103707273-Respiratory-Medicine-151-200

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Respiratory Medicine

151. A 32-year-old patient with asthma has been stable with inhaled salbutamol whenrequired. Recently she had to use her inhaler more frequently and also at night. What is the

next step in her therapy?

Inhaled 2-agonist at maximum dose

Regular inhaled budesonide, inhaled salbutamol when required Your answer

Addition of oral corticosteroids

Addition of oral leukotriene-receptor antagonist

Addition of oral theophylline

This patient needs step 2 in the management of chronic asthma because she needs her 2-

agonist inhaler more than once a day and also complains of night-time symptoms. Step 2therapy consists of a regular standard-dose inhaled corticosteroid and an additional inhaled

short-acting 2-agonist as required. Oral leukotriene-receptor antagonists and theophyllineare indicated in step 3 if the asthma is still not controlled. Oral corticosteroids should beadded in step 5.

152. A 50-year-old man patient was referred by his GP because of a long-standinghistory of persistent cough productive of mucopurulent sputum. He also noticedincreasing shortness of breath. The patient has been treated several times forrecurrent chest infections. What is the most likely diagnosis?

Lung cancer

Bronchiectasis

Your answer

Chronic cardiac failure

Extrinsic allergic alveolitis

Asthma

Bronchiectasis should be suspected when there is a history of persistent coughproductive of mucopurulent or purulent sputum throughout the year. Patientshave frequently been treated for recurrent chest infections and labelled as


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bronchitic, often despite the absence of a history of smoking. Patients mayproduce mucoid sputum early in their disease, developing purulent sputum whenthey suffer an exacerbation associated with a viral upper respiratory tractinfection. Such exacerbations may be associated with pleuritic chest pain,haemoptysis, fever and sometimes wheeze.

Those presenting as adults often recall a chesty cough or wheezy bronchitisassociated with upper respiratory tract infections in childhood, followed bycomplete resolution of symptoms in the teens and early adult life before thesereturn after a viral trigger. Upper respiratory tract symptoms such as nasal dripare common, and in about 30% of cases there is a history of chronic sinusitis.Patients with bronchiectasis also suffer from undue tiredness, which many findmore troublesome than the productive cough.

153. A 25-year-old basketball player is brought to the accident and emergency departmentwith a history of sudden onset of right-sided chest pain and breathlessness. On

examination, tachycardia is noted. Decreased breath sounds are heard on the right side.

What is the probable diagnosis?

Rupture of subpleural tuberculous focus

Rupture of a subphrenic abscess through the diaphragm

Rupture of apical subpleural blebs Your answer

Pulmonary embolism

Lobar pneumonia

Rupture of subpleural tuberculous focus is a rare cause, particularly in the UK. Rupture of a

subphrenic abscess through the diaphragm may cause empyema, not pneumothorax.

Primary spontaneous pneumothorax is due to rupture of apical pleural blebs. The incidence

of pneumothorax is highest in males aged 15-30 years where smoking, height and thepresence of apical subpleural blebs appear to be the most important aetiological factors.

Height may be a significant factor in this case as the patient is a basketball player. Lobar

pneumonia usually presents with a history of cough, fever and malaise. The majority ofpatients with pulmonary embolism present with pleurisy, shortness of breath and

haemoptysis. 75% of pulmonary emboli derive from deep vein thrombosis in the lower

limb. There does not appear to be any risk factor for venous thromboembolism in this case.

154. A 78-year-old man, who worked as a plumber, presents with a unilateralpleural effusion. He has felt unwell for some time and spends much of the daysitting in a chair. Pleural biopsies taken at thoracoscopy have shown malignantmesothelioma and extensive tumour on all pleural surfaces was noted. Havingexplained the diagnosis to him, which would be the most appropriate treatmentto consider next?


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Radical surgery alone

Radical surgery combined with chemotherapy and radiotherapy

Chemotherapy alone

Radiotherapy to the hemithorax

Radiotherapy to the thoracoscopy tract site

Your answer

Radical surgery (extraparietal pneumonectomy) involves removing the lung,

parietal pleura, diaphragm and pericardium. It is suitable only for fit patientswith a low tumour volume. Used alone, it does not improve survival, but studiesare underway using it as part of trimodality treatment with chemotherapy andradiotherapy. These suggest it may improve survival, although it is not curative.It has a perioperative morbidity of up to 50% and mortality of up to 8%.Chemotherapy, as yet, has not been found to have any impact on survival,although 30% of patients have an objective tumour response. Radiotherapy to theentire pleural surface is technically difficult and associated with a high risk ofradiation pneumonitis, hepatitis and pericarditis. Results are disappointing.Radiotherapy to chest instrumentation-tract sites is effective at preventingtumour seeding and growth (see Boutin et al 1995. Chest,108(3),754-8) and is

recommended after pleural procedures. This is routine practice, along withproviding symptomatic treatment.

155. A 70-year-old man with chronic bronchitis is admitted with dyspnoea and peripheral

cyanosis. On auscultation, there are scattered rhonchi but no wheeze or evidence ofconsolidation. Arterial blood-gas determinations show a pH of 7.38,pa(O2) 40 mmHg and

pa(CO2) 45 mmHg. 40% oxygen is given by facemask. Within 10 minutes his cyanosis

worsens and his respiratory rate falls. A repeat arterial blood-gas estimation shows a pH of7.24,pa(O2) 72 mmHg,pa(CO2) 63 mm Hg. What is the next step in his management?


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Obtain a chest X-ray

Do a ventilation/perfusion scan

Decrease the fraction of inspired oxygen Your answer

Initiate mechanical ventilation

Administer intravenous aminophylline

Patients with advanced COPD are at risk of developing acute respiratory failure. Oxygen

therapy is effective in reversing the hypoxaemia of respiratory failure. However, oxygenadministration may lead to hypercapnia as these patients have lost their sensitivity to

hypercapnia. When the hypoxaemia is corrected, they lose their stimulus to breathe and

develop carbon dioxide narcosis. Oxygen administration therefore has to be decreased prior

to initiating mechanical ventilation.

156. An 18-year-old woman presents with an acute pulmonary embolism in theninth week of pregnancy. No obvious factors contributed to the risk of pulmonaryembolus.

What is the most appropriate treatment for this patient throughout herpregnancy?

Aspirin

Intravenous unfractionated heparin

Subcutaneous low molecular weight heparin

Your answer

Subcutaneous unfractionated heparin

Warfarin

Warfarin is contraindicated in pregnancy because of the risk of teratogenicity. Itwould be impractical to treat this woman for the remaining 31 weeks of herpregnancy with intravenous heparin. This leaves daily injections of subcutaneouslow molecular weight heparin as the best treatment option. Warfarin might bean option during the middle weeks of pregnancy (13-36 weeks), but practically itwould probably be better to stick with low molecular weight heparin for theduration. Aspirin is an inadequate treatment for pulmonary embolus. Post-pregnancy, it seems sensible to screen this woman for inherited coagulopathy


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because of her young age and lack of predisposing factors apart from thepregnancy.

