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222 Diagnostic EMQs
For each of the following, what is the MOST likely diagnosis?
1. A 32-year-old receptionist attends your clinic with a history of sudden onset
shortness of breath and pleuritic chest pain. She reports that she has also devel-
oped a non-productive cough. Last week she had a LLETZ procedure following
the discovery of abnormal cervical cell changes detected on her recent cervical
screening test. She is also a smoker.
2. A 42-year-old refugee presents at your clinic complaining of a three-month his-
tory of cough with haemoptysis, he also reports pleuritic chest pain. He weighs
58 kg; he tells you that he last weighed himself shortly before his symptoms
commenced and he was 66 kg. On examination he has a temperature of 37.7
o
C.
You perform a chest X-ray which reveals patchy airway opacities in the left
upper lobe with a cavitary lesion.
3. A 61-year-old woman attends your GP clinic. She reports a one-year history of
chronic cough, which is worse in the morning and is associated with thick, foul
smelling sputum production. You review her le and note that she has been pre-
scribed antibiotics on several occasions by other GPs at your clinic for similar
such presentations. She reports that she has recently noticed that her sputum has
become blood tinged. Her chest X-ray reveals tram tracking at the bases of her
lungs. She is a non-smoker.
4. A 26-year-old woman presents to your clinic with epistaxis and nasal obstruc-
tion. She explains that her symptoms are associated with a cough, haemoptysis
and pleuritic chest pain. Urine dipstick reveals haematuria and proteinuria. She
has a strongly positive c-ANCA level detected in the serum.
5. A 25-year-old woman is brought into your emergency department after a
motor bike accident. She is struggling to breath on review and loses con-
sciousness. On examination she has a BP of 82/60 mmHg, heart rate of 120
beats per minute and respiratory rate of 30 breaths per minute. She has bruis-
ing down the right side of her chest wall, her trachea is deviated to the left,
she has absent breath sounds on the right side and there is dullness to percus-
sion on this side also.
See pages 238–239 for answers.
RESPIRATORY CONDITIONS 4
A. Acute pulmonary oedema
B. Asthma
C. Bronchiectasis
D. Chronic obstructive airways disease
E. Churg–Strauss syndrome
F. Cystic brosis
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Respiratory 223
G. Empyema
H. Goodpasture syndrome
I. Granulomatosis with polyangiitis
J. Haemothorax
K. Idiopathic pulmonary brosis
L. Lobar pneumonia
M. Lung abscess
N. Lung cancer
O. Mesothelioma
P. Mycoplasma pneumonia
Q. Pneumothorax
R. Pulmonary aspergillosis
S. Pulmonary embolism
T. Sarcoidosis
U. Silicosis
V. Tuberculo sis
For each of the following, what is the MOST likely diagnosis?
1. A 63-year-old retired re ghter presents to see you regarding shortness of
breath on exertion and associated loss of weight. You perform a chest X-ray
which reveals a small right sided pleural effusion and right sided pleural
thickening.
2. A 66-year-old man presents with shortness of breath. He explains that his symp-
toms have been present for the past 12 months and are progressively worsening,
they are worse with exertion and are associated with a dry cough. He previously
smoked a packet of cigarettes a day but quit 20years ago. On examination his
has ne bibasal crackles, clubbing of his ngers, a JVP of 3cm and no evidence
of peripheral oedema. Spirometry is performed which reveals FEV1 1.59 L
(51% of predicted), FVC 1.68 L (40% of predicted) and FEV1/FVC 94.6%.
3. A 37-year-old woman presents with worsening cough. She reports that recently
she has had episodes of haemoptysis. She is a non-smoker, has a history of
asthma and hay fever. On examination she has diffuse high pitched expiratory
rhonchi and wheeze bilaterally. You arrange for laboratory investigations which
reveal eosinophilia and positive p-ANCA.
4. A 53-year-old ex-smoker attends your clinic for review, he reports that over the
past six months he has been increasingly short of breath on moderate levels of
exertion. He has smoked a pack of cigarettes daily since the age of 19. On exam-
ination he has a barrel chest, faint wheeze throughout his chest and Hoover’s
sign is present. Achest X-ray is requested which demonstrates hyperination.
You perform a spirometry which reveals an FEV1/FVC of 0.67 and an FEV1 of
74% predicted.
5. A 68-year-old man presents to your emergency department with shortness of
breath associated with coughing. He has been symptomatic for the past six days
and has progressively worsened. He reports that he has become increasingly
fatigued and struggles with his daily activities. He has a history of T2DM,
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224 Diagnostic EMQs
hypertension and hyperlipidaemia. On examination he is afebrile, has a JVP of
6cm, his chest has bilateral basal crackles and he has bilateral pitting oedema
to the level of his knees.
See page 239 for answers.
