertigo
Q-110 H. Otitis media
Which one of the following patients is most likely to have
nasal polyps? For each one of the following scenarios select the most likely
diagnosis:
A. A 40-year-old man
B. A 40-year-old woman Q-111
C. An 8-year-old girl A 62-year-old man with a 3 month history of dizziness when
D. An 80-year-old woman he rolls over in bed. Episodes last for about 20 seconds
E. An 8-year-old boy
ANSWER:
ANSWER: Benign paroxysmal positional vertigo
A 40-year-old man
Q-112
EXPLANATION: A 51-year-old female with a 3 week history of vertigo, right
Nasal polyps are most common in male adults ear tinnitus and the sensation of fullness in her right ear. On
testing, there is noted to be right-sided hearing loss affecting
NASAL POLYPS low frequencies.
Around in 1% of adults in the UK have nasal polyps. They are
around 2-4 times more common in men and are not ANSWER:
commonly seen in children or the elderly. Ménière’s disease

Associations EXPLANATION:
• asthma* (particularly late-onset asthma) Acoustic neuroma is a differential and a MRI may be indicated
• aspirin sensitivity*
• infective sinusitis Q-113
• cystic fibrosis A 33-year-old with coryzal symptoms presents with a one
• Kartagener's syndrome day history of vertigo and nausea. There is no hearing loss on
examination.
• Churg-Strauss syndrome
ANSWER:
Features
Viral labyrinthitis
• nasal obstruction
• rhinorrhoea, sneezing
EXPLANATION Q-111 THROUGH 113:
• poor sense of taste and smell
VERTIGO
Vertigo may be defined as the false sensation that the body or
Unusual features which always require further investigation
environment is moving.
include unilateral symptoms or bleeding.
The table below lists the main characteristics of the most
Management
important causes of vertigo
• all patients with suspected nasal polyps should be
referred to ENT for a full examination
• topical corticosteroids shrink polyp size in around 80% of
Disorder Notes
patients
Viral labyrinthitis Recent viral infection
Sudden onset
*the association of asthma, aspirin sensitivity and nasal Nausea and vomiting
polyposis is known as Samter's triad Hearing may be affected
Vestibular neuronitis Recent viral infection
Recurrent vertigo attacks lasting hours or
Disorder Notes
days EXPLANATION:
No hearing loss This man has acute necrotizing ulcerative gingivitis with
Benign paroxysmal Gradual onset systemic upset. Treatment should be commenced whilst he is
positional vertigo Triggered by change in head position awaiting to see a dentist.
Each episode lasts 10-20 seconds
Ménière’s disease Associated with hearing loss, tinnitus and 'Gingivitis and common dental problems' are listed in the
sensation of fullness or pressure in one or
curriculum under statement 15.4.
both ears
Vertebrobasilar ischaemia Elderly patient
Dizziness on extension of neck
GINGIVITIS
Gingivitis is usually secondary to poor dental hygiene. Clinical
Acoustic neuroma Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign presentation may range from simple gingivitis (painless, red
Associated with neurofibromatosis type 2 swelling of the gum margin which bleeds on contact) to acute
necrotizing ulcerative gingivitis (painful bleeding gums with
Other causes of vertigo include halitosis and punched-out ulcers on the gums).
• trauma
• multiple sclerosis If a patient presents with acute necrotizing ulcerative
• ototoxicity e.g. gentamicin gingivitis CKS recommend the following management:
• refer the patient to a dentist, meanwhile the following is
Q-114 recommended:
A 34-year-old woman with recurrent vertigo is referred to • oral metronidazole* for 3 days
ENT and diagnosed with Ménière’s disease. What is the most • chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6%
appropriate advice with regards to the DVLA? mouth wash
• simple analgesia
A. Inform the DVLA, cannot drive for 4 weeks from
diagnosis *the BNF also suggest that amoxicillin may be used
B. Inform the DVLA, no restriction
C. Inform the DVLA, cannot drive for one week after each Q-116
acute episode A 60 year-old man presents with a two month history of
D. No need to inform the DVLA nasal blockage on the right side, which is now beginning to
E. Inform the DVLA, cannot drive until satisfactory control disrupt his sleep. He has not noticed any bleeding but has
of symptoms is achieved had postnasal drip. On examination you see a polyp on the
right side and an inflamed mucosa bilaterally. What is the
ANSWER: most appropriate management?
Inform the DVLA, cannot drive until satisfactory control of
symptoms is achieved A. Start saline nasal douche and review in 6 weeks
B. Start intranasal steroids and review in 6 weeks
EXPLANATION: C. Start saline douche and intranasal steroid and review in
Please see Q-107 for Ménière’s disease 6 weeks
D. Start antihistamine and intranasal steroid and review in
Q-115 6 weeks
A 21-year-old man presents with halitosis and mouth pain. E. Refer to ENT
Examination reveals very poor dental hygiene with bleeding
gums and widespread gingival ulceration. He has a ANSWER:
temperature of 38.0ºC. You advise him to see a dentist. Refer to ENT
What other treatment options should be offered?
EXPLANATION:
A. Paracetamol + oral phenoxymethylpenicillin This patient has a unilateral nasal polyp. Polyps due to
B. Paracetamol + oral phenoxymethylpenicillin + rhinosinusitis are usually bilateral so it is important to refer
chlorhexidine mouthwash this gentleman to be seen by an ENT doctor to exclude
C. Paracetamol + chlorhexidine mouthwash malignancy.
D. Paracetamol + oral metronidazole + chlorhexidine
mouthwash If small bilateral nasal polyps are seen these can be treated
E. Paracetamol + oral metronidazole in primary care with a saline nasal douche and intranasal
steroids, but if they are causing significant obstruction
ANSWER: patients should be referred to ENT.
Paracetamol + oral metronidazole + chlorhexidine mouthwash Please see Q-110 for Nasal Polyps
Q-117 audiometry testing and to arrange an MRI to exclude an
A 25 year old man presents with a four day history of acoustic neuroma. Intra-tympanic steroids can also be given
anorexia, feverishness and vertigo. He has had intermittent if there is no response to oral steroids.
difficulty balancing and staying upright when walking and
has had episodes of mild vertigo lasting 10-20 minutes at a Aciclovir is not routinely recommended as there is no
time. His hearing is unimpaired. On examination he has evidence of benefit.
some cervical lymphadenopathy. Examination is otherwise
unremarkable. What is the likely diagnosis? Please see Q-109 for Rinne’s and Weber’s Test

A. Ménière’s disease Q-119

B. Benign Paroxysmal Positional Vertigo A 23-year-old man is diagnosed as having nasal polyps.
C. Otitis media Sensitivity to which medication is associated with this
D. Vestibular neuronitis condition?
E. Multiple sclerosis
A. Sulfa drugs
ANSWER: B. ACE inhibitors
Vestibular neuronitis C. Penicillins
D. Paracetamol
EXPLANATION: E. Aspirin
Vestibular neuronitis may be preceded by viral symptoms.
Vestibular neuronitis is associated with spontaneous onset ANSWER:
vertigo and imbalance often associated with nausea and Aspirin
vomiting. Unlike labyrinthitis it does not cause tinnitus or
hearing loss. EXPLANATION:
Please see Q-110 for Nasal Polyps
Urgent referral should be considered with any of the
following red flags: Neurological symptoms or signs, acute Q-120
deafness, new type or new onset headache, vertical Which one of the following is least recognised in patients
nystagmus. with Ménière’s disease

