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A 32-year-old patient with asthma has been stable with inhaled salbutamol when required. Recently she had to use her inhaler more frequently and also at night. What is the next step in her therapy? Inhaled ß2-agonist at maximum dose Regular inhaled budesonide, inhaled salbutamol when required 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 ß2agonist inhaler more than once a day and also complains of night-time symptoms. Step 2 therapy consists of a regular standard-dose inhaled corticosteroid and an additional inhaled short-acting ß2-agonist as required. Oral leukotriene-receptor antagonists and theophylline are indicated in step 3 if the asthma is still not controlled. Oral corticosteroids should be added in step 5.
152. A 50-year-old man patient was referred by his GP because of a long-standing history of persistent cough productive of mucopurulent sputum. He also noticed increasing shortness of breath. The patient has been treated several times for recurrent 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 cough productive of mucopurulent or purulent sputum throughout the year. Patients have frequently been treated for recurrent chest infections and labelled as
bronchitic, often despite the absence of a history of smoking. Patients may produce mucoid sputum early in their disease, developing purulent sputum when they suffer an exacerbation associated with a viral upper respiratory tract infection. 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 bronchitis associated with upper respiratory tract infections in childhood, followed by complete resolution of symptoms in the teens and early adult life before these return after a viral trigger. Upper respiratory tract symptoms such as nasal drip are common, and in about 30% of cases there is a history of chronic sinusitis. Patients with bronchiectasis also suffer from undue tiredness, which many find more troublesome than the productive cough.
153. A 25-year-old basketball player is brought to the accident and emergency department with 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 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 the presence 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 of patients 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 unilateral pleural effusion. He has felt unwell for some time and spends much of the day sitting in a chair. Pleural biopsies taken at thoracoscopy have shown malignant mesothelioma and extensive tumour on all pleural surfaces was noted. Having explained the diagnosis to him, which would be the most appropriate treatment to consider next?
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 patients with a low tumour volume. Used alone, it does not improve survival, but studies are underway using it as part of trimodality treatment with chemotherapy and radiotherapy. 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 the entire pleural surface is technically difficult and associated with a high risk of radiation pneumonitis, hepatitis and pericarditis. Results are disappointing. Radiotherapy to chest instrumentation-tract sites is effective at preventing tumour seeding and growth (see Boutin et al 1995. Chest,108(3),754-8) and is recommended after pleural procedures. This is routine practice, along with providing 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 of consolidation. 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 of 7.24, pa(O2) 72 mmHg, pa(CO2) 63 mm Hg. What is the next step in his management?
Warfarin might be an option during the middle weeks of pregnancy (13-36 weeks). but practically it would probably be better to stick with low molecular weight heparin for the duration. This leaves daily injections of subcutaneous low molecular weight heparin as the best treatment option. It would be impractical to treat this woman for the remaining 31 weeks of her pregnancy with intravenous heparin. Aspirin is an inadequate treatment for pulmonary embolus. 156. oxygen administration may lead to hypercapnia as these patients have lost their sensitivity to hypercapnia. it seems sensible to screen this woman for inherited coagulopathy . Oxygen administration therefore has to be decreased prior to initiating mechanical ventilation. they lose their stimulus to breathe and develop carbon dioxide narcosis. Oxygen therapy is effective in reversing the hypoxaemia of respiratory failure. However.Obtain a chest X-ray Do a ventilation/perfusion scan Decrease the fraction of inspired oxygen Initiate mechanical ventilation Administer intravenous aminophylline Your answer Patients with advanced COPD are at risk of developing acute respiratory failure. No obvious factors contributed to the risk of pulmonary embolus. What is the most appropriate treatment for this patient throughout her pregnancy? 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. An 18-year-old woman presents with an acute pulmonary embolism in the ninth week of pregnancy. Postpregnancy. When the hypoxaemia is corrected.
pleural rubs and signs of pleural effusions. Serum is c-ANCA positive. often in the middle of activity. A 49-year-old woman has been admitted with haemoptysis and epistaxis. He mentions involuntary naps. Signs on chest examination depend on the nature of the pulmonary lesions and include fine crepitations and bronchial breathing or. haemoptysis and chest pain. 157. Symptoms include cough. less commonly. They may appear as single or multiple rounded lesions. What is the most likely diagnosis? Tuberculosis Carcinoma of the lung Echinococcosis Wegener’s granulomatosis Systemic lupus erythematosus Your answer Almost all the patients so diagnosed have evidence of granulomatous lung disease at presentation. which can cavitate. A 24-year-old thin man complains of constant daytime sleepiness. 158. the chest Xray shows multiple rounded lesions with alveolar shadowing.because of her young age and lack of predisposing factors apart from the pregnancy. He also caused an accident when he fell asleep while driving home from work. which can be pleuritic. which is often accompanied by alveolar capillaritis. Bronchoscopy often reveals granulomatous inflammation and the diagnosis can sometimes be made from bronchial biopsies. dyspnoea. Pulmonary granulomas are usually diagnosed from chest X-ray and CT scans. Which of the following treatments would be indicated? Nortriptyline Fluoxetine Diazepam Modafinil Continuous positive airway pressure-breathing device Your answer . The patient works as an office manager and has no history of exposure to chemicals. which occur suddenly and without warning. The bronchi can also be affected and bronchial stenoses occur as late manifestations.