PNEUMOTHORAX
A. Catamenial pneumothorax
B. Chylothorax
C. Fibrothorax
D. Haemothorax
E. Haemopneumothorax
F. Hydropneumothorax
G. Primary spontaneous pneumothorax
H. Secondary spontaneous pneumothorax
I. Tension pneumothorax
For each of the following, what is the MOST likely diagnosis?
1. An 18-year-old netball player is brought into your emergency department via
ambulance with sudden onset shortness of breath associated with right sided
chest pain. The ambulance ofcer explains that she was playing at a local tour-
nament and took a hard hit from another player while trying to obtain the ball,
she fell onto her right side and became extremely short of breath. She was able
to explain to the arriving ambulance ofcers what had occurred but had begun
to deteriorate rapidly shortly after. On arrival she is pale in colour and is strug-
gling to talk. On examination she has a temperature of 36.9
o
C, respiratory rate
of 36, heart rate of 124, blood pressure of 88/62 mmHg and saturations of 89%
at room air, she has decreased breath sounds on the right side of her chest and
associated tracheal deviation towards the left. She is a non-smoker, has no sig-
nicant past medical history and does not use any regular medication other than
the oral contraceptive pill.
2. You are a house ofcer with the surgical unit and are called to the ward to see
a 68-year-old male who is complaining of shortness of breath. His symptoms
have progressively worsened over the past two days since he had an oesopha-
gectomy. He has a history of oesophageal cancer, hypertension and T2DM. On
examination there is dullness to percussion and absent breath sounds on the
right side. He is afebrile and has signicant cervical lymphadenopathy on pal-
pation of the anterior neck. Achest X-ray is performed which reveals a right
sided pleural effusion. Thoracocentesis is performed and 500 ml of milky uid
is removed.
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Respiratory 225
3. A 62-year-old ex-smoker is brought into your rural emergency department with
acute onset of shortness of breath and left sided chest pain. The patient appears
to be distressed and is struggling to talk, his partner explains that he had gotten
up to use the bathroom and on his return his symptoms came on suddenly, she
subsequently called for an ambulance. On examination he is pale and obviously
distressed, he has a temperature of 36.3
o
C and saturations of 90% at room air,
he has decreased breath sounds on the left side of his chest with associated
hyperresonance and the trachea is midline. He has some paperwork from his
GP and a recent spirometry reading from six months ago which conrms a
diagnosis of COPD. He has had his inuenza vaccination this year and has not
had a chest infection in over 12 months.
4. A 36-year-old woman presents to your emergency department with chest pain
and shortness of breath. She reports that she has had similar episodes every
month for the past six months and has been admitted on three occasions during
this time for spontaneous pneumothoraces. She suffers from endometriosis and
her period started two days ago. You arrange for a chest X-ray which reveals a
right sided pneumothorax.
5. A 21-year-old t and healthy male is brought into your emergency department
with shortness of breath associated with right sided chest pain, he explains that
his symptoms started two days ago and have not improved. He is pale in colour
and is talking in full sentences. On examination he has a temperature of 36.7
o
C,
BP of 124/86 mmHg, RR of 18 and saturations of 98% at room air, he has mark-
edly decreased breath sounds on the right side of his chest, accessory muscle
use and the trachea is midline. He is a non-smoker, has no signicant past medi-
cal history and does not use any regular medication. His mother reports that he
was seated on a chair just prior to onset of his symptoms.
See pages 239–240 for answers.
OCCUPATIONAL RESPIRATORY CONDITIONS 1
A. Asbestosis
B. Bronchiolitis obliterans
C. Brucellosis
D. Byssinosis
E. Coal workers pneumoconiosis
F. Hypersensitivity pneumonitis
G. Legionnaires’ disease
H. Occupational asthma
I. Psittacosis
J. Q fever
K. Silicosis
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226 Diagnostic EMQs
For each of the following, what is the MOST likely diagnosis?
1. A 42-year-old woman presents with right sided chest pain and cough that has
persisted for the past three weeks. She was seen by another GP and commenced
on a course of amoxicillin last week without any resolution of her symptoms.
She lives at home alone and keeps many pigeons which she races competitively
on a monthly basis. On examination she appears to be comfortable, has a tem-
perature of 37.0
o
C, regular HR of 64, RR of 20 and saturations of 95% at room
air. Her chest has diffuse expiratory crackles bilaterally. She has not had any
sick contacts nor has she travelled recently.
2. A 32-year-old male presents with a four-year history of cough. He reports that dur-
ing this time he has also been suffering from episodes of shortness of breath, wheeze
and chest tightness. He is a vehicle body spray painter and uses mostly isocyanate-
based aerosol paints. He reports that his symptoms are worse whilst at work.