157. A 49-year-old woman has been admitted with haemoptysis and epistaxis, the chest X-ray shows multiple rounded lesions with alveolar shadowing. Serum is c-ANCA positive.

What is the most likely diagnosis?

Tuberculosis

Carcinoma of the lung

Echinococcosis

Wegeners granulomatosis Your answer

Systemic lupus erythematosus

Almost all the patients so diagnosed have evidence of granulomatous lung disease atpresentation, which is often accompanied by alveolar capillaritis. The bronchi can also be

affected and bronchial stenoses occur as late manifestations. Symptoms include cough,

dyspnoea, haemoptysis and chest pain, which can be pleuritic. Signs on chest examinationdepend on the nature of the pulmonary lesions and include fine crepitations and bronchial

breathing or, less commonly, pleural rubs and signs of pleural effusions. Pulmonary

granulomas are usually diagnosed from chest X-ray and CT scans. They may appear as

single or multiple rounded lesions, which can cavitate. Bronchoscopy often revealsgranulomatous inflammation and the diagnosis can sometimes be made from bronchial

biopsies.

158. A 24-year-old thin man complains of constant daytime sleepiness. He mentions

involuntary naps, often in the middle of activity, which occur suddenly and without

warning. He also caused an accident when he fell asleep while driving home from work.

The patient works as an office manager and has no history of exposure to chemicals. Whichof the following treatments would be indicated?

Nortriptyline

Fluoxetine

Diazepam

Modafinil Your answer

Continuous positive airway pressure-breathing device


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This patient has narcolepsy: a sleep disorder causing hypersomnia, which usually starts in

adolescence or young adulthood. Treatment involves the use of central nervous system

stimulants such as modafinil to allow daytime functioning.

Continuous positive airway pressure-breathing devices are used in the treatment of sleep

apnoea. A typical patient with sleep apnoea is usually older, obese and there will be a longhistory of gradually worsening snoring with apnoeas, possibly witnessed by the spouse,

who will probably have moved out of the bedroom because of the noise. There is usually ahistory of fairly high alcohol intake and smoking.

159. An 82-year-old man living alone in a bungalow came to the clinic complaining offeeling generally unwell for about the last 34 months and of losing about 9.5 kg (21 lbs) in

weight during this period. On further enquiry he said he had been having night sweats for

the last month. He also has a past history of angina and arthritis and was on medication. Onexamination he did not look well. He was pyrexic and without lymphadenopathy. Bibasal

crepitus on the lower zone was heard on chest auscultation. He had hepatosplenomegaly

and clubbing. Investigations showed WBC 12.3 106/l (neutrophils 52%, lymphocytes

39%), Hb 9.1 g/dl, with all other routine investigations being normal. A chest X-rayshowed 12 cm diameter miliary shadows all over the lung field. The Mantoux test was

negative. No bacteria grew in a sputum culture. What is the probable cause of the illness

and the X-ray finding?

Sarcoidosis

Mycoplasma pneumonia

Staphylococcal pneumoniaMiliary tuberculosis Your answer

Bacterial endocarditis

This is a case of miliary tuberculosis, which is caused by a diffuse disseminated spread of

tubercle bacilli via the bloodstream. In older patients it is difficult to diagnose. It presents

with a gradual onset of vague ill health, loss of weight and then fever. It can also present astubercular meningitis. Hepatosplenomegaly is seen in advanced disease. Choroidal

tubercles are seen in the eyes. Initially, a chest X-ray may be normal. Later, chest X-ray

reveals the presence of small 12 cm lesions. CT scanning may show a lung parenchymal

abnormality at an early stage. The Mantoux test may be negative in up to half of the

patients with severe disease. A transbronchial biopsy is positive at an early stage. Biopsy ofliver and bone marrow may be required. If untreated miliary tuberculosis is universally

fatal.


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160. A 26-year-old man presents with fever, headache and a moderate productive cough.

The chest X-ray shows increased interstitial markings. Laboratory examination shows an

elevated LDH and anaemia with the presence of cold agglutinins. What is the most likelydiagnosis?

Non-Hodgkins lymphomaPneumocystis jiroveci pneumonia

Mycoplasma pneumonia Your answer

Exogene allergic alveolitis

Chlamydia pneumonia

Acute, cold autoimmune haemolytic anaemia is commonly seen in adolescents and young

adults following infection withMycoplasma pneumoniae. Haemolysis occursapproximately 12 weeks following infection and is most commonly associated with a rise

in polyclonal anti-I IgM antibodies withMycoplasma pneumonia. The typical patient is

usually a young adult who experiences a respiratory tract infection accompanied by

headache, myalgia, cough and fever, and with a chest X-ray that shows bronchopneumonia.The cough is often non-productive, but when sputum is obtained it is mucoid, shows

predominantly mononuclear cells and no dominant organism. A characteristic feature is the

relatively high frequency of extrapulmonary complications such as rash, neurologicalsyndromes (aseptic meningitis, encephalitis, neuropathies), myocarditis, pericarditis and

haemolytic anaemia. The diagnosis should be suspected in those patients with a relatively

mild form of pneumonia, particularly in previously healthy young adults. With regard totreatment, the pathogen lacks a cell wall and hence is not susceptible to penicillin,

cephalosporins or other cell wall-active antibiotics. The usual therapeutic agents are

macrolides such as erythromycin, clarithromycin, azithromycin or doxycycline.

161. Which of the following treatments have been shown to prolong life in patients withCOPD?

Anticholinergics

2-agonists

Inhaled corticosteroids

Long-term oxygen therapy Your answer

Lung volume reduction surgery

The only treatment shown to prolong life in COPD is long-term oxygen therapy. It must be

taken in excess if 16 h per day. It is thought that by relieving hypoxia there is a reduction inpulmonary arterial pressure and hence prolongation of life. Suitable candidates are patients

with an FEV1 < 1.5 litres and apa(O2) < 7.3 kPa when well on two occasions some weeks

apart.


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162. A 60-year-old man who has a 30-pack year smoking history comes to clinicwith worsening shortness of breath over the last 6 months. He works as a bakerand keeps racing pigeons. On examination, he is clubbed, has saturations of 91%on air and has widespread fine inspiratory crepitations. His chest radiographshows reticulonodular shadowing and his CT scan confirms reticulation, mainly

subpleural and some honeycombing. What is the diagnosis?

Pulmonary sarcoidosis

Usual interstitial pneumonitis

Your answer

Hypersensitivity pneumonitis

Occupational asthma

Langerhans cell histiocytosis

Dyspnoea, clubbing and inspiratory crepitations are the classic features of usualinterstitial pneumonitis. Chest X-ray will show reticulation, which is classicallysubpleural in distribution on CT. Pulmonary sarcoidosis does not give clubbingand crepitations would be associated with end-stage fibrotic disease. The CT

appearances would be those of nodularity, including fissural nodularity. The CTin hypersensitivity pneumonitis shows: ground-glass shadowing, with reticularand nodular patterns; in occupational asthma, possibly non-specific features ofair trapping; and in Langerhanscell histiocytosis it shows nodules and cysticlesions.