Please see Q-111 THROUGH 113 for Vertigo A. Aural fullness

B. Symptoms triggered by sudden change in head position
Q-118 C. Sensorineural hearing loss
A 25 year-old man presents with a history of sudden hearing D. Tinnitus
loss on the right side. He had no preceding coryzal illness, E. Nystagmus
fevers, headache or ear pain. On examination his ear canal ANSWER:
and tympanic membrane appear normal. Weber testing Symptoms triggered by sudden change in head position
localises to the left side. What is the appropriate
management? EXPLANATION:
Please see Q-107 for Ménière’s disease
A. Refer routinely to ENT
B. Watch and wait Q-121
C. Refer urgently to ENT and start high dose oral steroids You see a 3-year-old boy as a follow-up appointment. Two
D. Start oral aciclovir and high dose steroids weeks ago he presented with left-sided otalgia associated
E. Start decongestant nasal spray and intranasal steroids with a purulent discharge. You prescribed amoxicillin and
arranged to see him today. His mum reports that he is much
ANSWER: better and says she has managed to keep the ear dry. On
Refer urgently to ENT and start high dose oral steroids examination of the left side a perforation of the tympanic
membrane is noted. What is the most appropriate action?
EXPLANATION:
This man has sudden sensorineural hearing loss, which in the A. Advise to keep ear dry and see in a further 4 weeks time
vast majority of cases is idiopathic. B. Prescribe gentamicin ear drops to prevent infection +
see in a further 6 weeks time
There is some evidence that high dose steroids (60mg/day) C. Advise to keep ear dry and see in a further 12 weeks
for seven days improves prognosis, so all patients should time
start treatment as soon as possible. ENT assessment should D. Refer to ENT
be arranged as soon as possible to allow pure tone E. Prescribe prophylactic dose amoxicillin to prevent
infection + see in a further 4 weeks time
 EXPLANATION:
ANSWER: The Modified Centor criteria help guide management of sore
Advise to keep ear dry and see in a further 4 weeks time throats by estimating the probability of the patient having
streptococcal pharyngitis. A point is given for each of:
EXPLANATION: • History of fever
When he presented initially with the perforation this boy • Tonsillar exudates
was given amoxicillin which is consistent with NICE • Tender anterior cervical lymphadenopathy
guidelines. There is no indication for continuing the • Absence of cough
antibiotics if the ear is dry. • Age <15 add 1 point
• Age >44 subtract 1 point
If there is still a perforation when the boy is reviewed in 4
weeks time (i.e. 6 weeks since the perforation occurred) then Antibiotics are recommended for 3 or more points. The first
ENT referral should be considered. line antibiotic would be penicillin V.
This patient has a total of 1 point only warranting
PERFORATED TYMPANIC MEMBRANE paracetamol only. For scores of 2-3 a throat swab may be
The most common cause of a perforated tympanic membrane performed and antibiotics given if Group A Streptococcus is
is infection. Other causes include barotrauma or direct grown.
trauma.
SORE THROAT
A perforated tympanic membrane may lead to hearing loss Sore throat encompasses pharyngitis, tonsillitis, laryngitis
depending on the size and also increase the risk of otitis
media. Clinical Knowledge Summaries recommend:
• throat swabs and rapid antigen tests should not be
Management carried out routinely in patients with a sore throat
• no treatment is needed in the majority of cases as the
tympanic membrane will usually heal after 6-8 weeks. It is Management
advisable to avoid getting water in the ear during this • paracetamol or ibuprofen for pain relief
time • antibiotics are not routinely indicated
• it is common practice to prescribe antibiotics to • there is some evidence that a single dose of oral
perforations which occur following an episode of acute corticosteroid may reduce the severity and duration of
otitis media. NICE support this approach in the 2008 pain, although this has not yet been incorporated into UK
Respiratory tract infection guidelines guidelines*
• myringoplasty may be performed if the tympanic
membrane does not heal by itself NICE indications for antibiotics
• features of marked systemic upset secondary to the acute
Q-122 sore throat
You see a 48 year old man who has no past medical history • unilateral peritonsillitis
of note. He has a two day history of a sore throat, non-
• a history of rheumatic fever
productive cough and feverishness. His allergies are listed as
• an increased risk from acute infection (such as a child
macrolides and quinolones. On examination he appears well
with diabetes mellitus or immunodeficiency)
but he has swollen tonsils with a few specks of white
• patients with acute sore throat/acute pharyngitis/acute
exudate on the surface. He has no lymphadenopathy, a clear
tonsillitis when 3 or more Centor criteria are present
chest and demonstrates a dry cough. His observations are:
blood pressure 131/74 mmHg, pulse 82 bpm, respiratory
The Centor criteria** are as follows:
rate 14/min, temperature 38.1ºC. What is the best
• presence of tonsillar exudate
management?
• tender anterior cervical lymphadenopathy or
A. Clarithromycin lymphadenitis
B. Paracetamol • history of fever
C. Blood monospot • absence of cough
D. Amoxicillin
E. Penicillin V If antibiotics are indicated then either
phenoxymethylpenicillin or erythromycin (if the patient is
ANSWER: penicillin allergic) should be given. Either a 7 or 10 day course
Paracetamol should be given

* the evidence was summarised in the following paper: BMJ

2017;358:j4090
** if 3 or more of the criteria are present there is a 40-60% Q-124
chance the sore throat is caused by Group A beta-haemolytic You review a 25-year-old man who has allergic rhinitis. He
Streptococcus has been using intranasal oxymetazoline which he bought
from the local chemist for the past 10 days. What is the main
Q-123 side-effect of using topical decongestants for prolonged
A 59-year-old man presents with recurrent attacks of vertigo periods?
and dizziness. These attacks are often precipitated by a
change in head position and typically last around half a A. Permanent loss of smell
minute. Examination of the cranial nerves and ears is B. Infective sinusitis
unremarkable. His blood pressure is 120/78 mmHg sitting C. Post-nasal drip
and 116/76 mmHg standing. Given the likely underlying D. Tachyphylaxis
disorder, what is the most appropriate next step to help E. Necrosis of the nasal septum
confirm the diagnosis?
ANSWER:
A. Epley manoeuvre Tachyphylaxis
B. Tilt table test EXPLANATION:
C. 24 hour ECG monitoring After using topical decongestants for prolonged periods
D. MRI of the cerebellopontine angle increasing doses are needed to provide the same effect, a
E. Dix-Hallpike manoeuvre phenomenon known as tachyphylaxis.
ANSWER: The January 2010 AKT feedback report stated 'Increasingly,
Dix-Hallpike manoeuvre patients are encouraged to self-manage conditions, perhaps
with advice from a pharmacist. Candidates did not perform
EXPLANATION: well with regard to issues related to over the counter
This patient has classical symptoms of benign paroxysmal medication, such as side-effects and contraindications.'
positional vertigo. A positive Dix-Hallpike manoeuvre is an
appropriate next step and would help support the diagnosis. ALLERGIC RHINITIS
Allergic rhinitis is an inflammatory disorder of the nose where
The change in blood pressure on standing is not significant. the nose become sensitized to allergens such as house dust
mites and grass, tree and weed pollens. It may be classified as
BENIGN PAROXYSMAL POSITIONAL VERTIGO follows, although the clinical usefulness of such classifications
Benign paroxysmal positional vertigo (BPPV) is one of the remains doubtful:
most common causes of vertigo encountered. It is • seasonal: symptoms occur around the same time every
characterised by the sudden onset of dizziness and vertigo year. Seasonal rhinitis which occurs secondary to pollens
triggered by changes in head position. The average age of is known as hay fever
onset is 55 years and it is less common in younger patients. • perennial: symptoms occur throughout the year
• occupational: symptoms follow exposure to particular
Features allergens within the work place
• vertigo triggered by change in head position (e.g. rolling
over in bed or gazing upwards) Features
• may be associated with nausea • sneezing
• each episode typically lasts 10-20 seconds • bilateral nasal obstruction
• positive Dix-Hallpike manoeuvre • clear nasal discharge
• post-nasal drip
BPPV has a good prognosis and usually resolves • nasal pruritus
spontaneously after a few weeks to months. Symptomatic
relief may be gained by: Management of allergic rhinitis
• Epley manoeuvre (successful in around 80% of cases) • allergen avoidance
• teaching the patient exercises they can do themselves at • oral or intranasal antihistamines are first line
home, termed vestibular rehabilitation, for example • intranasal corticosteroids
Brandt-Daroff exercises • course of oral corticosteroids are occasionally needed
• there may be a role for short courses of topical nasal
Medication is often prescribed (e.g. Betahistine) but it tends decongestants (e.g. oxymetazoline). They should not be
to be of limited value. used for prolonged periods as increasing doses are
required to achieve the same effect (tachyphylaxis) and
rebound hypertrophy of the nasal mucosa may occur
upon withdrawal
Q-125 Q-126
A 71-year-old man presents to surgery with his wife. She A 57-year-old woman presents with an 8 week history of
describes his hearing as having been 'terrible' for many years intermittent dizziness. These episodes typically occur when
but unfortunately it has recently got worse. Otoscopy shows she suddenly moves her head and are characterised by the
bilateral mild otitis externa with wax blocking the view of sensation that the room is 'spinning'. Most attacks last
the tympanic membranes. Treatment for otitis externa is around one minute before dissipating. Neurological
given, following which you arrange an audiogram: examination is unremarkable. What is the most likely
diagnosis?

A. Benign paroxysmal positional vertigo

B. Ménière’s disease
C. Crescendo transient ischaemic attacks
D. Multiple sclerosis
E. Viral labyrinthitis

ANSWER:
Benign paroxysmal positional vertigo

EXPLANATION:
Viral labyrinthitis typically causes constant symptoms of a
What does the audiogram show? shorter duration. Patients with Meniere disease usually have
associated hearing loss and tinnitus. Also, the vertigo
A. Left conductive hearing loss associated with Meniere disease typically lasts much longer.
B. Bilateral conductive hearing loss
C. Bilateral sensory hearing loss Please see Q-123 for benign paroxysmal positional vertigo
D. Left mixed hearing loss
E. Left sensorineural hearing loss Q-127
A 14-year-old male presents to surgery with a 3 day history
ANSWER: of a sore throat. Which one of the following features is not
Left mixed hearing loss an indication for antibiotic therapy?

EXPLANATION: A. Temperature of 39.1ºC

The AKT content guide lists 'Tests of hearing such as B. A past history of diabetes mellitus
tympanometry, audiometry, tuning fork tests including C. Two previous episodes in the past 5 months
Webers and Rinnes, neonatal and childhood screening tests'. D. Unilateral peritonsillitis on examination
E. A past history of rheumatic fever
AUDIOGRAMS
ANSWER:
Audiograms are usually the first-line investigation that is
Two previous episodes in the past 5 months
performed when a patient complains of hearing difficulties.
They are relatively easy to interpret as long as some simple EXPLANATION:
rules are followed: A temperature of 39.1ºC would indicate marked systemic
• anything above the 20dB line is essentially normal upset
(marked in red on the blank audiogram below)
• in sensorineural hearing loss both air and bone Please see Q-122 for Sore Throat
conduction are impaired
• in conductive hearing loss only air conduction is impaired Q-128
• in mixed hearing loss both air and bone conduction are A 52-year-old woman presents to surgery with a two week
impaired, with air conduction often being 'worse' than history of dizziness when she rolls over in bed. She says it
bone feels like the room is spinning around her. Examination of
her ears and cranial nerves is unremarkable. Given the likely
diagnosis of benign paroxysmal positional vertigo what is the
most appropriate management?

