🤔 MEDIUM

 There’s a tickle in your throat? I’m reading these words in medical school? Oh then you MUST be on ACEi mate … every good medical student knows that the number one differential of cough on med school stems is ramipril … or IS it????  

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Approach to the Patient with Cough - Part One

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Question 1

Stem 1 of 4

A 72YOM presents with chronic cough. He has a 45 year pack history for cigarettes (high tar) and keeps “getting an annoying tickle in the throat”. His cough is productive.
What colour is classical of the chronic cough, given the most likely diagnosis?
A
Blood streaked
B
Clear
C
Green
D
Pink-frothy
E
Yellow
Question 1 Explanation: 
Chronic bronchitis associated with production is classically a white-yellow sputum colour. This will change, and vary of course, as local trauma can cause blood and infective exacerbation could make yellow (viral) or green (bacterial) or both (bronchiectasis over time).
Question 2

Stem 2 of 4

Due to this diagnosis, which vaccinations must be prioritised in this demography?
A
Bordetella pertussis
B
Hepatitis B virus
C
Hepatitis C virus
D
Influenza
E
Streptococcus pneumoniae
Question 2 Explanation: 
Keeping up to date with vaccinations, lifestyle factors and quitting smoking are some of the most important things to be done in the management of this obstructive, progressive pulmonary disease. - The American CDC also mention that, if not vaccinated for pertussis as a child, this should be considered in addition to influenza and pneumococcus.
Question 3

Stem 3 of 4

Of the listed risk factors, which have the strongest published link to COPD?
A
Age (increased)
B
Air pollution
C
Cigarettes
D
Genetics
E
Male sex
Question 3 Explanation: 
Smoking, increases of age and genetics have by far the strongest link to COPD. All others are weaker links, though still a factor.
Question 4

Stem 4 of 4

The grouping is classified as GOLD group A. What is the first line therapy for his classification?
A
SABA
B
SAMA
C
LABA
D
LAMA
E
ICS
Question 4 Explanation: 
SABA - or short acting beta2 agonist - is offered first line to GOLD A patients (few symptoms, few risks for exacerbations). The GOLD criteria is recommended in the UK as the means to identify first line therapies for COPD - so well worth a check out.
Question 5

Stem 1 of 4

A 60YOF presents with dyspnoea. She has a known diagnosis of heart failure. On examination, she is hypertensive, tachycardic with added heart sounds and 7cm JVP elevation. Bilateral ankle oedema is noted.
What should be the height of the pulsations seen in the internal jugular vein?
A
>2cm above the sternal angle
B
>3cm above the sternal angle
C
>4cm above the sternal angle
D
>12cm above the xiphisternum
E
> 15cm above the xiphisternum
Question 5 Explanation: 
Horizontal line from the highest point of the double pulsatile wave intersecting with a vertical line from the sternal angle. >3cm is JVP elevation. Just one of those facts to remember for the general examination.
Question 6

Stem 2 of 4

Select all of the following that would be a first line investigation in this patient.
A
BNP
B
Cardiac angiography
C
Cardiac CT
D
CXR
E
ECG
F
Procalcitonin
G
TFT
H
Troponin
Question 6 Explanation: 
First line for HF acute exacerbation should include Bed (ECG, Echo), Bld (FBC, Hb, TFT, trop, BNP), Image (CXR).
Question 7

Stem 3 of 4

An ECG is performed and compared to a years previous. New Q waves are discovered. What could, therefore, have been the trigger for this exacerbation?
A
First degree heart block
B
Mobitz I heart block
C
Mobitz II heart block
D
NSTEMI
E
STEMI
Question 7 Explanation: 
Q waves with STe in contiguous leads are the classic hallmarks of STEMI changes on ECG.
Question 8

Stem 4 of 4

What is the first line management of this patient?
A
Eplerenone
B
Furosemide
C
ISMN (nitrate)
D
Oxygen
E
Thiazide diuretic
Question 8 Explanation: 
BMJ Best Practice and the OHCM recommend oxygen therapy first line with adjunct support. LMNOP is a good, commonly used tool, to remember the acute mx of heart failure and if you reverse the letters, you get the order of succession: position (upright), oxygen, nitrates, morphine, loop diuretics.
Question 9

Stem 1 of 4

A 40YOM presents with a longstanding history of chronic, non-productive cough and irritable sensation at the back of the throat. General examination is otherwise normal.
How does NICE define a “chronic cough”?
A
3+ weeks
B
5+ weeks
C
7+ weeks
D
8+ weeks
E
20+ weeks
Question 9 Explanation: 
NICE: “Cough can be acute (lasting less than 3 weeks), sub-acute (lasting 3–8 weeks), or chronic (lasting more than 8 weeks).”
Question 10

Stem 2 of 4

What else would form key differentials to a chronic cough presentation?
A
Asthma
B
Captopril
C
Foreign body inhalation
D
Gastro-oesophageal reflux disease
E
Sarcoidosis
Question 10 Explanation: 
GASP - GORD, asthma, ACEi, sarcoid, post-nasal drip form the bulk of chronic cough.
Question 11