163. Which of the following statements fits best with 1-antitrypsin (AAT) deficiency?

AAT deficiency is never associated with asthma and bronchiectasis

AAT is an autosomal co-dominant condition Your answer

Emphysema with a late presentation is the major respiratory

complication

Severe deficiency affects the lungs and kidney predominantly

The main function of AAT is to neutralise eosinophil elastase in the

lung


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AAT deficiency is an autosomal co-dominant condition with the gene located on the long

arm of chromosome 14. AAT neutralises neutrophil elastase thereby preventing lung

destruction. Deficiency (Pi ZZ homozygotes) results in premature emphysema. Asthma andbronchiectasis do occur but less frequently than emphysema.

164. A 48-year-old woman is admitted with a couple of days history of fever with rigorsand breathlessness. On examination she looks extremely unwell and is confused, cyanosed,

has a respiratory rate of 36/min and a systolic blood pressure of 86 mmHg. There is

dullness on percussion and bronchial breathing at her right base. The chest radiographreveals consolidation. Which of the following would be the most appropriate antibiotic

regimen to use?

Oral amoxicillin

Oral amoxicillin and oral clarithromycinIntravenous cefotaxime and intravenous clarithromycin Your answer

Intravenous ceftazidime and intravenous vancomycin

Intravenous amoxicillin and intravenous clarithromycin

This woman has severe pneumonia as defined by the British Thoracic Society guidelines. It

requires any two of the following features: confusion, urea > 7 mmol/l, respiratory rate >30/min and hypotension (SBP < 90 mmHg, DBP < 60 mmHg). Appropriate treatment (as

recommended by the British Thoracic Society) is with intravenous antimicrobials: co-

amoxiclav 1.2 g three times daily or cefuroxime 1.5 g three times daily or cefotaxime 1 gthree times daily or ceftriaxone 2 g once daily plus erythromycin 500 mg four times daily

or clarithromycin 500 mg twice daily.

165. A 24-year-old patient presents with anorexia, fever and hot flushes. The chest X-ray

shows a 4-cm, large, left upper lobe cavity. Active tuberculosis is suspected. What is thenext appropriate step to confirm the diagnosis?

Computed tomographic (CT) scanning

Mantoux test

Blood cultures

Sputum sample Your answer

Serum inflammatory markers

The laboratory diagnosis of pulmonary tuberculosis relies on examination and culture of

sputum or other respiratory tract specimens. The definitive diagnosis requires the growth ofMycobacterium tuberculosis from respiratory secretions, while a probable diagnosis can be

based on typical clinical and chest X-ray findings with either sputum positive for acid-fast


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bacilli or other specimens, or typical histopathological findings on biopsy material. The

specificity of these latter approaches depends on the prevalence of disease due to non-

tuberculosis mycobacteria in the population.

166. A 60-year-old woman attends the clinic complaining of shortness of breathover the preceding 2 months. She has also had problems with nasal irritation,discharge and sinus pain. She is known to have asthma, which has recently beenpoorly controlled, despite inhaled steroids. Her full blood count has shown aneosinophilia of 13% and her chest X-ray shows peripheral pulmonary shadows.What is the most likely diagnosis?

Severe asthma

Allergic bronchopulmonary aspergillosis (ABPA)

ChurgStrauss syndrome

Your answer

Wegeners granulomatosis

Cryptogenic organising pneumonia (COP)

This womans eosinophil count is high, higher than it would be with asthmaalone. Eosinophil levels in the blood are tightly regulated. Eosinophilsaccumulate in allergic or hypersensitivity disease, including asthma withassociated eczema, as well as allergic bronchopulmonary aspergillosis, ChurgStrauss syndrome, Loefflers syndrome, tropical pulmonary eosinophilia, chronicpulmonary eosinophilia, hypereosinophilic syndrome and acute eosinophilicpneumonia. ChurgStrauss syndrome is an eosinophilic granulomatousinflammation of the respiratory tract with small- and medium-vessel necrotisingvasculitis. It is diagnosed on finding four out of the following: asthma, blood

eosinophilia > 10%, vasculitic neuropathy, pulmonary infiltrates, sinus disease orextravascular eosinophils on biopsy findings. It is diagnosed clinically, although abiopsy should be sought for pathological confirmation.

Wegeners granulomatosis is not typically associated with an eosinophilia,neither is COP. ABPA is a condition where people with asthma have a vigorous IgEresponse to aspergillus, with associated eosinophilia, a positive skin-prick test to


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aspergillus and flitting consolidation on the chest X-ray. There is no associatedsinus disease.

167. A 72-year-old woman is admitted with a sudden-onset, left-sided pleuritic chest painwith shortness of breath. She is being treated for asthma, which has been well controlled on

a low dose of inhaled corticosteroids and long-acting -agonist. She underwent left

hemiarthroplasty 12 days ago, and was discharged as she was doing well. Her chest is clearon auscultation. She is tachycardic (132 beats/min) and an ECG shows sinus tachycardia.

Her peak expiratory flow (PEF) rate is 300 l/min (best 400 l/min). Arterial blood gases are

as follows: pH 7.34,pa(O2) 7.6 kPa,pa(CO2) 3.5 kPa. She is started on oxygen. A chestradiograph is normal. What would be the most appropriate immediate action taken by you

as a medical SHO?

Start nebulised bronchodilators and monitor PEF rate

Request D-dimers urgently

Start low molecular weight heparin suspecting PE, and request a V/Q

scan

Start low molecular weight heparin suspecting PE, and request CT

pulmonary angiography

Your

answer

Request a chest radiograph in expiration

Her PEF rate is only mildly reduced (75% best). It is unlikely that this patients symptoms

are due to an exacerbation of her asthma. A small pneumothorax, not apparent on the

inspiratory chest radiograph, is also unlikely since it would not cause marked hypoxia. The

symptoms and findings point towards a pulmonary embolism (PE), for which the clinicalprobability is high. D-Dimers should not be measured, since the result would not alter the

need for definitive investigation: because she has had a recent operation it would be highanyway. D-Dimers should only be measured when the probability of PE is low and further

investigations would not be pursued. A V/Q scan is unlikely to be helpful in view of her

asthma. Therefore a CT pulmonary angiogram would be the imaging procedure of choice

in this case, after starting low molecular weight heparin.

168. Regarding the value of lung function tests

The peak expiratory flow rate is not dependent on ageYour

answer

In a restrictive disease, the flow-volume loop is different in shape to

normal

A mid-expiratory flow rate between 25% and 75% of expired vitalcapacity is not indicative of airway obstruction


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They are not needed as a routine in the management of asthma

They cannot differentiate between different causes of wheeze

The most accurate correlation of the PEFR is with height. In a restrictive pattern, the fv

loop is reduced in size but looks similar in shape to normal. A mid-expiratory flow rate

(between 25% and 75% of the expired vital capacity) is a good measure of airwaysobstruction. PEFR readings are an objective measure of airway obstruction and in any child

able to do PEFR, it is advisable to do them regularly to assess lung function.