A. Trial of prochlorperazine
B. Request MRI brain
C. Advise review by an optician
D. Perform Epley manoeuvre
E. Trial of cinnarizine
 Q-131
ANSWER: You review a 23-year-old woman who presents with a three
Perform Epley manoeuvre week history of bilateral nasal obstruction, cough at night
and a clear nasal discharge. She had similar symptoms
EXPLANATION: around this time last year and the only history of note is
The majority of GPs would probably not feel confident asthma. What is the most likely diagnosis?
performing this manoeuvre and may refer the patient to ENT
A. Allergic rhinitis
Please see Q-123 for benign paroxysmal positional vertigo B. Chronic sinusitis
C. Nasal hypertrophy secondary to the steroid inhaler
Q-129 D. Nasal polyps
Which one of the following is least recognised as a cause of E. Vasomotor rhinitis
vertigo?
ANSWER:
A. Gentamicin Allergic rhinitis
B. Ménière’s disease
C. Acoustic neuroma EXPLANATION:
D. Multiple sclerosis Please see Q-124 for Allergic Rhinitis
E. Motor neuron disease
Q-132
ANSWER: A 40-year-old woman presents with recurrent episodes of
Motor neuron disease vertigo associated with a feeling or 'fullness' and 'pressure'
in her ears. She thinks her hearing is worse during these
EXPLANATION: attacks. Clinical examination is unremarkable. What is the
Please see Q-111 THROUGH 113 for Vertigo most likely diagnosis?

Q-130 A. Meniere's disease

A 62-year-old man presents 2 days after receiving a punch to B. Benign paroxysmal positional vertigo
his head on the right side. Since the injury, he feels his C. Acoustic neuroma
hearing has been muffled on the right side. On examination D. Cholesteatoma
there is no bruising. Both his ears are obscured by a thin E. Somatisation
translucent layer of wax. On the right, Rinne's test
demonstrates the tuning fork is easier to hear when pressed ANSWER:
on the mastoid bone. On Weber's test the sound is heard Ménière’s disease
best on the right hand side. What is the most likely
diagnosis? EXPLANATION:
Please see Q-107 for Ménière’s disease
A. Otosclerosis
B. Base of skull fracture Q-133 THROUGH 135
C. Otitis media Theme: Neck lumps
D. Earwax
E. Perforated eardrum A. Lymphoma
B. Tuberculosis
ANSWER: C. Reactive lymph nodes
Perforated eardrum D. Cystic hygroma
E. Branchial cyst
EXPLANATION: F. Goitre
Tympanic membrane perforation is a relatively common G. Carotid aneurysm
complication of trauma to the skull. It is important to H. Pharyngeal pouch
distinguish this from sensorineural hearing loss resulting I. Thyroglossal cyst
from a base of skull fracture. J. Cervical rib

Rinne's test her shows that there is a conductive hearing loss For each one of the following scenarios select the most likely
in the affected ear. Weber's test confirms that there is no diagnosis
sensorineural hearing loss on the right.

Please see Q-109 for Rinne’s and Weber’s Test

Q-133 Condition Notes
A 75-year-old man presents with dysphagia and halitosis. On Most are evident at birth, around 90% present
the left side of the neck is a small, fluctuant swelling which before 2 years of age
gurgles when palpated. Branchial cyst An oval, mobile cystic mass that develops between
the sternocleidomastoid muscle and the pharynx
ANSWER: Develop due to failure of obliteration of the
second branchial cleft in embryonic development
Pharyngeal pouch
Usually present in early adulthood
Cervical rib More common in adult females
Q-134 Around 10% develop thoracic outlet syndrome
A 44-year-old woman presents with a neck swelling. She is Carotid aneurysm Pulsatile lateral neck mass which doesn't move on
systemically well. On examination she is noted to have a swallowing
midline, non-tender neck swelling which moves upwards
when she swallows. Q-136
A 17-year-old female presents with a sore throat. On
ANSWER: examination she is noted to have bilaterally enlarged tonsils
Goitre associated with tender cervical lymphadenopathy. From
reviewing her notes you can see that this is her 7th episode
Q-135 of tonsillitis in the past year. She reports having missed days
A newborn baby is noted to have a large swelling on the left- at college due to her sore throats over the past 12 months.
side of the neck. On examination a soft, fluctuant and highly Her Centor score is 3/4 and you therefore elect to prescribe a
transilluminable lump is noted just beneath the skin. course of penicillin V. What other management option
should be considered?
ANSWER:
Cystic hygroma A. Advise her to take vitamin C and zinc supplements
B. Check her serum immunoglobulin levels
EXPLANATION Q-133 THROUGH 135: C. Refer to ENT for consideration of a tonsillectomy
D. Prescribe penicillin at a prophylactic dose following the
NECK LUMPS acute course of penicillin
E. Screen for infectious mononucleosis
The table below gives characteristic exam question features
for conditions causing neck lumps: ANSWER:
Refer to ENT for consideration of a tonsillectomy

Condition Notes EXPLANATION:

Reactive By far the most common cause of neck swellings. Tonsillectomies are performed much less often nowadays
lymphadenopathy There may be a history of local infection or a than they were 20-30 years ago. This reflects a greater
generalised viral illness
awareness of the potential complications and the modest
Lymphoma Rubbery, painless lymphadenopathy
benefits. However, in this scenario the patient fits the
The phenomenon of pain whilst drinking alcohol is
very uncommon
referral criteria as specified by NICE.
There may be associated night sweats and
splenomegaly TONSILLITIS AND TONSILLECTOMY
Thyroid swelling May be hypo-, eu- or hyperthyroid
symptomatically Complications of tonsillitis include:
Moves upwards on swallowing • otitis media
Thyroglossal cyst More common in patients < 20 years old • quinsy - peritonsillar abscess
Usually midline, between the isthmus of the • rheumatic fever and glomerulonephritis very rarely
thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected The indications for tonsillectomy are controversial. NICE
Pharyngeal pouch More common in older men
recommend that surgery should be considered only if the
Represents a posteromedial herniation between person meets all of the following criteria
thyropharyngeus and cricopharyngeus muscles • sore throats are due to tonsillitis (i.e. not recurrent upper
Usually not seen but if large then a midline lump respiratory tract infections)
in the neck that gurgles on palpation • the person has five or more episodes of sore throat per
Typical symptoms are dysphagia, regurgitation,
year
aspiration and chronic cough
• symptoms have been occurring for at least a year
Cystic hygroma A congenital lymphatic lesion (lymphangioma)
typically found in the neck, classically on the left • the episodes of sore throat are disabling and prevent
side normal functioning
 EXPLANATION:
Other established indications for a tonsillectomy include DEAFNESS
• recurrent febrile convulsions secondary to episodes of The most common causes of hearing loss are ear wax, otitis
tonsillitis media and otitis externa. The table below details some of the
• obstructive sleep apnoea, stridor or dysphagia secondary characteristic features of other causes:
to enlarged tonsils
Condition Key features
• peritonsillar abscess (quinsy) if unresponsive to standard
Presbycusis Presbycusis describes age-related sensorineural hearing
treatment loss. Patients may describe difficulty following
conversations
Complications of tonsillectomy Audiometry shows bilateral high-frequency hearing loss
• primary (< 24 hours): haemorrhage in 2-3% (most Otosclerosis Autosomal dominant, replacement of normal bone by
commonly due to inadequate haemostasis), pain vascular spongy bone. Onset is usually at 20-40 years -
• secondary (24 hours to 10 days): haemorrhage (most features include:
commonly due to infection), pain
• conductive deafness
Q-137 THROUGH 139 • tinnitus
Theme: Deafness • tympanic membrane - 10% of patients may
have a 'flamingo tinge', caused by hyperaemia
A. Parkinson's disease • positive family history
B. Presbycusis
C. Ménière’s disease Glue ear Also known as otitis media with effusion
D. Digoxin induced
E. Noise damage • peaks at 2 years of age
F. Amiodarone induced • hearing loss is usually the presenting feature
G. Acoustic neuroma (glue ear is the commonest cause of
H. Furosemide induced conductive hearing loss and elective surgery
I. Vestibular neuritis in childhood)
J. Cholesteatoma • secondary problems such as speech and
language delay, behavioural or balance
problems may also be seen
For each one of the following scenarios please select the
most likely diagnosis:
Meniere's More common in middle-aged adults
disease
Q-137
A 61-year-old woman with a history of cardiac problems
develops hearing loss after a prolonged admission in • recurrent episodes of vertigo, tinnitus and
hearing loss (sensorineural). Vertigo is usually
hospital. Drug toxicity is suspected. the prominent symptom
• a sensation of aural fullness or pressure is now
ANSWER: recognised as being common
Furosemide induced • other features include nystagmus and a
positive Romberg test
Q-138 • episodes last minutes to hours
A 78-year-old man complains of difficultly following
conversations. His wife says he has the TV turned up too Drug Examples include aminoglycosides (e.g. Gentamicin),
loud. Audiometry shows sensorineural hearing loss at the ototoxicity furosemide, aspirin and a number of cytotoxic agents
higher frequencies. Noise Workers in heavy industry are particularly at risk
damage
ANSWER: Hearing loss is bilateral and typically is worse at
Presbycusis frequencies of 3000-6000 Hz
Acoustic Features can be predicted by the affected cranial nerves
Q-139 neuroma (mor
e correctly
A 37-year-old cello player complains of a three month
called
history of vertigo and hearing loss on the left side. On • cranial nerve VIII: hearing loss, vertigo, tinnitus
vestibular
examination he has an absent corneal reflex on the left eye. schwannomas)
• cranial nerve V: absent corneal reflex
• cranial nerve VII: facial palsy
ANSWER:
Acoustic neuroma Bilateral acoustic neuromas are seen in
neurofibromatosis type 2
Q-140 Q-142
During a routine cranial nerve examination the following A 25-year-old woman presents as she has noticed an unusual
findings are observed: appearance of her tongue. This has been present for the past
few weeks. She reports getting a burning sensation when
Rinne's test: Air conduction > bone conduction in both ears she eats spicy food.