which usually starts in adolescence or young adulthood. A transbronchial biopsy is positive at an early stage.1 g/dl.5 kg (21 lbs) in weight during this period. He was pyrexic and without lymphadenopathy. Treatment involves the use of central nervous system stimulants such as modafinil to allow daytime functioning. It can also present as tubercular meningitis. who will probably have moved out of the bedroom because of the noise. The Mantoux test was negative. with all other routine investigations being normal. a chest X-ray may be normal. A chest X-ray showed 1–2 cm diameter miliary shadows all over the lung field. He also has a past history of angina and arthritis and was on medication. Later. Initially. loss of weight and then fever. He had hepatosplenomegaly and clubbing. CT scanning may show a lung parenchymal abnormality at an early stage. Hb 9. Continuous positive airway pressure-breathing devices are used in the treatment of sleep apnoea. 159. What is the probable cause of the illness and the X-ray finding? Sarcoidosis Mycoplasma pneumonia Staphylococcal pneumonia Miliary tuberculosis Bacterial endocarditis Your answer This is a case of miliary tuberculosis. lymphocytes 39%). On examination he did not look well.3 × 106/l (neutrophils 52%. A typical patient with sleep apnoea is usually older. . An 82-year-old man living alone in a bungalow came to the clinic complaining of feeling generally unwell for about the last 3–4 months and of losing about 9. On further enquiry he said he had been having night sweats for the last month. No bacteria grew in a sputum culture. obese and there will be a long history of gradually worsening snoring with apnoeas. Hepatosplenomegaly is seen in advanced disease. If untreated miliary tuberculosis is universally fatal. It presents with a gradual onset of vague ill health. Biopsy of liver and bone marrow may be required. Bibasal crepitus on the lower zone was heard on chest auscultation. Investigations showed WBC 12. In older patients it is difficult to diagnose. The Mantoux test may be negative in up to half of the patients with severe disease. Choroidal tubercles are seen in the eyes. There is usually a history of fairly high alcohol intake and smoking. which is caused by a diffuse disseminated spread of tubercle bacilli via the bloodstream. chest X-ray reveals the presence of small 1–2 cm lesions.This patient has narcolepsy: a sleep disorder causing hypersomnia. possibly witnessed by the spouse.
What is the most likely diagnosis? Non-Hodgkin’s lymphoma Pneumocystis jiroveci pneumonia Mycoplasma pneumonia Exogene allergic alveolitis Chlamydia pneumonia Your answer Acute. neuropathies). the pathogen lacks a cell wall and hence is not susceptible to penicillin. A 26-year-old man presents with fever. azithromycin or doxycycline. myocarditis. Which of the following treatments have been shown to prolong life in patients with COPD? Anticholinergics β2-agonists Inhaled corticosteroids Long-term oxygen therapy Lung volume reduction surgery Your answer The only treatment shown to prolong life in COPD is long-term oxygen therapy. Laboratory examination shows an elevated LDH and anaemia with the presence of cold agglutinins. It is thought that by relieving hypoxia there is a reduction in pulmonary arterial pressure and hence prolongation of life. The usual therapeutic agents are macrolides such as erythromycin. The diagnosis should be suspected in those patients with a relatively mild form of pneumonia. Suitable candidates are patients with an FEV1 < 1. A characteristic feature is the relatively high frequency of extrapulmonary complications such as rash. headache and a moderate productive cough. shows predominantly mononuclear cells and no dominant organism. With regard to treatment. particularly in previously healthy young adults. clarithromycin.5 litres and a pa(O2) < 7. . and with a chest X-ray that shows bronchopneumonia. 161. cough and fever. myalgia. neurological syndromes (aseptic meningitis. It must be taken in excess if 16 h per day. encephalitis. pericarditis and haemolytic anaemia.3 kPa when well on two occasions some weeks apart. Haemolysis occurs approximately 1–2 weeks following infection and is most commonly associated with a rise in polyclonal anti-I IgM antibodies with Mycoplasma pneumonia. The typical patient is usually a young adult who experiences a respiratory tract infection accompanied by headache.160. cold autoimmune haemolytic anaemia is commonly seen in adolescents and young adults following infection with Mycoplasma pneumoniae. The chest X-ray shows increased interstitial markings. but when sputum is obtained it is mucoid. cephalosporins or other cell wall-active antibiotics. The cough is often non-productive.
