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????
Approach to the Patient with Cough - Part One
Congratulations - you have completed Approach to the Patient with Cough - Part One . You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%
Your answers are highlighted below.
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?
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).
Stem 2 of 4Due to this diagnosis, which vaccinations must be prioritised in this demography?
Hepatitis B virus
Hepatitis C virus
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.
Stem 3 of 4Of the listed risk factors, which have the strongest published link to COPD?
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.
Stem 4 of 4The grouping is classified as GOLD group A. What is the first line therapy for his classification?
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.
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?
>2cm above the sternal angle
>3cm above the sternal angle
>4cm above the sternal angle
>12cm above the xiphisternum
> 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.
Stem 2 of 4Select all of the following that would be a first line investigation in this patient.
Question 6 Explanation:
First line for HF acute exacerbation should include Bed (ECG, Echo), Bld (FBC, Hb, TFT, trop, BNP), Image (CXR).
Stem 3 of 4An ECG is performed and compared to a years previous. New Q waves are discovered. What could, therefore, have been the trigger for this exacerbation?
First degree heart block
Mobitz I heart block
Mobitz II heart block
Question 7 Explanation:
Q waves with STe in contiguous leads are the classic hallmarks of STEMI changes on ECG.
Stem 4 of 4What is the first line management of this patient?
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.
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”?
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).”
Stem 2 of 4What else would form key differentials to a chronic cough presentation?
Foreign body inhalation
Gastro-oesophageal reflux disease
Question 10 Explanation:
GASP - GORD, asthma, ACEi, sarcoid, post-nasal drip form the bulk of chronic cough.
Stem 3 of 4According to the NICE criteria, which of the following vignettes would suggest a patient requiring emergent admission to hospital due to cough?
Respiratory rate of 27 with a cough
Tachycardia of 100 with a cough
Systolic blood pressure of 100 with a cough
Oxygenation of 91% with a cough
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 ;
Stem 4 of 4Which medication listed below would be both diagnostic, and therapeutic, in this patient?
Decongestant therapy (eg nasal)
First generation antihistamine
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.
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?
Shortness of breath
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.
Stem 2 of 6A chest X-ray is undertaken, and blood is drawn. What are the most likely imaging findings?
Bilateral lung infiltrate
Clear lung fields
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.
Stem 3 of 6RT-PCR of the nasopharynx is undertaken and negative. What is the next best step?
Adopt watch and wait approach
Culture and sensitivity for other cause
Order a high resolution CT thorax
Repeat RT-PCR due to clinical picture
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.
Stem 4 of 6The patient continues to deteriorate and, amongst other tests, a coagulation study is performed. Which of the following might you suspect of serious disease?
Elevated fibrin-degradation products
Question 16 Explanation:
Elevated fibrinogen, FDP and prolongation of PTT are hallmarks of severe inflammation.
Stem 5 of 6The patient is aggressively treated in hospital. Amongst a cocktail of medications, enoxaparin is given. What is the mechanism of this medication?
Antithrombin three activator
Direct factor ten inhibitor
Direct factor two inhibitor
Cofactor (V, VIII) inhibitor
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.
Stem 6 of 6The patient recovers and is discharged home 10 days after the initial diagnosis. How many more days must he self-isolate for?
Question 18 Explanation:
UK law states that you must self-isolate for 14 days after a positive test/clinical diagnosis for COVID19.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
There are 18 questions to complete.
- BMJ Best Practice – http://bestpractice.bmj.com
- Churchill Pocketbook of Differential Diagnoses, 4th Ed 2014
- Geeky Medics – https://geekymedics.com/jugular-venous-pressure-jvp/
- NICE CKS Cough – https://cks.nice.org.uk/topics/cough/
- Oxford Handbook of Clinical Medicine – 10th Ed 2017