Weber's test: Localises to the right side

What do these tests imply?

A. Left conductive deafness

B. Normal hearing
C. Right conductive deafness
D. Right sensorineural deafness
E. Left sensorineural deafness

ANSWER:
Left sensorineural deafness What is the most likely diagnosis?

EXPLANATION: A. Strawberry tongue

In Weber's test if there is a sensorineural problem the sound B. Geographic tongue
is localised to the unaffected side (right) indicating a C. Hairy leukoplakia
problem on the left side D. Oral Candida
E. Glossitis likely secondary to anaemia
Please see Q-109 for Rinne’s and Weber’s Test
ANSWER:
Geographic tongue
Q-141
A 19-year-old woman presents with hearing problems for EXPLANATION:
the past six months. She initially thought it was due to wax GEOGRAPHIC TONGUE
but her hearing has not improved after ear syringing. You Geographic tongue is a benign, chronic condition of unknown
perform an examination of her auditory system including cause. It is present in around 1-3% of the population and is
Rinne's and Weber's test: more common in females.

Left ear: air conduction > bone conduction

Features
Rinne's test:
Right ear: air conduction > bone conduction • erythematous areas with a white-grey border (the
Weber's test: Lateralises to the left side irregular, smooth red areas are said to look like the
outline of a map)
What do these tests imply? • some patients report burning after eating certain food

Management
A. Left sensorineural deafness • reassurance about benign nature
B. Right conductive deafness
C. Normal hearing Q-143
D. Right sensorineural deafness A 41-year-old complains of some difficulties with his hearing
E. Left conductive deafness which have got gradually worse over the past few weeks. An
audiogram is arranged:
ANSWER:
Right sensorineural deafness

EXPLANATION:
In Weber's test if there is a sensorineural problem the sound
is localised to the unaffected side (left) indicating a problem
on the right side.

Please see Q-109 for Rinne’s and Weber’s Test

 Q-145
What does the audiogram show? Jodie is a 5-year-old who presents with her mum requesting
a referral for an adenotonsillectomy. She has suffered with 3
A. Right sensorineural hearing loss severe bouts of acute tonsillitis last year and 4 bouts the
B. Right conductive hearing loss previous year which caused her to miss a total of 5 days
C. Bilateral mixed hearing loss school. However, she has been told she would not fulfil the
D. Right mixed hearing loss criteria for an adenotonsillectomy. Why does she not meet
E. Spurious results - need to repeat referral criteria?

ANSWER: A. Needs proven bacterial swab showing streptococcus

Right conductive hearing loss B. Needs to have taken be off a minimum of 10 days off
sick from school
EXPLANATION: C. Needs 4 or more bouts of acute tonsillitis in each of the
The AKT content guide lists 'Tests of hearing such as previous 2 years
tympanometry, audiometry, tuning fork tests including D. Needs 5 or more bouts of acute tonsillitis in each of the
Webers and Rinnes, neonatal and childhood screening tests'. preceding 2 years
E. Need evidence of episodes of acute tonsillitis over the
Please see Q-125 for Audiograms past 3 years

Q-144 ANSWER:
A 40-year-old man presents with a 4-day history of vertigo. Needs 5 or more bouts of acute tonsillitis in each of the
This seems to have followed a viral upper respiratory tract preceding 2 years
infection in the past week. He is generally fit and well. His
symptoms are associated with some nausea but there is no EXPLANATION:
hearing loss or tinnitus. On examination fine horizontal The correct answer is 'Needs 5 or more bouts of acute
nystagmus is noted. What is the most likely diagnosis? tonsillitis in each of the preceding 2 years'.

A. Vestibular neuronitis Guidance on the criteria for adenotonsillectomy in recurrent

B. Viral labyrinthitis tonsillitis has been produced by SIGN. These suggest:
C. Transient ischaemic attack
D. Acoustic neuroma The following are recommended as indications for
E. Ménière’s disease consideration of adenotonsillectomy for recurrent acute sore
throat in both children and adults:
ANSWER: Sore throats are due to acute tonsillitis
Vestibular neuronitis The episodes of sore throat are disabling and prevent normal
functioning
EXPLANATION: Seven or more well documented, clinically significant,
The absence of hearing loss suggests a diagnosis of adequately treated sore throats in the preceding year OR
vestibular neuronitis rather than viral labyrinthitis. Five or more such episodes in each of the preceding two
years OR
VESTIBULAR NEURONITIS Three or more such episodes in each of the preceding three
Vestibular neuronitis is a common cause of vertigo that often years
develops following a viral infection.
With reference to the above case, Jodie has suffered with
Features acute tonsillitis over the past 2 years with 3 and 4 bouts
• recurrent vertigo attacks lasting hours or days respectively. Given that the minimum according to SIGN is of
• nausea and vomiting may be present 5 episodes over the past 2 years she would not fulfil the
• horizontal nystagmus is usually present criteria.
• no hearing loss or tinnitus
Please see Q-136 for Tonsillitis and Tonsillectomy
Management
• vestibular rehabilitation exercises are the preferred Q-146
treatment for patients who experience chronic symptoms A 54-year-old woman with a history of hypertension
• betahistine is often used although the evidence base presents to surgery. She has a 4 week history of hoarseness
suggests it is less effective than vestibular rehabilitation which followed an upper respiratory tract infection 6 weeks
ago. She is otherwise fit and well and is a non-smoker. What
is the most appropriate management?
A. Urgent chest x-ray Otoscopy
B. Check full blood count • 'attic crust' - seen in the uppermost part of the ear drum
C. Urgent referral to ear, nose and throat
D. Reassure Management
E. Suggest chlorhexidine mouthwash • patients are referred to ENT for consideration of surgical
removal
ANSWER:
Urgent referral to ear, nose and throat Q-148
Which one of the following statements regarding Meniere's
EXPLANATION: disease is correct?
HOARSENESS
Causes of hoarseness include: A. More common in patients from the Indian Subcontinent
• voice overuse B. Symptoms resolve in the majority of patients after 6-12
• smoking months
• viral illness C. It is very rare that patients develop permanent hearing
• hypothyroidism loss
• gastro-oesophageal reflux D. More common in children
• laryngeal cancer E. Approximately equal incidence in males and females
• lung cancer
ANSWER:
When investigating patients with hoarseness a chest x-ray Approximately equal incidence in males and females
should be considered to exclude apical lung lesions.
EXPLANATION:
NICE guidelines on referral for suspect cancer suggest: Please see Q-107 for Ménière’s disease
• NICE now recommend referring patients >= 45 years who
have persistent and unexplained hoarseness under the 2 Q-149
week wait rule to ENT A 25-year-old rugby player presents the day following a
match. His right ear is signficantly swollen and red. On
Q-147 examination he appears to have an auricular haematoma.
Which one of the following statements regarding What is the most appropriate management?
cholesteatomas is correct?
A. Take a two-week course of ibuprofen
A. Cholesteatoma is 3 times more common in diabetics B. Apply a compression bandage
B. Typically presents with a lesion of the 5th cranial nerve C. Apply an ice-pack six times a day for the next three days
C. The peak incidence is 10-20 years D. Perform a needle aspiration in surgery
D. The most common presenting symptoms is persistent E. Refer to secondary care
otalgia
E. Management usually involves chemotherapy ANSWER:
Refer to secondary care
ANSWER:
The peak incidence is 10-20 years EXPLANATION:
Auricular haematomas are specifically mentioned in the
EXPLANATION: RCGP curriculum.
CHOLESTEATOMA
A cholesteatoma consists of squamous epithelium that is AURICULAR HAEMATOMAS
'trapped' within the skull base causing local destruction. It is Auricular haematomas are common in rugby players and
most common in patients aged 10-20 years. wrestlers. Prompt treatment is important to avoid the
formation of 'cauliflower ear'.
Main features
• foul smelling discharge Management
• hearing loss • incision and drainage has been shown to be superior to
needle aspiration
Other features are determined by local invasion:
• vertigo Q-150
• facial nerve palsy Which one of the following features is least consistent with a
diagnosis of otosclerosis?
• cerebellopontine angle syndrome
 development of a haematoma between the septal cartilage
A. Tinnitus and the overlying perichondrium.
B. Positive family history
C. Normal tympanic membrane Features
D. Conductive deafness • may be precipitated by relatively minor trauma
E. Onset after the age of 50 years • the sensation of nasal obstruction is the most common
symptom
ANSWER: • pain and rhinorrhoea are also seen
Onset after the age of 50 years • on examination, classically a bilateral, red swelling arising
from the nasal septum
EXPLANATION: • this may be differentiated from a deviated septum by
OTOSCLEROSIS gently probing the swelling. Nasal septal haematomas are
Otosclerosis describes the replacement of normal bone by typically boggy whereas septums will be firm
vascular spongy bone. It causes a progressive conductive
deafness due to fixation of the stapes at the oval window. Management
Otosclerosis is autosomal dominant and typically affects • surgical drainage
young adults • intravenous antibiotics