3. A 53-year-old re ghter presents to your clinic with worsening shortness of
breath. He has no signicant medical history, takes no regular medication and
has no history of cigarette smoking. On examination you note ne crackles in
bilateral lower zones. Achest X-ray is arranged which reveals irregular opaci-
ties associated with a ne reticular pattern and multiple pleural plaques.
4. A 36-year-old man presents with a 12-month history of progressive shortness
of breath. He reports that his symptoms are worse with exertion and are associ-
ated with a dry cough. He is a non-smoker, has no medical history of note and
has been working as a coal mine engineer for the past 11years. On examination
his chest is clear. Achest X-ray reveals small irregular opacities throughout the
chest measuring between 1–5mm.
5. A 27-year-old factory worker presents to your clinic with a two-year history of
cough and worsening shortness of breath. He has no medical history of note and
is a non-smoker. He works at a popcorn manufacturing company and has done
so for the past three years. HRCT shows bronchial wall thickening and mosaic
attenuation with air trapping.
See page 240 for answers.
OCCUPATIONAL RESPIRATORY CONDITIONS 2
A. Asbestosis
B. Bronchiolitis obliterans
C. Brucellosis
D. Byssinosis
E. Coal workers pneumoconiosis
F. Hypersensitivity pneumonitis
G. Legionnaires’ disease
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Respiratory 227
H. Occupational asthma
I. Psittacosis
J. Q fever
K. Silicosis
For each of the following, what is the MOST likely diagnosis?
1. A 53-year-old farmer presents to your GP clinic complaining of worsening
shortness of breath on exertion over the past eight days. He reports that he gets
chest tightness during the episodes, he also suffers from tightness in his chest.
He further reports that he has had intermittent fevers over the past four days. He
tells you that his symptoms are usually worse when he is on the farm. He has no
signicant medical history, takes no regular medications and has never smoked
cigarettes.
2. A 38-year-old cotton factory worker presents with a 12-month history of per-
sistent dry cough. He explains that his cough has gradually worsened and is
associated with a small amount of sputum production. He is a non-smoker and
has no signicant medical history.
3. A 45-year-old man presents with a six-month history of productive cough and
shortness of breath on exertion. He is a non-smoker and has no signicant medi-
cal history. He has worked as a sand blaster for 20years and reports no signi-
cant family medical history. He has seen several doctors who have prescribed
him a variety of antibiotics and steroids to no avail. Achest X-ray reveals bilat-
eral hilar adenopathy with egg shell calcication.
4. A 58-year-old man presents to your emergency department with worsening
shortness of breath. He has had a four-day history of cough productive of thick
yellow sputum, myalgia and fever. He is an air conditioner repairman and works
in high rise buildings. He has a history of type 2 diabetes mellitus and has been
smoking a packet of cigarettes a day for the past 30years. He is compliant with
his medications. On examination he has a temperature of 38.0
o
C, regular HR of
104, RR of 26 and saturations of 93% at room air. His chest has diffuse expira-
tory crackles bilaterally. He has not had any sick contacts nor has he travelled
recently.
5. A 26-year-old man presents to your clinic with a low-grade fever and cough.
He also reports myalgia and joint pain. His symptoms have been present for the
past two days and are worsening. He has no signicant medical history. He has
recently returned from travel to Portugal, three days ago, where he worked at
a dairy farm for a year. He explains that he is normally t and active, he also
explains that he eats healthy and has been consuming unpasteurised dairy prod-
ucts while abroad.
See pages 240–241 for answers.
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228 Diagnostic EMQs
LUNG CANCER
A. Bronchial carcinoid
B. Bronchioloalveolar carcinoma
C. Large cell lung carcinoma
D. Lung adenocarcinoma
E. Lymphoma
F. Mesothelioma
G. Pancoast tumor
H. Small cell lung carcinoma
I. Squamous cell lung cancer
J. Teratoma
For each of the following, what is the MOST likely diagnosis?
1. A 50-year-old accountant presents with a nine-month history of cough. He has
no signicant medical history and he is a non-smoker. Achest X-ray reveals an
irregularly shaped lesion in the left lung. Bronchoscopy is normal.
2. A 70-year-old woman presents to your clinic with a three-month history of right
shoulder pain radiating into her scapula and axilla. She reports that she has also
had progressive weakness in her right upper limb particularly in her hand. She
has not had any trauma. On examination she has reduced grip strength in her
right hand.
3. A 46-year-old man presents with a chronic cough. His symptoms have been
present for 12 months and have recently been associated with haemoptysis
and dyspnoea. He has no signicant medical history and is a non-smoker. You
arrange for bronchoscopy which reveals a cherry red lesion in the left superior
lobar bronchus.
4. A 67-year-old man presents with an exacerbation of COPD, he has had multiple
similar episodes this year. You have not been able to successfully treat his cur-
rent symptoms with the use of oral steroids and antibiotics and have arranged
for a chest X-ray which reveals a 2cm mass in the left lower lobe. Blood elec-
trolyte levels reveal hyponatraemia.