169. A 23-year-old woman who is 34 weeks pregnant is admitted to theemergency department with shortness of breath, cough and wheeze. She is

known to have moderate asthma and normally takes fluticasone 750 gsalmeterol twice a day and salbutamol as needed. Her peak flow is usually 450.

She has been deteriorating over the past 3 days despite increasing herfluticasone and starting 40 mg oral prednisolone daily. She is now unable tospeak in sentences, her peak flow is less than 150 l/min and her pulse rate is130/minute. Saturations are 96% and you hear a widespread wheeze onexamination. Herp(O2) is 15 kPa andp(CO2) 4.5 kPa. She has been given high-flow oxygen, repeated nebulised salbutamol and Atrovent. Which of thefollowing would you consider to be appropriate next?

Liase with the obstetricians regarding emergency section

Intravenous aminophylline

Your answer

Intravenous hydrocortisone

Non-invasive ventilation

Intubation and ventilation

Drug therapy for the pregnant woman should be delivered as for the non-pregnant patient. Saturations should be maintained above 95% with oxygen andclose monitoring essential. Intravenous aminophylline is safe, although levelsneed monitoring, and this would be the next step in the management of thiswoman. She has had adequate doses of oral steroids, so does not need ivhydrocortisone. It is of paramount importance to stabilise her and an emergency


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section would not be in her best interests. She has features of acute severeasthma, but may respond to iv aminophylline and the nebulisers and not requireintubation. However, if her blood gases deteriorate, with hypoxia andhypercapnia, or she tires or becomes drowsy, she would need to be transferredto intensive care for intubation and ventilation. There is minimal evidence at

present to support the use of non-invasive ventilation in acute asthma (seeBritish Guideline on the Management of Asthma 2003. Thorax,58,Suppl. 1).

170. A 47-year-old man presents to hospital with acute breathlessness. His arterial bloodgases show apa(O2) of 8.5 kPa (65 mmHg) and apa(CO2) of 5.6 kPa (42.5 mmHg) whilst

breathing room air. Which of the following is the least likely explanation for this

abnormality?

Ventilation/perfusion (VQ) mismatchRight-to-left shunting

Hypoventilation Your answer

Diffusion abnormality

Anaemia

The Alveolararterial (Aa) oxygen gradient is one way to find the answer to this question,although the clinical history of breathlessness does make hypoventilation seem an unlikely

answer.

pA(O2) = FiO2 (pa(CO2)/0.8) = 21 (5.6/0.8) = 14 kPa

Therefore, Aa gradient = 14 8.5 = 5.5 kPa (42 mmHg), the normal being approximately

0.52.0 kPa (< 15 mmHg). VQ mismatch, diffusion abnormalities and right-to-left shuntingall cause widening of the Aa gradient. Hypoventilation causes hypoxaemia with a normal

Aa gradient and is therefore the most unlikely explanation in this case.

171. A 62-year-old man presents with flushing and wheezing. A mass is seen on his chest

radiograph. You suspect he may have a carcinoid tumour, but which one of the followingwould be unusual with this diagnosis?

Histological appearance similar to that of a small-cell carcinoma

Highly vascular appearance

Unlikely to be seen at bronchoscopy Your answer

A low percentage develop carcinoid syndrome


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90% 5year survival post-surgery

Carcinoid tumours make up 1% of all lung tumours and 60% are visible in the bronchial

tree. They originate from the APUD cell line. Typically, they are very vascular structuresthat on bronchoscopy appear as cherry-red balls that tend to bleed easily. Only a small

percentage develops carcinoid syndrome (flushing, cramp, diarrhoea and wheezing).Histologically, they may resemble small-cell carcinoma. With surgery the 5-year survival

is 90% and 10-year survival is 75%.

172. A 25-year-old male patient with cystic fibrosis is to undergo lung transplantation.

Which of the following is NOT true about the lung transplant in this patient?

Donor-selection parameters include age under 40 years

Donors chest measurements should be slightly smaller than those of the

recipientIt is essential to match for the ABO blood group

Matching for the rhesus blood group compatibility is not essential

A single lung transplant is preferred to double lung transplantYour

answer

Indications for the treatment are patient under 60 years with life expectancy of less than 18

months. No underlying cancer or serious systemic disease should be present. Donor is

matched for the ABO grouping and the rhesus blood group compatibility is not essential.Donor should have good cardiac and lung function and should be under the age of 40. The

chest of the donor should be slightly less than the recipient. Double lung transplant is

usually performed because of the risk of chronic infection in the remaining lung.

173. A 45-year-old woman known to suffer from systemic lupus erythematosus(SLE) is referred to the chest clinic with a history of worsening dyspnoea. She ison a maintenance dose of 15 mg of prednisolone. She has never smoked, andaccording to her she developed an unproductive cough and dyspnoea threemonths ago. There is no history of fever, night sweats or weight loss. Her doctorhas tried various types of inhalers with no benefit. A PEFR diary shows no

nocturnal dips. A chest X-ray shows a reticulonodular pattern. Examination isunremarkable apart from the skin changes of SLE. What is the most likelydiagnosis?

Asthma


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Bronchiectasis

Bronchiolitis obliterans

Your answer

Tuberculosis

Fungal infection

Bronchiolitis obliterans is the term used to describe fibrous scarring of thesmall airways. It is seen following: toxic-fume inhalation; mineral-dust exposure;viral infection; mycoplasma and legionella infection; bone marrow, heartlung

and lung transplantation; rheumatoid arthritis; SLE; and as a side-effect ofpenicillamine. It presents as a dry cough and dyspnoea. Physical examination isunremarkable. Expiratory wheeze may be audible. The chest X-ray findings canvary from normal to a reticular or reticulonodular pattern. The diagnosis can beconfirmed by lung biopsy. Patients rarely respond to steroids. The prognosis ispoor.

174. Which one of the following features is MOST accurate regardingPneumocystis jirovecipneumonia (PCP)?

Occurs exclusively in AIDS

Pleural effusion is frequently bilateral

Auscultation of the lungs usually reveals no abnormalityYour answer

Blood culture is positive in one-third of cases

Metronidazole is the treatment of choice

Pneumocystis jiroveci pneumonia (PCP) is a pulmonary disease characterised bydyspnoea, tachypnoea and hypoxaemia that occur in patients deficient in


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immunoglobulin G and M, and patients deficient in cellular mediated immunity.The vast majority of adult patients have AIDS, however, it can also occur inthose who received chemotherapy for haematological malignant disease or organtransplant. It can also occur in malnourished or premature infants. Onexamination patients usually show signs of respiratory distress (tachypnoea,

dyspnoea). Auscultation of the lung usually reveals no abnormalities. Thetrophozoite does not enter the blood, the organism is identified in pulmonarysecretions obtained by bronchopulmonary lavage or lung biopsy and stained bymethenamine silver or Giemsa stain. Pentamidine isethionate or cotrimoxazole isthe recommended treatment (metronidazole is not effective in the treatment ofPCP).