Onset is usually at 20-40 years - features include: If untreated irreversible septal necrosis may develop within 3-
• conductive deafness 4 days. This is thought to be due to pressure-related
• tinnitus ischaemia of the cartilage resulting in necrosis. This may result
• normal tympanic membrane* in a 'saddle-nose' deformity
• positive family history
Q-152 THROUGH 154
Management Theme: Deafness
• hearing aid
• stapedectomy A. Acute suppurative otitis media
B. Presbycusis
*10% of patients may have a 'flamingo tinge', caused by C. Meniere's disease
hyperaemia D. Drug ototoxicity
E. Otitis externa
Q-151 F. Congenital rubella infection
A 9-year-old boy is reviewed after falling off his skateboard G. Acoustic neuroma
two hours ago. He fell forward, breaking his fall with his right H. Glue ear
arm. On examination he has minor abrasions on his right I. Otosclerosis
forearm but no sign of a fracture. His nose is erythematous J. Cholesteatoma
with some abrasions. Examination of the nostrils reveals a
bilateral red swelling arising from the midline, which is For each one of the following scenarios please select the
slightly boggy. No other signs of a head injury are seen. What most likely diagnosis:
is the most appropriate management?
Q-152
A. Reassure that the swelling should subside over the next A 36-year-old man presents with recurrent episodes of right-
week and give standard head injury advice sided tinnitus, hearing loss and vertigo. These episodes
B. Prescribe topical chlorhexidine + neomycin cream typically last between 10-30 minutes. He also describes a
(Naseptin) and give standard head injury advice 'full' sensation in his right ear. Otoscopy is unremarkable and
C. Arrange a review with ENT for 2 weeks time when the the cranial nerve examination is normal.
swelling has settled
D. Arrange an urgent ENT review ANSWER:
E. Prescribe a 7-day course of co-amoxiclav and give Meniere’s disease
standard head injury advice
Q-153
ANSWER: A 31-year-old man presents with bilateral hearing loss and
Arrange an urgent ENT review tinnitus. There is a family history of similar problems.
Examination of the tympanic membranes is unremarkable.
EXPLANATION: Audiometry shows bilateral conductive hearing loss.
NASAL SEPTAL HAEMATOMA
Nasal septal haematoma is an important complication of nasal ANSWER:
trauma which should always be looked for. It describes the Otosclerosis
 Q-157
Q-154 A 17-year-old girl presents with a painless swelling in the
A 2-year-old boy is brought in by his mother due to concerns neck. She is currently well. A midline, cystic swelling is noted
about his hearing and delayed speech. She has noticed in the region of the hyoid bone. It moves upwards when she
problems for the past three months. You can see from the swallows or sticks her tongue out.
notes that he has had frequent courses of amoxicillin for
otitis media in the past. There is no evidence of excessive ear ANSWER:
wax on examination. Thyroglossal cyst

ANSWER: EXPLANATION Q-155 THROUGH 157:

Glue ear Please see Q-133 THROUGH 135 for Neck Lumps

EXPLANATION Q-152 THROUGH 154: Q-158

Please see Q-137 THROUGH 139 for Deafness A 25-year-old woman asks you to look at her tongue. It has
had this appearance for 'a few months' and she is
Q-155 THROUGH 157 asymptomatic.
Theme: Neck lumps

A. Lymphoma
B. Tuberculosis
C. Reactive lymph nodes
D. Cystic hygroma
E. Branchial cyst
F. Goitre
G. Carotid aneurysm
H. Pharyngeal pouch
I. Thyroglossal cyst What is the most likely diagnosis?
J. Cervical rib
A. Oral lichen planus
For each one of the following scenarios select the most likely B. Iron-deficiency anaemia
diagnosis C. Vitamin C deficiency
D. Geographic tongue
Q-155 E. Oral leukoplakia
A 19-year-old man presents with a swelling on the left side
of his neck. He has recently had an upper respiratory tract ANSWER:
infection. On examination he has a smooth swelling in Geographic tongue
between the sternocleidomastoid muscle and the pharynx. It
is fluctuant but doesn't transilluminate or move during EXPLANATION:
swallowing. Please see Q-142 for geographic tongue

ANSWER: Q-159
Branchial cyst You are a GP visiting a residential home patient. The patient
is a 76-year-old female with a 4 week history of oral
Q-156 ulceration. It has caused her some pain and bleeding. She
A 28-year-old Bangladeshi woman presents with a three day states that her dentures have not been fitting very well and
history of sweats, headache, lethargy and muscle aches. On so has stopped using them. She has lost a few kilograms in
examination she has bilateral tender swellings in the weight over the past few weeks. According to NICE
submandibular region. guidelines for suspected cancer, which details in this patients
history would prompt referral (within 2 weeks) for oral
ANSWER: cancer?
Reactive lymph nodes
A. Unexplained ulceration in the oral cavity lasting for
EXPLANATION: more than 3 weeks
The patient probably has the flu B. Age above 75 years
C. Ulceration in the oral cavity causing pain
D. Ulceration in the oral cavity causing bleeding
E. Recent weight loss
 a red or red and white patch in the oral cavity consistent
ANSWER: with erythroplakia or erythroleukoplakia. [new 2015]
Unexplained ulceration in the oral cavity lasting for more than
3 weeks MOUTH LESIONS
2 week wait referrals to oral surgery should be done in all of
EXPLANATION: the following cases:
Oral ulcers are characterised by a loss of the mucosal layer • Unexplained oral ulceration or mass persisting for greater
within the mouth. They are one of the most common oral than 3 weeks
problems presenting in primary care and may arise as a • Unexplained red, or red and white patches that are
result of problems locally, around the oropharynx or systemic painful, swollen or bleeding
conditions. The most common causes are local trauma and • Unexplained one-sided pain in the head and neck area for
recurrent aphthous ulceration. Other causes include chemical greater than 4 weeks, which is associated with ear ache,
injury, for example, from direct contact of the mucosa with but does not result in any abnormal findings on otoscopy
aspirin or bisphosphonates. Thermal injury can cause • Unexplained recent neck lump, or a previously
ulceration from mucosal contact with hot food and fluids. undiagnosed lump that has changed over a period of 3 to
Infection with herpes simplex virus type 1 (HSV-1) and herpes 6 weeks
simplex virus type 2 (HSV-2) is also causative. Mechanical • Unexplained persistent sore or painful throat
injury is most often caused by dentures, braces or sharp, • Signs and symptoms in the oral cavity persisting for more
broken teeth. Ulcers generally start to heal within 10 days than 6 weeks, that cannot be definitively diagnosed as a
after removal of the offending cause. Persistence after the benign lesion
presumed cause has been removed warrants urgent further
investigation. The level of suspicion should be higher in patients who are
over 40, smokers, heavy drinkers and those who chew
Cancer Research UK statistics show the incidence of oral tobacco or betel nut (areca nut).
cavity cancers is rising in the UK, with an increase of 92%
since the late 1970s. The majority are caused by squamous Q-160
cell carcinoma (SCC), accounting for 90%, with the remainder A 3-year-old boy is brought to surgery. His mum reports that
being made up of malignant melanoma, lymphoma and he has been complaining of a sore left ear for the past 2-3
metastases. Tobacco smoking is associated with 65% of weeks. This morning she noticed some 'green gunge' on his
cases in the UK whilst alcohol consumption is associated with pillow. On examination his temperature is 37.8ºC. Otoscopy
30% of cases. SCC may start as precursor lesions which may of the right ear is normal. On the left side the tympanic
be white (leukoplakia) or red (erythroplakia). Leukoplakia membrane cannot be visualised as the ear canal is full with a
carry a 5% risk of malignancy whereas erythroplakia are yellow-green discharge. What is the most appropriate
malignant until proven otherwise (50% risk). They often action?
present as indolent, painless, non-healing ulcers with raised
A. Review in 2 weeks
borders.
B. Admit to paediatrics
C. Advise olive oil drops followed by ear syringing
(source: patient.co.uk)
D. Urgent referral to ENT
E. Amoxicillin + review in 2 weeks
The AKT Examiners feedback report October 2016 specifically
mentions candidates should have an awareness of rare ANSWER:
conditions, and in this case there were difficulties around Amoxicillin + review in 2 weeks
cancer diagnosis and investigation in children.
EXPLANATION:
NICE Guidelines for suspected cancer (June 2015) state: This boy is likely to have had an acute otitis media with
perforation.
Consider referral (within 2 weeks) for oral cancer in people
with either: Please see Q-121 for perforated tympanic membrane
unexplained ulceration in the oral cavity lasting for more
than 3 weeks or Q-161
a persistent and unexplained lump in the neck. [new 2015] Which one of the following conditions is least associated
with nasal polyps?
Consider an urgent referral (within 2 weeks) for assessment
A. Wegener's granulomatosis
for possible oral cancer by a dentist in people who have
B. Kartagener's syndrome
either:
C. Asthma
a lump on the lip or in the oral cavity or
D. Infective sinusitis
E. Cystic fibrosis
 Single ulcers, or recurrent ulcers in the same place, may be
ANSWER: caused by damage to the mouth, for example biting the
Wegener's granulomatosis cheek, or damage to the buccal mucosa with a toothbrush or
a sharp tooth or filling.
EXPLANATION:
Please see Q-110 for nasal polyps People with recurrent ulcers may have a genetic
predisposition. Precipitating factors include:
Q-162 • Oral trauma (for example excessive tooth brushing).
A 29 year old male smoker presents with multiple, painful • Anxiety or stress.
aphthous ulcers, he puts this down to stress at work. He only • Certain foods (typically chocolate, coffee, peanuts,
gets ulcers on his tongue and oral mucosa. He is otherwise almonds, strawberries, cheese, tomatoes, and wheat
well. He has never had any joint or bowel symptoms. He flour).
reports several previous episodes similar to this one, with • Stopping smoking.
painful oral ulceration lasting a week or two, dating back to • Hormonal changes related to the menstrual cycle.
when he was a teenager.
Aphthous ulcers present as one or more rounded or ovoid
Which of the following features should lead to an urgent mouth ulcers with a clearly-defined margin, a floor of
referral to secondary care? yellowish-grey slough, and an erythematous periphery. They
generally occur on non-keratinized mucosal surfaces such as
A. No response to topical corticosteroids the inside of the lips, the inside of the cheeks, the floor of the
B. First onset at age under 30 years old mouth, or the undersurface of the tongue.
C. Unexplained ulceration persisting for 2 weeks
D. Current or ex-smoker Investigations are generally unnecessary. Investigations
E. Unexplained red and white patches of the oral mucosa should be considered (for example full blood count,
that are painful, swollen, or bleeding erythrocyte sedimentation rate, ferritin, folate and vitamin
B12) if an underlying systemic disease is suspected based on
ANSWER: history and examination findings.
Unexplained red and white patches of the oral mucosa that
are painful, swollen, or bleeding Most aphthous ulcers heal within 10-14 days without scarring.

