MRCGP - AKT practice questions: asthma

In this new series, questions from www.examdoctor.co.uk, produced according to RCGP curriculum topics, are provided to help registrars prepare for the applied knowledge test.

Short answers can be found below.

CLICK HERE TO VIEW THE FULL EXPLANATION FOR EACH ANSWER

1. A 32-year-old woman with known asthma attends the out-of-hours service. She is presenting for the fifth time this year due to a panic attack with palpitations. Her chest is clear on examination with no respiratory distress. The doctor on duty suggests using propranolol to help deal with her panic attacks. Identify the MOST important ethical principle involved:

a. Autonomy

b. Beneficence

c. Non-maleficence

d. Informed consent

e. Confidentiality

2. A four-year-old boy presents with his mother. He has a history of cough. Which of the following features makes asthma a more likely diagnosis?

a. Symptoms occur only during an URTI

b. Cough without wheeze or difficulty breathing

c. History of moist cough

d. Family history of atopy

e. No wheeze on clinical examination

3. A six-year-old boy presents with his mother. He was diagnosed with asthma two years ago and takes a salbutamol inhaler. His mother reports that he is using his inhaler much more frequently than usual. In particular he has been coughing at night. On examination, his chest is clear at present, but his peak flow is reduced to 70 per cent of his best. Which is the next most appropriate step?

a. Add inhaled steroid 200 microgram/day

b. Add inhaled steroid 800 microgram/day

c. Add inhaled steroid 1,000 microgram/day

d. Add inhaled steroid 2,000 microgram/day

e. Add oral leukotriene receptor antagonist

4. For asthma, which is the appropriate hypersensitivity reaction type?

a. Type I hypersensitivity

b. Type II hypersensitivity

c. Type III hypersensitivity

d. Type IV hypersensitivity

e. Type V hypersensitivity

- This topic falls under section 15.8 of the RCGP curriculum 'Respiratory problems', www.healthcarerepublic.com/curriculum

Answers explained
1. Non-maleficence means 'do no harm'. This involves avoiding scenarios where treatments known to be harmful are given - here giving a beta-blocker in a patient with asthma.

2. Features that increase the probability of asthma include:
  • more than one of the following: wheeze, cough, difficulty breathing, chest tightness, especially if frequent and recurrent
  • symptoms worse at night and in the early morning
  • symptoms occur in response to triggers such as exercise, pets, cold or damp
  • symptoms occur inbetween infections
  • history of atopy/family history of atopy
  • wheeze heard on auscultation
  • history of improvement in symptoms or lung function in response to adequate therapy.

Clinical features that lower the probability of asthma include:

  • symptoms with an URTI only, no interval symptoms
  • isolated cough in the absence of wheeze or difficulty breathing
  • history of moist cough
  • prominent dizziness, light-headedness, peripheral tingling
  • repeatedly normal physical examination of chest when symptomatic
  • normal peak flow or spirometry when symptomatic
  • no response to a trial of asthma therapy
  • clinical features pointing to an alternative diagnosis.

3. Below are summaries of the treatment steps for asthma. For each of the stepwise guidelines, always use the lowest step to maintain control and reassess after each step.

Management in children under 5:
Step 1 – Mild intermittent asthma: inhaled short-acting beta 2 agonist (SABA) as required.
Step 2 – Regular preventer therapy: add inhaled steroid 200–400 micrograms/day according to severity of symptoms or leukotriene receptor antagonist if inhaled steroid cannot be used.
Step 3 – Initial add-on therapy: inhaled steroid and leukotriene receptor antagonist. In under twos, consider moving to step 4.
Step 4 – Persistent poor control: refer to respiratory paediatrician.

Management in children 5–12 years:
Step 1 – Mild intermittent asthma: inhaled SABA.
Step 2 – Regular preventer therapy: add inhaled steroid 200–400 micrograms/day.
Step 3 – Initial add-on therapy: add long-acting beta-agonist (LABA). Maximise inhaled steroid. Consider leukotriene receptor antagonist or SR theophylline.
Step 4 – Persistent poor control: increase inhaled steroid up to 800 micrograms/day.
Step 5 – Continuous or frequent use of oral steroids: maintain high-dose inhaled steroid at 800 micrograms/day. Refer to respiratory physician.

Management in adults:
Step 1 – Mild intermittent asthma: inhaled SABA as required.
Step 2 – Regular preventer therapy: add inhaled steroid 200–800 micrograms/day, appropriate to severity of disease.
Step 3 – Initial add-on therapy: LABA and assess response. Maximize inhaled steroid. Consider leukotriene receptor antagonist or SR theophylline.
Step 4 – Persistent poor control: consider increasing steroid to 2,000 micrograms/day. Addition of fourth drug: leukotriene receptor antagonist, SR theophylline or beta-agonist tablet.
Step 5 – Continuous or frequent use of oral steroids: daily steroid tablet. Maintain high-dose steroids. Refer for specialist care.

4. Type I hypersensitivity (anaphylactic or immediate): antigen and IgE on mast cells and basophils react. It occurs in asthma, atopy and some acute drug reactions.

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