175. A 20-year-old woman complains of a sudden onset of dyspnoea associated with

pleuritic chest pain. Which assessment is the most accurate to confirm your diagnosis of

pulmonary embolism?

D-Dimer

Echocardiography

Ventilation/perfusion scan

Contrast-enhanced spiral computed tomography

Pulmonary angiography Your answer

Although pulmonary angiography is associated with serious complications in about 1% ofpatients, it remains the diagnostic reference test for pulmonary embolism.

A negative D-dimer test is useful for excluding pulmonary embolism in patients who areclinically thought to be at low risk, but a positive result does not establish the diagnosis.

Echocardiography may show right ventricular dilatation and evidence of pulmonaryhypertension, which, in the proper clinical setting, may strengthen the clinical impression

that a pulmonary embolism has occurred. The Prospective Investigation of Pulmonary

Embolism Diagnosis (PIOPED) study emphasised the poor predictive value of scansreported as intermediate probability, a common occurrence in routine clinical practice.

176. A 64-year-old mechanic and lifelong smoker noticed haemoptysis a few daysafter he had a cold. Clinical examination is unremarkable. His chest X-ray showsbilateral hilar enlargement and mediastinal widening. What is the most likelydiagnosis?

Tuberculosis


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Bronchial carcinoma

Your answer

Lymphoma

Hilar metastases

Lung abscess

The value of the chest X-ray in the diagnosis and management of pulmonaryneoplasm needs no emphasis. No initial examination is complete without alateral film. Coned views of the ribs may help where rib invasion is suspectedclinically. However, the finding of a normal X-ray of the chest does not exclude

bronchial carcinoma as patients presenting with haemoptysis and a normal chestX-ray are sometimes found to have a central tumour on bronchoscopy.

The common appearance of a tumour arising from the main central airways (70%of all cases) is enlargement of one or other hilum. Even experienced observerssometimes have difficulty in deciding whether or not a hilar shadow is enlarged,and if there is any suspicion, investigation by bronchoscopy and/or CT should bepursued.

Consolidation and collapse distal to the tumour may have occurred by the timethe patient presents, with the tumour itself often being obscured in the process.Collapse of the left lower lobe is often hard to identify, as is a tumour situated

behind the heart. Apically located masses or superior sulcus tumours (Pancoasttumours) may be misdiagnosed as pleural caps, and patients often have a longhistory of pain in the distribution of the brachial nerve roots. Loss of the head ofthe first, second or third rib is not unusual. The mediastinum may be widened byenlarged nodes. Involvement of the phrenic nerve may lead to paralysis andelevation of the hemidiaphragm, which then moves paradoxically on sniffing.

Tumour spreading to the pleura causes effusion, but such an abnormality may besecondary to infection beyond obstruction caused by a central tumour. The ribsand spine should be carefully examined for the presence of metastases. Spreadof tumour from mediastinal nodes peripherally along the lymphatics gives the

characteristic appearance of lymphangitis carcinomatosa bilateral hilarenlargement with streaky shadows fanning out into the lung fields on either side.Rarely, localised obstructive emphysema may be observed.


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177. A 49-year-old man with unexplained cough undergoes bronchoscopy and

transbronchial biopsy. Histology shows evidence of neutrophil infiltrate, granulomas are

absent. Which is the most likely diagnosis?

Histiocytosis X

HistoplasmosisChurgStrauss syndrome

Berylliosis

Polyarteritis nodosa (PAN) Your answer

Histiocytosis X (eosinophilic granuloma) is a disease of young adults with widespread

nodules in the lungs. Fibrosis appears early and may progress to respiratory failure and

death. Histoplasmosis is the commonest fungal infection in North America and has bothacute (usually self-limiting) and chronic (those with previous lung disease) forms. Churg

Strauss syndrome is characterised by a prodromal phase of asthma, a second phase of tissue

and peripheral eosinophilia and a final phase of systemic vasculitis. PAN affects medium-

sized arteries (cf small arteries in ChurgStrauss syndrome) and the infiltrate is composedof neutrophils but granulomas are absent. Berylliosis has features similar to sarcoid.

178. A 33-year-old man is found to have strongly positive aspergillus precipitins in hisblood and complains of a cough with intermittent bloody sputum. He has a business

working as a builder, particularly involved in renovating farm houses and barns.

What is the most likely diagnosis?

Allergic bronchopulmonary aspergillosis (ABPA)

Colonising aspergillosis Your answer

Invasive aspergillosis

Aspergers syndrome

Type I hypersensitivity toAspergillus fumigatus

Aspergillus precipitins are IgG antibodies typically found in colonising aspergillosis(aspergilloma), which occurs in areas of damaged lungs, eg cavities. Type I

hypersensitivity toAspergillus fumigatus occurs in ABPA. Invasive aspergillosis occurs in

immunocompromised patients. Aspergers syndrome has nothing to do with aspergillusinfection.

179. A 36-year-old woman with systemic sclerosis develops breathlessness on exertion.

Her pulmonary function tests show normal spirometry but a decreased gas transfer factor

(TLCO, transfer factor for carbon monoxide) and transfer coefficient (KCO). Which of thefollowing is the most likely explanation for this abnormality?


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Fibrosing alveolitis

Pulmonary vascular disease Your answer

Severe thoracic skin thickening

Pleural involvement

Respiratory muscle weakness

Isolated decreases in gas transfer are typical of pulmonary vascular disease, eg vasculitis,

recurrent pulmonary embolism (PE). In fibrosing alveolitis you would also expect to seedecreased lung volumes with a restrictive ratio (> 80%) on spirometry. The other three

answers would all give a picture of extrapulmonary restriction with a restrictive ratio, low

TLCO but normal/high KCO (same cardiac output going through smaller alveolar volume).

180. A 49-year-old homosexual accountant came to the clinic with increasedbreathlessness. He had began to become wheezy after a tooth extraction procedure 5

months ago and also had an associated troublesome cough. He used to smoke 15 cigarettesper day but gave up smoking about 2 months ago. Salbutamol and beclometasone inhalerspoorly controlled his symptoms. Recently he had been unwell: he had had a fever and had

lost about 3.2 kg (7 lb.) in weight. There was no history of recent foreign travel and no

significant past illness. On examination, he had a temperature of 37.2 C and occasionalrhonchi on both sides. Tests showed: Hb 14.6 g/dl, WBC 10.2 109/l (neutrophils 53%,

lymphocytes 30%, raised eosinophils noted) , ESR 110 mm in first hour; normal U&E;

normal urine dipstick. Chest X-ray showed extensive symmetrical homogenous shadowing

affecting all the peripheral lung field. A skin test for inhaled antigens, includingAspergillus fumigatus , was negative. His serum IgE was normal. A serological screen for

parasitic infection was negative. Pulmonary function was within normal limits. Oxygen

saturations are 97% and there is no desaturation on exerciese.