EXPLANATION: Management of aphthous ulcers includes:

This question tests knowledge of red flags for oral ulceration. • Avoidance of precipitating factors, and
These include: • Symptomatic treatment for pain, discomfort, and swelling
Unexplained ulceration of the oral mucosa or mass persisting e.g. a short course of a low potency topical corticosteroid
for more than 3 weeks. (hydrocortisone lozenges), an antimicrobial mouthwash,
Unexplained red and white patches (including suspected or a topical analgesic.
lichen planus) of the oral mucosa that are painful, swollen, • People with a mouth ulcer that persists for more than 3
or bleeding. weeks should be referred urgently to a specialist
Symptoms or signs related to the oral cavity that persist for
more than 6 weeks if a definitive diagnosis of a benign lesion Q-163
cannot be made. A 15-year-old girl presents with a sore throat. She has no
cough, a temperature of 38.4ºC, and enlarged tonsils with
Being a smoker is a risk factor for aphthous ulcers. First onset white exudate. What is the fourth element of the Centor
over the age of 30 is an atypical feature which should criteria?
warrant consideration of an alternative cause (e.g. trauma
to the mouth) but is not an indication for referral. Not all Neck pain
ulcers respond to corticosteroids, but if the ulcer has Difficulty swallowing
persisted for more than 3 weeks, then an urgent referral is Tachycardia
warranted. The implication is that prolonged ulceration Tender anterior cervical lymphadenopathy
could be malignant. Tender posterior cervical lymphadenopathy

APHTHOUS MOUTH ULCERS ANSWER:

Aphthous mouth ulcers are painful, clearly defined, round or Tender anterior cervical lymphadenopathy
ovoid, shallow ulcers that are confined to the mouth and are
not associated with systemic disease. They are often EXPLANATION:
recurrent, with onset usually in childhood. The Centor criteria are the history of fever, the presence of
tonsillar exudate, the absence of a cough, and tender
anterior cervical lymphadenopathy. The other answers are Management
not part of this scoring system.(AKT feedback report October • tongue scraping
2016) • topical antifungals if Candida

Please see Q-122 for Sore Throat Q-165

A 40-year-old musician complains of problems detecting
Q-164
pitch when he is playing the violin. You arrange an
A patient presents due to a 'brown coating' on his tongue.
audiogram:
He is 34-years-old and has no significant medical history. The
coating has been present for the past few weeks. He is
asymptomatic other than a slight 'tickling' sensation on his
tongue.

What does the audiogram show?

A. Right mixed hearing loss

B. Right sensorineural hearing loss
C. Right conductive hearing loss
D. Left conductive hearing loss
E. Bilateral mixed hearing loss

ANSWER:
What is the most likely diagnosis? Right sensorineural hearing loss

A. Lichen Planus EXPLANATION:

B. Oral Candida The AKT content guide lists 'Tests of hearing such as
C. Iron-deficiency anaemia tympanometry, audiometry, tuning fork tests including
D. Hairy leukoplakia Webers and Rinnes, neonatal and childhood screening tests'.
E. Black hairy tongue
Please see Q-125 for Audiograms
ANSWER:
Black hairy tongue Q-166
A 34-year-old man is found to have impacted ear wax on the
EXPLANATION: left-side. Which one of the following preparations and
BLACK HAIRY TONGUE techniques is it least suitable to recommend?
Black hairy tongue is relatively common condition which
results from defective desquamation of the filiform papillae. A. Sodium bicarbonate 5%
Despite the name the tongue may be brown, green, pink or B. Docusate sodium 5%
another colour. C. Almond oil
D. Olive oil
Predisposing factors E. Irrigation with water
• poor oral hygiene
• antibiotics ANSWER:
• head and neck radiation Docusate sodium 5%
• HIV
• intravenous drug use EXPLANATION:
Docusate sodium 5% is found in some proprietary
The tongue should be swabbed to exclude Candida preparations but is listed in the BNF as being less suitable for
prescription.
EAR WAX ANSWER:
Ear wax is a normal physiological substance which helps Monoamine oxidase inhibitor
protect the ear canal. Impacted ear wax is extremely common
and may cause a variety of symptoms including: EXPLANATION:
• pain A monoamine oxidase inhibitor combined with
• loss of hearing pseudoephedrine could potentially cause a hypertensive
crisis.
• tinnitus
• vertigo The January 2010 AKT feedback report stated 'Increasingly,
patients are encouraged to self-manage conditions, perhaps
The main treatment options in primary care are ear drops or with advice from a pharmacist. Candidates did not perform
irrigation ('ear syringing'). Treatment should not be given if a well with regard to issues related to over the counter
perforation is suspected. The following drops may be used: medication, such as side-effects and contraindications.'
• olive oil
• sodium bicarbonate 5% SINUSITIS
• almond oil Sinusitis describes an inflammation of the mucous
membranes of the paranasal sinuses. The sinuses are usually
Q-167 sterile - the most common infectious agents seen in acute
A 7-year-old girl is brought to surgery due to a sore throat. sinusitis are Streptococcus pneumoniae, Haemophilus
She has a temperature of 39.2ºC and is not eating due to the influenzae and rhinoviruses.
pain, although she is tolerating fluids. She has had no other
Predisposing factors include:
related symptoms such as a cough or a rash. Her heart rate is
• nasal obstruction e.g. Septal deviation or nasal polyps
120/min and auscultation of the chest is unremarkable. The
• recent local infection e.g. Rhinitis or dental extraction
tonsils are covered in exudate bilaterally. Examination of the
ears is unremarkable. Other than supportive treatment, • swimming/diving
what is the most appropriate management? • smoking

Features
A. Erythromycin for 10 days
• facial pain: typically frontal pressure pain which is worse
B. Amoxicillin for 7 days
on bending forward
C. Antibiotics are not indicated
• nasal discharge: usually thick and purulent
D. Phenoxymethylpenicillin for 10 days
• nasal obstruction: e.g. 'mouth breathing'
E. Phenoxymethylpenicillin for 5 days
• post-nasal drip: may produce chronic cough
ANSWER: Management of acute sinusitis
Phenoxymethylpenicillin for 10 days • analgesia
• intranasal decongestants
EXPLANATION: • oral antibiotics are not normally required but may be
This girl has marked systemic upset and should be treated given for severe presentations. Amoxicillin is currently
with antibiotics. A 7 or 10 day course of antibiotics is first-line
appropriate to ensure eradication of possible Streptococcus
infection. Phenoxymethylpenicillin is the first-line antibiotic Management of recurrent or chronic sinusitis
choice in the BNF • treat any acute element as above
• intranasal corticosteroids are often beneficial
Please see Q-122 for Sore Throat • referral to ENT may be appropriate
Q-168 Q-169
A 24-year-old man who is suffering from sinusitis asks about A 35-year-old man presents to his GP surgery as he is having
using Sudafed (pseudoephedrine). Which one of the some difficulties with his hearing. He now struggles to follow
following medications would make the use of Sudafed conversation and often has the TV volume turned up high.
contraindicated? Otoscopy is normal. An audiogram is requested:

A. Sodium valproate
B. Monoamine oxidase inhibitor
C. Salbutamol
D. Triptan
E. Selective serotonin reuptake inhibitor
What does the audiogram show? For each one of the following scenarios select the most likely
diagnosis:
A. Bilateral mixed hearing loss
B. Right conductive hearing loss Q-171
C. Normal hearing A 64-year-old woman with a one week history of pain above
D. Bilateral conductive hearing loss and lateral to her left eye. On examination she is tender over
E. Bilateral sensorineural hearing loss that area.

