All candidates will receive extensive written answers and notes covering both the pre-course material and the further paper covered on the day. Below is a sample of a typical EMQ question and answer. An MCQ question and the answer can be found here.
A 20 year old West Indian female presents with increasing shortness of breath over a 10 week period. She has noticed increasing difficulty in climbing stairs and carrying her shopping home. She has also developed a dry persistent cough, and has lost 5 kg in weight. There has been no chest pain. She is a non smoker, although has lived in a city all her adult life.
In the past she has been fit and well apart from occasional upper respiratory tract infections over the winter period. She takes no regular medication. She works in an air conditioned office, and has not had contact with birds.
On examination she is thin and pale. There is no evidence of central cyanosis. There is no finger clubbing or flap of CO2 retention. There are several enlarged lymph nodes in the anterior cervical area, which are rubbery and non tender. The trachea is central, and apex un-displaced. Chest expansion is symmetrical but reduced. Percussion is normal. Auscultation reveals fine end inspiratory crepitations at both lung bases. There was a rash on both shins consisting of dusky red lesions, which were tender to palpation.
The patient has pulmonary sarcoidosis with respiratory impairment due to pulmonary fibrosis. The rash is erythema nodosum and although this may occur in TB (along with the cervical lymphanenopathy) it is less likely and is less likely to give pulmonary fibrosis ('fine end inspiratory crepitations'). Lymphoma is the other main differential diagnosis.
Spirometry will show a restrictive pattern indicating pulmonary fibrosis (FEV1/FVC >80%).
CXR may show hilar lymphadenopathy (? Carcinoma, TB, Sarcoid , lymphoma, histoplasmosis).
Transbronchial biopsy gives the diagnosis.
ACE is done but is not specific being raised in asbestosis, silicosis, lymphoma and TB.
Sarcoid granulomas can occur anywhere (eye, skin, brain, bone, liver, parotids heart), hence it is a multi-systemic disease much loved by examiners.
Be aware of sarcoidosis as a cause of hypercalcaemia due to 1a hydroxylation of Vit D.
Prognosis worse in blacks, and those with predominantly pulmonary fibrosis fair worse than hilar lymphadenopathy alone.