What is the probable diagnosis?

Pneumocystis pneumonia

Lofflers syndrome

Asthma

Cryptogenic pulmonary eosinophilia Your answer

Churg-Strauss Syndrome

This patient has eosinophilia and associated definite pulmonary signs. There is noindication of drug involvement or malignancy. Nothing was mentioned about atopy or

extrapulmonary involvement in the scenario. ChurgStrauss syndrome is unlikely. The IgElevel is normal unlike fungal and parasitic hypersensitivity. Patients may have systemic

features of malaise, weight loss, fever and a raised ESR, and about half of them have

features of asthma. When the disease is self-limiting and lasts less than a month it isLoefflers syndrome. The disease responds to steroid treatment, which needs to be


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continued for about one year. There is no relation to the patients sexual orientation and

Pneumocystis jiroveci secondary to HIV is unlikely.

181. After a tennis match, a 20-year-old thin woman complains of left-sided chest pain that

radiates into her abdomen. The physical examination reveals reduced air entry at the right

base of the lung with hyper-resonant percussion. The abdominal examination showsgeneralised tenderness. A few minutes later she develops cyanosis. What is the diagnosis?

Myocardial infarction

Tension pneumothorax Your answer

Ectopic pregnancy

Pulmonary embolism

Acute pancreatitis

If a tension pneumothorax is present, a cannula of adequate length should be promptly

inserted into the second intercostal space in the mid-clavicular line and left in place until a

functioning intercostal tube can be positioned. Tension pneumothorax occurs when theintrapleural pressure exceeds the atmospheric pressure throughout inspiration as well as

expiration. It is thought to result from the operation of a one-way valve system, drawing air

into the pleural space during inspiration and not allowing it out during expiration. Thedevelopment of tension pneumothorax is often, but not always, heralded by a sudden

deterioration in the cardiopulmonary status of the patient related to impaired venous return,

reduced cardiac output and hypoxaemia. The development of tension in a pneumothorax isnot dependent on the size of the pneumothorax, and the clinical scenario of tension

pneumothorax may correlate poorly with chest X-ray findings. The clinical status isstriking. The patient rapidly becomes distressed with rapid laboured respiration, cyanosis,

sweating and tachycardia. It should be particularly suspected in those on mechanicalventilators or nasal non-invasive ventilation who suddenly deteriorate or develop EMD

arrest, and is frequently missed in the ICU setting. If a tension pneumothorax occurs, the

patient should be given high-concentration oxygen and a cannula should be introduced intothe pleural space, usually in the second anterior intercostal space mid-clavicular line. Air

should be removed until the patient is no longer compromised and then an intercostal tube

should be inserted into the pleural space as previously described. Advanced Trauma LifeSupport guidelines recommend the use of a 36 cm long cannula to perform needle

thoracocentesis for life-threatening tension pneumothorax. However, in 57% of patients

with tension pneumothorax the thickness of the chest wall has been found to be greaterthan 3 cm. It is therefore recommended that a cannula length of at least 4.5 cm should be

used in needle thoracocentesis of tension pneumothoraces. The cannula should be left in

place until bubbling is confirmed in the underwater-seal system to confirm proper function

of the intercostal tube.


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182. A 74-year-old man with previously stable emphysema presents to A&E with right-

sided pleuritic chest pain and sudden increase in shortness of breath. There are no other

associated symptoms and no signs to suggest acute infection. There appears to be increasedresonance over the upper right side of the chest. Which is the most likely diagnosis in this

case?

An exacerbation of COPD

A spontaneous pneumothorax Your answer

Acute-onset pneumonia

Empyema

Pulmonary embolism

Underlying chronic obstructive pulmonary disease (COPD) is the usual cause ofpneumothorax in patients of this age group. The sudden onset of shortness of breath

associated with pleuritic chest pain in this case makes pneumothorax more likely than

COPD exacerbation. Other, rarer causes of pneumothorax include asthma, underlying

carcinoma, lung abscess and severe pulmonary fibrosis with cyst formation. If possible,pneumothoraces occurring in relation to COPD should be managed conservatively or with

needle air-aspiration depending on their size. Formal chest drain may be required where the

size is > 50% or there is significant respiratory compromise. Unfortunately, they tend to berecurrent when linked to emphysema.

183. A 26-year-old woman arrives in the UK from Australia. A few days later she presents

to hospital with pleuritic chest pain and breathlessness. She is not on the oral contraceptivepill and has no family or personal history of DVT/PE. A pulmonary embolus is confirmed

radiologically and she is commenced on warfarin.

How long would you continue warfarin therapy in these circumstances?

46 weeks Your answer

3 months

6 months

1 year

Lifelong

This young womans only risk factor given is the long-haul flight, which is only atemporary risk factor. The standard duration of anticoagulation is: 46 weeks for temporary

risk factors; 3 months for first idiopathic; at least 6 months for other. The risk of bleeding

needs to be balanced against the risk of further emboli.


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184. A 36-year-old lorry driver who smokes heavily presents with a 2-day historyof cough associated with fever. He also complains of right-sided chest pain oninspiration. On examination he is slightly cyanosed. His temperature is 38 C,respiratory rate 38/min, BP 100/70 mmHg and pulse 130/min. He has basalcrepitations and dullness to percussion at the right lung base. What is the most

important next step in confirming the diagnosis?

ESR (Erythrocyte sedimentation rate)

D-Dimer

Chest X-ray

Your answer

Sputum sample

Blood cultures

The classic presentation of pneumonia is of a cough and fever with the variablepresence of sputum production, dyspnoea and pleurisy. Most patients haveconstitutional symptoms such as malaise, fatigue and asthenia, and many alsohave gastrointestinal symptoms. Examination of the lung might reveal decreased

vesicular breath sounds, localised foci of crepitations, dullness to percussion andsometimes a bronchial wheeze. The chest X-ray is a pivotal test for theconfirmation of pneumonia.

185. Which one of the following features is MOST characteristic of cystic fibrosis?

Inherited as autosomal dominant

Pancreatic insufficiency is almost always identified in adult patientsYour

answer

In patients with recurrent chest infectionsPseudomonas cepacia is the

most frequent organism isolated from sputum

Family members who carry the gene are at risk of developing mildrecurrent bronchitis

Patients typically have reduced levels of sodium and chloride in the sweat


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Cystic fibrosis (CF) is an autosomal recessive disease affecting both eccrine and exocrine

gland function, characterised by elevated levels of sodium and chloride in the sweat. It is

caused by abnormal viscid secretions from mucous glands leading to chronic pulmonarydisease and pancreatic insufficiency, which will be evident in more than 95% of adult

cases. Recurrent chest infections are usually caused byPseudomonas aeruginosa and

Staphylococcus aureus.Pseudomonas cepacia occurs in 510% of cases. The carrier rate is5% in the Caucasian population, heterozygotes are clinically normal.