ANSWER: ANSWER:
Normal hearing Temporal arteritis

EXPLANATION: Q-172
The AKT content guide lists 'Tests of hearing such as A 62-year-old woman presents with a two week history of
tympanometry, audiometry, tuning fork tests including shooting pains across her left cheek. The pain is sometimes
Webers and Rinnes, neonatal and childhood screening tests'. triggered by touching her face. She has no past medical
history note
Please see Q-125 for Audiograms
ANSWER:
Q-170 Trigeminal neuralgia
A 22-year-old man complains of hearing problems. You
perform an examination of his auditory system including Q-173
Rinne's and Weber's test: A 42-year-old man with a 3 month history of chronic cough
presents with a persistent headache
Left ear: bone conduction > air conduction
Rinne's test:
Right ear: air conduction > bone conduction ANSWER:
Weber's test: Lateralises to the left side
Sinusitis

EXPLANATION Q-171 THROUGH 173:

What do these tests imply?
FACIAL PAIN
A. Normal hearing
The table below gives characteristic exam question features
B. Left conductive deafness
for conditions causing facial pain
C. Right conductive deafness
D. Left sensorineural deafness
Condition Characteristic exam feature
E. Right sensorineural deafness
Sinusitis Facial 'fullness' and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to
ANSWER: cough
Left conductive deafness Trigeminal Unilateral facial pain characterised by brief electric
neuralgia shock-like pains, abrupt in onset and termination
EXPLANATION: May be triggered by light touch, emotion
Cluster headache Pain typical occurs once or twice a day, each episode
Please see Q-109 for Rinne’s and Weber’s Test lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Q-171 THROUGH 173 Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal
Theme: Facial pain
stuffiness
Temporal Tender around temples
A. Sinusitis
arteritis Raised ESR
B. Dental abscess
C. Acute glaucoma
Q-174
D. Temporal arteritis
A 55-year-old lady presents with a 4-day history of dizzy
E. Shingles
spells.She describes 'seeing the room spinning' and feeling
F. Cluster headache
sick for 'a minute or two' before everything returns to
G. Trigeminal neuralgia
normal. The patient attends today as she has noticed that
H. Atypical facial pain
when she looks down it seems to start an episode.
I. Temporomandibular joint dysfunction
Examination of both ears and cranial nerves is
J. Parotitis
unremarkable. The blood pressure is 126/ 82 mmHg. What
test can be performed to confirm the diagnosis?
 Please see Q-108 for otitis media
A. Dix- Hallpike manoeuvre
B. Epley manoeuvre Q-176
C. Brant Daroff exercises A middle-aged man of Chinese origin represents to you in
D. Simmond's Test surgery to discuss his recurrent nosebleeds. They started 2
E. Finkelstein's Test months previously and have been occurring unprovoked
with increasing frequency. He is not on any anticoagulants,
ANSWER: has never had any previous episodes of unexplained or
Dix- Hallpike manoeuvre excessive bleeding, and has no family history of any bleeding
disorders. On further questioning, the nosebleeds always
EXPLANATION: seem to be from the left nostril which feels a bit blocked. He
The Dix- Hallpike manoeuvre is used to diagnose benign has tried 2 weeks of Naseptin (chlorhexidine dihydrochloride
paroxysmal positional vertigo. The Epley manoeuvre or Brant and neomycin sulfate nasal cream) with no change in his
Daroff exercises are both used to treat this condition but not symptoms. He mentions that the previous GP he saw asked
to diagnose it. Simmond's test is used to diagnose Achilles about weight loss which he denied at the time, however, he
tendon rupture and Finkelstein's test is used to diagnose De volunteers that he has been tightening his belt more now.
Quervain's tenosynovitis. (AKT feedback report October Blood tests reveal normal coagulation screen, haemoglobin
2016) within the normal range and a thrombocytosis. What
condition is it most important to investigate for?
Please see Q-123 for benign paroxysmal positional vertigo
A. Hereditary telangiectasia
Q-175 B. Nasopharyngeal cancer
A 18-month-old girl is brought in by her mother with C. Nasal polyps
bilateral earache. This has been ongoing for one week D. Von Willebrand's disease
despite using regular paracetamol and neurofen. E. Angiofibroma
On examination, she has a temperature of 39.2ºC. Her pulse ANSWER:
is 130 beats per minute and the tympanic membranes are Nasopharyngeal cancer
red, congested and bulging in both ears.
EXPLANATION:
What is the most appropriate management? The NICE guidelines regarding epistaxis recommend referring
to ear, nose and throat for investigation of recurrent
A. Acetic acid spray epistaxis in patients at high risk of having an underlying
B. Amoxicillin disorder. In this case, this patient of Chinese origin has
C. Flucloxacillin recurrent epistaxis, nasal obstruction and is high risk for
D. Otomize spray nasopharyngeal cancer due to his ethnicity and his age.
E. Monitor symptoms Weight loss is also a concerning feature coupled with the
results of the full blood count- thrombocytosis may be
ANSWER: indicative of malignancy.
Amoxicillin The lack of family history and start of nosebleeds in later life
makes a diagnosis of hereditary telangiectasia or Von
EXPLANATION: Willebrand's disease unlikely. Nasal polyps may present with
Antibiotics should be avoided or delayed for most people nasal obstruction, postnasal drip, snoring or obstructive
with acute otitis media. A prescription should be offered in sleep apnoea, epistaxis is not a feature of this condition. This
the following circumstances: patient is in the wrong age group to suspect an angiofibroma
• people who are systemically unwell (otherwise known as juvenile nasopharyngeal angiofibroma)
• people at high-risk from co-morbidities as the cause of his nosebleeds. This is a benign tumour that
• ongoing symptoms for at least 4 days without signs of occurs in pre-pubescent and adolescent males; it is rare over
improvement the age of 25 years.
• children under the age of 2 years with bilateral otitis (AKT feedback report October 2016)
media
• people with perforation and/or discharge in the ear NASOPHARYNGEAL CARCINOMA
canal • Squamous cell carcinoma of the nasopharynx
• Rare in most parts of the world, apart from individuals
Amoxicillin is the first-line drug of choice. Acetic acid spray, from Southern China
otomize spray and flucloxacillin can be used for otitis • Associated with Epstein Barr virus infection
externa. Symptoms should usually be monitored but this
patient fulfils a few of the above criterion.
Presenting features
Systemic Local
Cervical lymphadenopathy Otalgia
Unilateral serous otitis media
Nasal obstruction, discharge and/ or
epistaxis
Cranial nerve palsies e.g. III-VI

Imaging
Combined CT and MRI.

Treatment
Radiotherapy is first line therapy. What is the most likely diagnosis?

Q-177 A. Acute otitis media with perforation

A 15-year-old boy is brought for review by his mother due to B. Cholesteatoma
a recurrent discharge from his right ear. He also feels that his C. Glue ear
hearing is worse on that side. As a child he had glue ear D. Normal tympanic membrane
treated with grommets but his symptoms settled by the age E. Acute otitis media
of 6 years and the mother thinks the grommets fell out by
themselves at some point. He is otherwise fit and well. ANSWER:
Otoscopy shows the following: Acute otitis media

EXPLANATION:
The bulging nature of the tympanic membrane strongly
suggests a diagnosis of otitis media. The colour of the
tympanic membrane alone has a low predictive value for
otitis media as it may be reddened by coughing, nose
blowing, and fever.

Please see Q-108 for otitis media

Q-179
A 28-year-old male surfer from New Zealand presents with
recurrent ear infections. He has recently moved to the UK
and is generally fit and well. The patient reports difficulty in
getting water out of his ears following a shower and left
sided ear discomfort. You examine his ears: there seems to
What is the most likely diagnosis?
be something protruding into the canal in the left ear,
blocking a complete view of the tympanic membrane. From
A. Normal tympanic membrane with small amount of wax
what you can see the tympanic membrane is normal on the
B. Chronic suppurative otitis media
right side. The canals are not inflamed on either side. What
C. Bullous myringitis
is the most likely diagnosis?
D. Cholesteatoma
E. Retained grommet
A. Cholesteatoma
B. Exostosis (Surfer's ear)
ANSWER:
C. Foreign body
Cholesteatoma
D. Wax
E. Otitis externa
EXPLANATION:
Please see Q-147 for cholesteatoma
ANSWER:
Exostosis (Surfer’s ear)
Q-178
A 6-year-old boy is brought to surgery. His mother says he
EXPLANATION:
has been complaining of left sided otalgia for the past three
The protrusion into the left ear canal is a bony prominence or
days. Otoscopy demonstrates the following:
exostosis.
Wax or foreign body are not the answers as they were not Q-181
found on examination. Patients that spend a lot of time in A 27-year-old woman complains of recurrent ear discharge.
water may be more predisposed to otitis externa; however, Otoscopy is as follows:
the typical features of red, inflamed canals with evidence of
debris are not seen here. Similarly, cholesteatoma is not the
answer as the typical features of foul smelling 'cheesy'
discharge and an abnormality of the attic seen on
examination are not present. (AKT feedback report October
2016)

SURFER'S EAR (EXOSTOSIS)

Surfer's ear is a condition seen secondary to repeated
exposure to cold water- often seen in surfers, divers, and
kayakers. It is more common in New Zealand and the USA.
Some areas of the United Kingdom such as Cornwall may see
cases. Patients with this condition may suffer from repeated
ear infections, decreased hearing and water plugging. It is a
progressive condition and preventative measures ought to be What is the most likely diagnosis?
taken to prevent repeated exposure - hoods, ear plugs or
swim caps can be used. Surgery may be undertaken. A. Otitis externa
B. Chronic suppurative otitis media
Q-180 C. Mastoiditis
A 59-year-old man presents with a severe pain deep within D. Cholesteatoma
his right ear. He feels dizzy and reports that the room 'is E. Acute otitis media
spinning'. Clinical examination shows a partial facial nerve
palsy on the right side and vesicular lesions on the anterior ANSWER:
two-thirds of his tongue. What is the most likely diagnosis? Cholesteatoma