5. A 60-year-old retired pipe lagger presents to see you regarding shortness of breath
on exertion and associated loss of weight. You perform a chest X-ray which
reveals a small right sided pleural effusion and right sided pleural thickening.
See page 241 for answers.
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Respiratory 229
CHEST IMAGING FINDINGS 1
A. Acute pulmonary edema
B. Asbestosis
C. Bronchiectasis
D. Chronic obstructive airways disease
E. Coarctation of the aorta
F. Left atrial enlargement
G. Lobar consolidation
H. Lung abscess
I. Pericardial effusion
J. Pleural effusion
K. Pleural empyema
L. Pneumomediastinum
M. Pneumothorax
N. Pulmonary embolism
O. Round atelectasis
P. Sarcoidosis
Q. Tetralogy of Fallot
R. Total anomalous pulmonary venous return
S. Transposition of the great arteries
For each of the following, what is the MOST likely diagnosis?
1. Double density sign seen on a chest X-ray.
2. Blunting of the costophrenic angle seen on a chest X-ray.
3. Double diaphragm sign seen on a supine chest X-ray.
4. Split pleura sign seen on CT of the chest.
5. Cluster of black pearls sign seen on contrast enhanced CT of the chest.
6. Holly leaf sign seen on a chest X-ray.
7. Bulging ssure sign on chest X-ray.
See pages 241–242 for answers.
CHEST IMAGING FINDINGS 2
A. Acute pulmonary edema
B. Asbestosis
C. Bronchiectasis
D. Chronic obstructive airways disease
E. Coarctation of the aorta
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230 Diagnostic EMQs
F. Left atrial enlargement
G. Lobar consolidation
H. Lung abscess
I. Pericardial effusion
J. Pleural effusion
K. Pleural empyema
L. Pneumomediastinum
M. Pneumothorax
N. Pulmonary embolism
O. Round atelectasis
P. Sarcoidosis
Q. Tetralogy of Fallot
R. Total anomalous pulmonary venous return
S. Transposition of the great arteries
For each of the following, what is the MOST likely diagnosis?
1. Water bottle sign seen on a chest X-ray.
2. Batwing appearance of chest X-ray.
3. Comet tail sign seen on CT of the chest.
4. Boot shaped heart seen on chest X-ray.
5. Egg on a string sign seen on chest X-ray.
6. Signet ring sign seen on CT of chest.
See page 242 for answers.
CHEST IMAGING FINDINGS 3
A. Acute pulmonary edema
B. Asbestosis
C. Bronchiectasis
D. Chronic obstructive airways disease
E. Coarctation of the aorta
F. Left atrial enlargement
G. Lobar consolidation
H. Lung abscess
I. Pericardial effusion
J. Pleural effusion
K. Pleural empyema
L. Pneumomediastinum
M. Pneumothorax
N. Pulmonary embolism
O. Round atelectasis
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Respiratory 231
P. Sarcoidosis
Q. Tetralogy of Fallot
R. Total anomalous pulmonary venous return
S. Transposition of the great arteries
For each of the following, what is the MOST likely diagnosis?
1. Figure3 sign seen on a chest X-ray.
2. Snowman sign seen on chest X-ray.
3. Sabre-sheath trachea seen on CT of the chest.
4. Continuous diaphragm sign seen on chest X-ray.
5. Fleischner sign seen on chest X-ray.
6. Irregularly shaped cavity with an air uid level seen on a chest X-ray.
See pages 242–243 for answers.
RESPIRATORY MICROBIOLOGY 1
A. Aspergillus fumigatus
B. Bordetella pertussis
C. Chlamydia psittaci
D. Haemophilus inuenzae
E. Legionella pneumophila
F. Mycoplasma pneumoniae
G. Mycoplasma tuberculosis
H. Pneumocystis jirovecii
I. Pseudomonas aeruginosa
J. Staphylococcus aureus
K. Streptococcus pneumoniae
L. Streptococcus pyogenes
For each of the following situations, what is the MOST likely cause?
1. A 58-year-old man presents with worsening shortness of breath. He has had a
four-day history of cough productive of thick yellow sputum, myalgia and fever.
He is an air conditioner repairman and works in high-rise buildings. He has a
history of type 2 diabetes mellitus and has been smoking a packet of cigarettes a
day for the past 30years. He is compliant with his medications. On examination
he has a temperature of 38.0
o
C, regular HR of 104, RR of 26 and saturations of
93% at room air. His chest has diffuse expiratory crackles bilaterally. He has
not had any sick contacts nor has he travelled recently.
2. A 45-year-old presents with a two-week history of cough and associated short-
ness of breath. He has a history of hypertension, appendicectomy at the age of
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