186. A 26-year-old, previously healthy, naval officer is admitted to the hospitalwith a sudden-onset, left-sided chest pain. A chest X-ray confirms a small left-sided pneumothorax. The patient is not breathless and his oxygen saturation onair is 95%. He smokes 1015 cigarettes a day. Which of the following statementsis true?

Simple aspiration is the first-line treatment if the patient issymptomatic

Your

answer

If admitted for observation, he does not need oxygen

Once the pneumothorax has resolved he can go back to work,including resuming his diving duties

Smoking cessation has no role in management, apart from in theprevention of COPD in later life

He should be treated with a small (1014 F)-sized chest drain

A small pneumothorax in a person with no previous chest disease should beaspirated if the patient is breathless. A pneumothorax can be classed as small or

large depending on the presence of a visible rim of < 2 cm or 2 cm betweenthe lung margin and the chest wall. Ideally, an asymptomatic patient with asmall, primary spontaneous pneumothorax can be discharged with the advice toreturn if he becomes symptomatic.

If a patient is admitted for observation, high-flow oxygen increases theabsorption of air from the pleural cavity. Smoking increases the chances of a


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recurrence. Diving is contraindicated unless the patient has undergonepleurectomy.

187. A young adult was referred because of cough and shortness of breath. An extrinsicallergic alveolitis was diagnosed. Beside reduction of exposure to the allergen, which other

therapy is most likely to be successful?

Antibiotics

Non-steroidal anti-inflammatory drugs

Immunoglobulins

Corticosteroids Your answer

Desensitisation

Management of the patient centres on reducing any further exposure to a minimum, butfirst the diagnosis must be secure. Desensitisation has no beneficial effect. Ideally, affected

individuals change their relevant working, domestic and recreational environment

completely, but this may mean a profound loss of income or great expense, and is oftenunrealistic. Nor is it fully justified on purely medical grounds since continued exposure

does not inevitably lead to progressive disease. Affected individuals who continue to work

in the occupation responsible for their disease can often reduce their exposure substantially

by changing the pattern of their particular duties. An alternative is to use industrialrespirators, which filter out 9899% of respirable dust from the ambient air. These are

especially valuable when exposures are intermittent and short, but they may be

uncomfortably hot when worn for long periods or when there is heavy work, and so

compliance with their use may be poor. Whatever course is followed, continuing exposureshould be accompanied by regular medical surveillance. If there is no progression, it is

reasonable for some exposure to continue. When there is progressive disease, exposureshould cease. This may involve a loss of earnings, and may entitle the affected worker to

compensation. Occasionally, individuals with progressive disease may refuse to change

their occupation or hobby, and their physician must weigh the possible advantages of long-

term corticosteroid therapy against the risks.

188. Which of the following conditions is most likely to be associated with a decreasedDLCO?

Polycythaemia

Anaemia

Pulmonary embolism Your answer

Exercise


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Acute poliomyelitis

DLCO, the diffusion capacity in the lung for carbon monoxide, is decreased in any

condition that reduces the effective alveolar surface area or affects the alveolar membrane.Examples include pulmonary embolism and emphysema in which the alveolar surface area

is reduced.

189. A 73-year-old woman presents with weight loss and a chronic cough. Her husband hasnoticed that her pupil is constricted and her right eyelid is drooping. She has had pain in her

right shoulder for some months, which her GP has described as 'probable rheumatism'.

Unfortunately her chest x-ray reveals a mass in the right lung apex with possiblelymphadenopathy at the right hilum.

What is the most likely diagnosis in this case?

Eaton-Lambert Syndrome

Horners syndrome caused by Pancoasts tumour Your answer

Small-cell carcinoma

Tuberculosis

Aspergilloma

Eaton-Lambert syndrome is a paraneoplastic syndrome associated with proximal

myopathy, related to a deficient action of cholinergic neurones. Horners syndrome iscaused by an apical lung tumour, which leads to spinal cord damage between spinal levels

C8 and T1. Symptoms are pupil constriction, ptosis and facial anhydrosis. Pancoaststumours are mostly squamous or adenocarcinomas, only 3-5% are said to be due to small

cell tumours, this is because small-cell carcinoma of the bronchus is more likely to occurcentrally and so wouldnt be expected to present like this.It is associated with SIADH in 5-

10% of cases.

190. A 60-year-old hairdresser complains that, after an attack of flu last year, she has beenmore breathless than usual when taking her evening walk, and has also felt short of breath

when climbing the stairs. She has become concerned that she has a cardiac problem. She

has lost about 6.4 kg (14 lbs) during the last year. She has smoked 20 cigarettes per day for45 years but does not drink alcohol. Other than an occasional paracetamol for her

headache, she is on no regular medication. On examination she was apyrexic and had

bilateral clubbing. No lymphadenopathy was seen. Her JVP was not raised and heart

sounds were normal. Bibasal inspiratory crepts were audible. No pedal oedema was seen.Bilateral reticular shadowing, mostly on the bases, was seen on chest X-ray. Routine

bloods were normal, except for an ESR of 35 mm in the first hour. Her HRCT showed

peripheral reticular ground-glass opacification, best seen in the basal region. Respiratory


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function test showed restrictive ventilatory defect. Bronchoalveolar lavage showed an

increased number of cells neutrophils and macrophages but no malignant cells. An

open-lung biopsy showed an exudate of intra-alveolar macrophages with patchy interstitialfibrosis. What is the likely diagnosis?

Cryptogenic fibrosing alveolitis Your answerExtrinsic alveolitis

Lymphangitis carcinomatosis

Chronic left heart failure

Sarcoidosis

Cryptogenic fibrosing alveolitis is the group of disease consisting of interstitial pneumonia

with differing amounts of cellularity and fibrosis. Patients with desquamative histologyhave a favourable response to treatment with prednisolone. All other causes should be

excluded before diagnosing cryptogenic fibrosing alveolitis. Median survival time is

approximately 5 years. Azathioprine or cyclophosphamide may be added to the treatment

and a single lung transplant may be offered.

191. In which of the following emergency medical presentations is non-invasive ventilation

an established treatment?

Tension pneumothorax

Acute asthma

Acute exacerbation of COPD Your answer

ARDS

Pulmonary oedema

Non-invasive ventilation (NIV) is currently being evaluated in an number of emergencysituations. The best evidence relates to exacerbations of chronic obstructive pulmonary

disease (COPD). In particular, this type of therapy is effective in patients with

decompensated type-2 respiratory failure. Physiological responses (heart and respiratory

rate, and arterial blood gases) improve more quickly with NIV in these patients comparedto standard treatment. Intubation is also less frequently required.

192. An arterial blood sample from a 48-year-old male patient with progressive dyspnoeahas an oxygen tension of 8.5 kPa (11.3-12.6), and a carbon dioxide tension of 8.5kPa (4.7-

6.0). Given these blood gas results, what is the most likely diagnosis?