A. Meniere's disease EXPLANATION:

B. Herpes zoster ophthalmicus
C. Ramsay Hunt syndrome Please see Q-147 for cholesteatoma
D. Acoustic neuroma
E. Trigeminal neuralgia Q-182
A 37-year-old man presents with nasal obstruction and loud
ANSWER: snoring. He has noticed these symptoms get gradually worse
Ramsay Hunt syndrome for the past two months. His left nostril feels blocked whilst
his right feels clear and normal. There is no history of
EXPLANATION: epistaxis and he is systemically well. On examination a large
Whilst vesicular lesions are more classically seen in the nasal polyp can be seen in the left nostril. What is the most
external auditory canal and pinna they may also be seen on appropriate action?
the anterior 2/3rds of the tongue and the soft palate.
A. Reassure + provide patient information leaflet on nasal
RAMSAY HUNT SYNDROME polyps
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the B. Enquire about cocaine use
reactivation of the varicella zoster virus in the geniculate C. Refer to ENT
ganglion of the seventh cranial nerve. D. Trial of intranasal steroids
E. Nasal cautery
Features
• auricular pain is often the first feature ANSWER:
• facial nerve palsy Refer to ENT
• vesicular rash around the ear
• other features include vertigo and tinnitus EXPLANATION:
Given that his symptoms are unilateral it is important he is
Management referred to ENT for a full examination.
• oral aciclovir and corticosteroids are usually given
Please see Q-110 for Nasal Polyps
Q-183
A 25-year-old woman presents with recurrent attacks of ANSWER:
'dizziness'. These attacks typically last around 30-60 minutes Refer urgently to secondary care
and occur every few days or so. During an attack 'the room
seems to be spinning' and the patient often feels sick. These EXPLANATION:
episodes are often accompanied by a 'roaring' sensation in Unexplained oral ulceration persisting for more than 3 weeks
the left ear. Otoscopy is normal but Weber's test localises to is an indication for urgent referral to secondary care, in order
the right ear. What is the most likely diagnosis? to rule out malignancy. Although smoking is a risk factor for
both aphthous ulcers and oral malignancy, it is not an
A. Acoustic neuroma indication for referral. Interestingly stopping smoking can
B. Vestibular neuritis make aphthous ulcers more troublesome. Local analgesics
C. Benign paroxysmal positional vertigo available over the counter such as Difflam (benzydamine
D. Multiple sclerosis hydrochloride) and Bonjela can provide symptomatic relief
E. Meniere's disease but there is no evidence that they reduce the duration or
frequency of ulceration. There is some evidence that
ANSWER: antibacterial mouthwashes (e.g. chlorhexidine) and topical
Meniere’s disease corticosteroids (e.g. hydrocortisone oromucosal tablets) can
shorten the duration and severity of symptoms, however
EXPLANATION: they do not reduce the frequency of recurrence.
In sensorineural hearing loss Weber's test localises to the
contralateral ear. Please see Q-162 for Aphthous Mouth Ulcers

Please see Q-107 for Meniere’s disease Q-186

A 41-year-old woman presents with a sore throat.
Q-184 Examination of the throat reveals:
A 30-year-old man presents with sneezing, nasal blockage
and a constant runny nose. Which one of the following does
not have a role in the management of allergic rhinitis?

A. Oral decongestants
B. Oral corticosteroids
C. Intranasal corticosteroids
D. Oral antihistamines
E. Intranasal antihistamines

ANSWER:
Oral decongestants What is the most likely diagnosis?

A. Tonsillar carcinoma
EXPLANATION: B. Peritonsillar abscess (quinsy)
Please see Q-124 for Allergic Rhinitis C. Acute tonsillitis
D. Infectious mononucleosis
Q-185 E. Retropharyngeal abscess
A 35 year old female smoker complains of multiple painful
aphthous ulcers, for which she was recommended a topical ANSWER:
analgesic (benzydamine hydrochloride gel) by a pharmacist. Acute tonsillitis
She has been using this for 3 weeks but her ulcers are still
symptomatic. There is no evidence of joint or bowel EXPLANATION:
pathology in the history or examination. She is otherwise fit Infectious mononucleosis is a possibility but a simple
and well. What is the most appropriate next step? tonsillitis is the most likely diagnosis.

Please see Q-136 for Tonsillitis and tonsillectomy

A. Advise to stop smoking and provide smoking cessation
advice Q-187
B. Prescribe chlorhexidine gluconate A 61-year-old woman presents with bilateral tinnitus. She
C. Prescribe 'Bonjela' gel reports no change in her hearing or other ear-related
D. Refer urgently to secondary care symptoms. Ear and cranial nerve examination is
E. Prescribe hydrocortisone oromucosal tablets unremarkable. Which medication is she most likely to have
recently started?
 ANSWER:
A. Ciprofloxacin Urgent referral (within 2 weeks) for assessment by a dentist
B. Nifedipine
C. Repaglinide EXPLANATION:
D. Quinine Erythroplakia is defined as any erythematous area on a
E. Bendroflumethiazide mucous membrane, that cannot be attributed to any other
pathology. Leukoplakia is used to describe a white area on a
ANSWER: mucous membrane without a known cause. Both are types of
Quinine premalignant lesion in the mouth. Lesions containing both
red and white areas are called erythroleukoplakia.
EXPLANATION:
TINNITUS Erythroplakia presents as a red macule or plaque with well-
Causes of tinnitus include: demarcated, raised borders which is often painless and
grows slowly. It is most commonly found in elderly men and
Meniere's Associated with hearing loss, vertigo, tinnitus and both tobacco smoking and alcohol consumption are
disease sensation of fullness or pressure in one or both ears recognised risk factors.
Otosclerosis Onset is usually at 20-40 years
Conductive deafness Erythroplakia is much less common than leukoplakia,
Tinnitus however carries a significantly higher risk of transforming
Normal tympanic membrane*
into invasive squamous cell carcinoma (50%). Leukoplakia
Positive family history
carry a 5% risk of malignancy Any lesion suspicious of
Acoustic Hearing loss, vertigo, tinnitus
neuroma Absent corneal reflex is important sign erythroplakia or leukoplakia in the oral cavity warrants
Associated with neurofibromatosis type 2 urgent further investigation.
Hearing loss Causes include excessive loud noise and presbycusis
Drugs Aspirin (source: patient.co.uk)
Aminoglycosides
Loop diuretics The AKT Examiners feedback report October 2016 specifically
Quinine mentions candidates should have an awareness of rare
conditions, and there were some difficulties with diagnosis
Other causes include and investigation of cancer in children.
• impacted ear wax
• chronic suppurative otitis media According to NICE Guidelines for suspected cancer (June
2015):
*10% of patients may have a 'flamingo tinge', caused by
hyperaemia
Consider referral (within 2 weeks) for oral cancer in people
Q-188 with either:
A 60-year-old gentleman presents to his GP due to concern • unexplained ulceration in the oral cavity lasting for more
over an unusual patch on the inside of his cheek. He than 3 weeks or
describes noticing a patch of red-white on the inside of his • a persistent and unexplained lump in the neck. [new
mouth when he was brushing his teeth. He is not sure how 2015]
long it has been there. He has a 30 pack year smoking history
and drinks approximately 21 units of alcohol per week. Consider an urgent referral (within 2 weeks) for assessment
There is no family history of oral cancer. On examination he for possible oral cancer by a dentist in people who have
is systemically well, no cervical lymphadenopathy is either:
detected. There is a 2 cm red and white macule, velvety in • a lump on the lip or in the oral cavity or
texture on the buccal vestibule of the oral cavity consistent • a red or red and white patch in the oral cavity consistent
with erythroleukoplakia. What is the most appropriate with erythroplakia or erythroleukoplakia. [new 2015]
course of action?
Please see Q-159 for Mouth Lesions
A. Watch and wait, review in 2 weeks
B. Prescribe antibiotics and antibacterial mouth wash, Q-189
review in 1 week A 46-year-old woman presents with tinnitus (worse on the
C. Urgent referral (within 2 weeks) for assessment by a right side), episodic vertigo and hearing loss. Otoscopy is
dentist unremarkable. An audiogram shows the following:
D. Advice on reducing alcohol consumption and smoking
cessation
E. Urgent admission to hospital
What does the audiogram show?

A. Right mixed hearing loss

B. Right sensorineural hearing loss
C. Right conductive hearing loss
D. Bilateral conductive hearing loss
E. Bilateral sensorineural hearing loss

ANSWER:
Bilateral sensorineural hearing loss

EXPLANATION:
The AKT content guide lists 'Tests of hearing such as
tympanometry, audiometry, tuning fork tests including
Weber’s and Rinne’s, neonatal and childhood screening
tests'.

Please see Q-125 for Audiograms

Q-190
A 30-year-old man presents with facial pain and a 'heavy
head' sensation after having a cold. A diagnosis of acute
sinusitis is suspected. Which one of the following should be
considered for symptomatic relief?

A. Intranasal decongestants
B. Intranasal corticosteroids
C. Oral antihistamine
D. Oral mucolytics
E. Steam inhalation

Analgesia is also important. Please see the CKS guidelines for

more information.

ANSWER:
Intranasal decongestants

EXPLANATION:
Please see Q-168 for Sinusitis