12/4/2016

BMJ OnExamination Assessment : REF4502 : REF4502

Work Hard - MRCP Part 2 Written

Exam Options

Work hard progresses you systematically through the case problems giving you questions from all topics relevant to the current exam

in a random pattern; this encourages you to answer as many questions as possible, testing your knowledge on multiple topics.

1953/ 1956 questions answered

Question 1953 of 1956

A 66-year-old retired foundry worker was referred to the medical admissions unit after developing sudden onset of right sided chest pain. For the past
24 hours he has felt unwell, with malaise, headache and myalgias. The GP's letter states that the patient has become mildly confused over the past
three to four hours.
On examination he is febrile (39C) and confused. Pulse 62 per minute, blood pressure 110/75.
Investigations showed:
Haemoglobin

165 g/L

(130-180)

White cell count

20.1 109/L

(4-11)

Neutrophils

18.5 109/L

(1.5-7)

Lymphocytes

0.8 109/L

(1.5-4)

Monocytes

0.8 109/L

(0-0.8)

Platelets

390 109/L

(150-400)

Serum sodium

121 mmol/L

(137-144)

Serum potassium

4.3 mmol/L

(3.5-4.9)

Serum urea

6.2 mmol/L

(2.5-7.5)

Serum creatinine

99 mol/L

(60-110)

Serum bilirubin

7 mol/L

(1-22)

Serum AST

63 U/L

(1-31)

Serum ALP

100 U/L

(45-105)

Serum albumin

39 g/L

(37-49)

ABGs on air:
pH

7.42

(7.36-7.44)

pO2

9.9 kPa

(11.3-12.6)

pCO2

3.9 kPa

(4.7-6.0)

Bicarbonate

22 mmol/L

(20-28)

Urinalysis:

Protein +

His chest x ray is shown below.

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12/4/2016

BMJ OnExamination Assessment : REF4502 : REF4502

Which of the following investigations is most likely to establish the identity of the causative organism?
(Please select 1 option)
Blood cultures

Chlamydia pneumoniae serology

Immunocytological staining of bronchoalveolar lavage uid

Legionella urinary antigen

Correct

PCR
This patient's symptoms, signs and investigations are highly suggestive of Legionella pneumonia.
The illness may start abruptly with a brief prodrome of malaise, myalgia and headache. High fever and non-productive cough are common and may be
accompanied by pleuritic chest pain. Confusion may represent toxic encephalopathy.
A marked neutrophil leukocytosis may be associated with concomitant lymphopenia.
Hyponatraemia occurs more commonly than with other pneumonias.
Liver function abnormalities are common but non-specic.
Proteinuria (sometimes myoglobinuria) is common.
Chest x ray usually shows lobar consolidation and progresses to bilateral involvement in 50% of cases.
Although the diagnosis may be made by culturing the organism from sputum, tests for Legionella antigens in urine offer a rapid test. Urinary antigen
testing is 70-100% sensitive and 100% percent specic.
Immunological staining and PCR are not as sensitive or specic as urinary antigen testing.

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Test Analysis

Correct
Incorrect
Partially Correct

Score: 60.24%
Total Answered: 332

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