Pulmonary embolus

Aspirin overdose


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Ankylosing spondylitis Your answer

Viral pneumonitis

Lobar pneumonia

This is type II respiratory failure.pa(CO2) rises due to hypoventilation and this can occur

acutely due to drug overdose or more chronically with gross obesity, kyphoscoliosis (andsimilar musculoskeletal disorders) and end-stage muscle, neurological and airways

disorders. Lobar pneumonia causes hypoxia but a normal/low pa(CO2) (type I respiratoryfailure) unless exhaustion supervenes when the patient may start to retain carbon dioxide.

193.A 58-year-old memorial stonemason presents to the chest clinic. Over the past few

years he has noted a gradual increase in shortness of breath, with cough and occasional

wheeze. He is a non-smoker and has no other past history of note. His chest X-ray isabnormal with small rounded opacities and irregular upper zone fibrosis. There is hilar

lymphadenopathy with eggshell calcification. Pulmonary function testing reveals arestrictive picture and there is mild hypoxia. Which diagnosis best fits with this clinicalpicture?

Silicosis Your answer

Asthma

Idiopathic pulmonary fibrosis

Tuberculosis

Byssinosis

This mans job is likely to have exposed him to silica dust, and unfortunately he is

suffering from silicosis. Silicosis is characterised by shortness of breath, wheeze and coughwith lung function tests and chest X-ray suggestive of irregular fibrosis. Pathogenesis is

related to activation of alveolar macrophages via ingestion of silica dust, releasing a

number of proteolytic enzymes and inflammatory cytokines. Chronic silicosis may not

progress, but accelerated forms and continued exposure are associated with respiratoryfailure over a few years. Management involves removal of exposure, screening for and

treatment of tuberculosis if found in association and supportive measures such as

bronchodilators and oxygen therapy.

194. Which of the following is not a common symptom of lung cancer on presentation?

Cough

Chest pain

Cough and chest pain

Coughing blood


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Shortness of breath Your answer

Cough is the commonest symptom (about 41% of patients) at presentation, followed by

chest pain in 22% of patients who have later been diagnosed to have lung carcinoma.About 15% of patients present with both cough and chest pain. Only 7% of patients present

with the symptom of coughing up blood. In less than 5% of cases they present with othersymptoms: shortness of breath, hoarseness, weight loss, malaise and distant spread.

195. A 36-year-old woman is under follow up for recurrent pulmonary thrombo-embolicdisease. Which of the following features is she most likely to have?

Quiet P2

Matched ventilation perfusion defect

Paroxysmal dyspnoea

Increased transfer factor

Widening of the alveolararterial (Aa) gradient on exercise Your answer

Recurrent pulmonary emboli (PE) should always be considered in cases of progressive

SOB with no obvious cause. Possible clues include pulmonary hypertension, right

ventricular enlargement, hypoxia with a lowpa(CO2) and a low transfer factor. Widening ofthe lveolararterial (Aa) gradient on exercise is likely to be found. Mismatched defects are

classical of PE.

196. Which of the following is a poor prognostic factor in patients suffering frompneumonia?

White cell count (WCC) 17 109/l

Blood pressure 110/70mmHg

Respiratory rate 35/min Your answer

Rigors

Temperature 39C

The following are poor prognostic factors in patient with pneumonia:

confusion: abbreviated mental test score of 8 or less urea greater than 7 mmol/l respiratory rate greater than 30/min

blood pressure: systolic less than 90 mmHg and/or diastolic less than 60mmHg.


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197. A 65-year-old man known to have COPD presented with progressive respiratoryfailure. He was treated in ITU with mechanical ventilation and improved. After extubation

he was transferred to the ward. On the second day on the ward, his temperature spiked andhe developed a productive cough with a yellow-greenish sputum. Blood results showed

leucocytosis. A chest X-ray revealed a right-sided middle and lower lobe pneumonia. Whatis the most probable cause of his pneumonia?

Pneumococcal pneumonia

Aspiration pneumonia

Pseudomonas pneumonia Your answer

Staphylococcal pneumonia

Haemophilus pneumonia

Pseudomonas is a common pathogen in patients with bronchiectasis and cystic fibrosis. Italso causes hospital-acquired infections, particularly on the ITU or after surgery.Nosocomial or hospital-acquired infections should be suspected in patients with an onset of

symptoms at least 48 hours after admission to the hospital. The sputum colour also gives a

clue to the most likely diagnosis. Treatment is with anti-pseudomonal penicillin,ceftazidime, meropenem or ciprofloxacin.

198. A fit 50-year-old man with a 20-pack year smoking history presents withhaemoptysis and a 3-cm right upper lobe mass on his chest radiograph.Bronchoscopy has shown this is a squamous-cell carcinoma; CT has confirmed themass and has also shown enlarged 1-cm short-axis hilar and paratracheal nodes.He is discussed at the lung-cancer multidisciplinary team meeting. What are theylikely to think is the most appropriate next course of management?

Refer for PET scan

Your answer

Refer for surgical resection of the mass

Refer for radiotherapy to the mass

Refer for chemotherapy


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Refer to the palliative care team

This is a man with potentially operable non-small-cell lung cancer. He hasenlarged hilar nodes, but these could be removed with pneumonectomy, but he

also has enlarged mediastinal nodes, which if they were cancerous, would makethe cancer resection non-curative. However CT is not great at assessing whetherenlarged nodes are inflammatory or malignant. He therefore needs furtherassessment of his mediastinal nodes prior to surgery, and this can be done withmediastinoscopy or a positron-emission tomography (PET) scan. In a PET scan,radiolabelled glucose is injected peripherally and is taken up by metabolicallyactive tissues, such as the brain and any cancer. It would show metastases fromthe primary cancer. If his cancer is inoperable, palliative radiotherapy can begiven to the mass, to try and control the haemoptysis. Chemotherapy could alsobe considered. Palliative care team referral would be appropriate if he does notwant interventions or has troublesome symptoms.

199. Which of the following is the best predictor for obstructive sleep apnoea?

Neck size

Your answer

Chest size

Abdominal girth

Waist to hip ratio

Uvulopalatal distance

Neck size is the best predictor of OSA, with > 43 cm (>17 inches) beingassociated with an increased risk. The mass loading from the obese or muscularneck overwhelms the residual dilator muscle action of the pharynx when thepatient is asleep, causing airway obstruction and subsequent apnoea. Patientsmay also have a small or set back mandible, which predisposes them to OSA as


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well. Typically, patients also have upper body obesity, which is the typical malefat pattern.

200. What are the indications for home oxygen?

Low forced expiratory colume in 1 s (FEV1)

Low p(CO2)

Cor pulmonale

Low p(O2) Your answer

Ischaemic heart disease

The National Institute for Clinical Excellence (NICE) states that the following are

indications for considering long-term oxygen therapy (LTOT): patients with a pa(O2) of lessthan 7.3 kPa when stable, or pa(O2) of 7.38.0 kPa when stable and also an additional risk

feature like secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema or

pulmonary hypertension. Oxygen should be used for at least 15 h a day.

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