Stem 3 of 4

According to the NICE criteria, which of the following vignettes would suggest a patient requiring emergent admission to hospital due to cough?
A
Respiratory rate of 27 with a cough
B
Tachycardia of 100 with a cough
C
Systolic blood pressure of 100 with a cough
D
Oxygenation of 91% with a cough
E
PEFR 60% expected
Question 11 Explanation: 
The following changes suggest acute admission to hospital according to NICE, 2021: 1) >30RR ; 2) >130HR ; 3) SBP <90 ; 4) PaO2 <92% ; 5) central cyanosis ; 6) PEFR <33% expect ; 7) ALOC ; 8) accessory muscle utilisation ;
Question 12

Stem 4 of 4

Which medication listed below would be both diagnostic, and therapeutic, in this patient?
A
Antibiotic/antifungal cover
B
Decongestant therapy (eg nasal)
C
First generation antihistamine
D
Inhaled corticosteroid
E
Second generation antihistamine
Question 12 Explanation: 
As Dr. House MD once said, swathed in questionable things, “treating is quicker than testing”. For post-nasal drip, that’s actually something desirable. A positive response to a trial of first-generation antihistamines supports a diagnosis of post-nasal drip.
Question 13

Stem 1 of 6

A 61 year old patient, with hyperlipidaemia and controlled primary hypertension, is brought to ED by his wife (July 2020). He has a dry cough, high subjective fever and anosmia. His vitals are as follows:
T39ºC ; HR122 ; RR21 ; PaO2 89% ; GCS15 ; SBP120 ;
What are the four cardinal diagnostic factors for COVID19?
A
Altered smell/taste
B
Chest pain
C
Cough
D
Dizziness
E
Fatigue
F
Fever
G
GI symptoms
H
Headache
I
Muscle pain
J
Shortness of breath
K
Sore throat
L
Sputum production
Question 13 Explanation: 
As of 2021, the UK Department of Health and Social Care states that every person with a fever, cough, shortness of breath OR altered sense of smell/taste should trigger suspicion of COVID19 and immediately undergo household isolation. They should be tested as soon as possible and closely monitor their symptoms for progression.
Question 14

Stem 2 of 6

A chest X-ray is undertaken, and blood is drawn. What are the most likely imaging findings?
A
Basal effusion
B
Bilateral lung infiltrate
C
Clear lung fields
D
Lung abscess
E
Pleuritis
Question 14 Explanation: 
COVID19 has a very characteristic bilateral lung infiltrate pattern on CXR in 3 out of 4 cases - this is the most common finding. HRCT is the more ideal test, but is harder to repeat, more resource intensive (in a resource-poor environment of a pandemic) and slower.
Question 15

Stem 3 of 6

RT-PCR of the nasopharynx is undertaken and negative. What is the next best step?
A
Adopt watch and wait approach
B
Culture and sensitivity for other cause
C
Order a high resolution CT thorax
D
Repeat RT-PCR due to clinical picture
E
Undertake rapid antigen testing
Question 15 Explanation: 
The WHO (as of February 2021) states that RT-PCR, and all molecular testing, is an adjunct to the clinical picture - and context - of the patient. If the PCR is negative, mutation may have occurred, or the swab might have missed the region of colonisation in the pharynx. Repeat the test, ideally with another molecular profile. Please note, a pandemic is a fast-evolving situation - priorities, diagnostic criteria etc change very suddenly, not always due to science, but availability and politics.
Question 16

Stem 4 of 6

The patient continues to deteriorate and, amongst other tests, a coagulation study is performed. Which of the following might you suspect of serious disease?
A
Elevated D-Dimer
B
Elevated fibrin-degradation products
C
Prolonged PTT
D
Elevated fibrinogen
E
Decreased APTT
Question 16 Explanation: 
Elevated fibrinogen, FDP and prolongation of PTT are hallmarks of severe inflammation.
Question 17

Stem 5 of 6

The patient is aggressively treated in hospital. Amongst a cocktail of medications, enoxaparin is given. What is the mechanism of this medication?
A
Antithrombin three activator
B
Direct factor ten inhibitor
C
Direct factor two inhibitor
D
Cofactor (V, VIII) inhibitor
E
Tissue plasminogen activator
Question 17 Explanation: 
Low molecular weight heparin is the NICE approved first line therapy to prevent venous prophylaxis in patients with severe, hospitalised COVID19. TED is how you remember them - tinzaparin, enoxaparin, dalteparin.
Question 18

Stem 6 of 6

The patient recovers and is discharged home 10 days after the initial diagnosis. How many more days must he self-isolate for?
A
0 days
B
1 day
C
2 days
D
3 days
E
4 days
Question 18 Explanation: 
UK law states that you must self-isolate for 14 days after a positive test/clinical diagnosis for COVID19.
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References

  1. BMJ Best Practice – http://bestpractice.bmj.com
  2. Churchill Pocketbook of Differential Diagnoses, 4th Ed 2014
  3. Geeky Medics – https://geekymedics.com/jugular-venous-pressure-jvp/
  4. NICE CKS Cough – https://cks.nice.org.uk/topics/cough/
  5. Oxford Handbook of Clinical Medicine – 10th Ed 2017

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