162. mainly subpleural and some honeycombing. Chest X-ray will show reticulation. clubbing and inspiratory crepitations are the classic features of usual interstitial pneumonitis. in occupational asthma. His chest radiograph shows reticulonodular shadowing and his CT scan confirms reticulation. Pulmonary sarcoidosis does not give clubbing and crepitations would be associated with end-stage fibrotic disease. which is classically subpleural in distribution on CT. and in Langerhans’cell histiocytosis it shows nodules and cystic lesions. with reticular and nodular patterns. possibly non-specific features of air trapping. Which of the following statements fits best with α1-antitrypsin (AAT) deficiency? AAT deficiency is never associated with asthma and bronchiectasis AAT is an autosomal co-dominant condition 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 Your answer . The CT appearances would be those of nodularity. A 60-year-old man who has a 30-pack year smoking history comes to clinic with worsening shortness of breath over the last 6 months. he is clubbed. including fissural nodularity. He works as a baker and keeps racing pigeons. has saturations of 91% on air and has widespread fine inspiratory crepitations. The CT in hypersensitivity pneumonitis shows: ground-glass shadowing. On examination. What is the diagnosis? Pulmonary sarcoidosis Usual interstitial pneumonitis Your answer Hypersensitivity pneumonitis Occupational asthma Langerhans’ cell histiocytosis Dyspnoea. 163.
urea > 7 mmol/l.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. What is the next appropriate step to confirm the diagnosis? Computed tomographic (CT) scanning Mantoux test Blood cultures Sputum sample Serum inflammatory markers Your answer The laboratory diagnosis of pulmonary tuberculosis relies on examination and culture of sputum or other respiratory tract specimens. respiratory rate > 30/min and hypotension (SBP < 90 mmHg. The chest X-ray shows a 4-cm. cyanosed. A 48-year-old woman is admitted with a couple of days’ history of fever with rigors and breathlessness. A 24-year-old patient presents with anorexia. The chest radiograph reveals consolidation. Appropriate treatment (as recommended by the British Thoracic Society) is with intravenous antimicrobials: coamoxiclav 1. On examination she looks extremely unwell and is confused. Asthma and bronchiectasis do occur but less frequently than emphysema.5 g three times daily or cefotaxime 1 g three times daily or ceftriaxone 2 g once daily plus erythromycin 500 mg four times daily or clarithromycin 500 mg twice daily. Deficiency (Pi ZZ homozygotes) results in premature emphysema. left upper lobe cavity. DBP < 60 mmHg). Which of the following would be the most appropriate antibiotic regimen to use? Oral amoxicillin Oral amoxicillin and oral clarithromycin Intravenous cefotaxime and intravenous clarithromycin Intravenous ceftazidime and intravenous vancomycin Intravenous amoxicillin and intravenous clarithromycin Your answer This woman has severe pneumonia as defined by the British Thoracic Society guidelines. large. 165. It requires any two of the following features: confusion. There is dullness on percussion and bronchial breathing at her right base. The definitive diagnosis requires the growth of Mycobacterium tuberculosis from respiratory secretions. 164. fever and hot flushes.2 g three times daily or cefuroxime 1. has a respiratory rate of 36/min and a systolic blood pressure of 86 mmHg. while a probable diagnosis can be based on typical clinical and chest X-ray findings with either sputum positive for acid-fast . Active tuberculosis is suspected.
neither is COP. hypereosinophilic syndrome and acute eosinophilic pneumonia. Her full blood count has shown an eosinophilia of 13% and her chest X-ray shows peripheral pulmonary shadows. 166. including asthma with associated eczema. Churg– Strauss syndrome. Wegener’s granulomatosis is not typically associated with an eosinophilia. It is diagnosed clinically. vasculitic neuropathy. ABPA is a condition where people with asthma have a vigorous IgE response to aspergillus. A 60-year-old woman attends the clinic complaining of shortness of breath over the preceding 2 months. chronic pulmonary eosinophilia. The specificity of these latter approaches depends on the prevalence of disease due to nontuberculosis mycobacteria in the population. tropical pulmonary eosinophilia. Loeffler’s syndrome. What is the most likely diagnosis? Severe asthma Allergic bronchopulmonary aspergillosis (ABPA) Churg–Strauss syndrome Your answer Wegener’s granulomatosis Cryptogenic organising pneumonia (COP) This woman’s eosinophil count is high. or typical histopathological findings on biopsy material. pulmonary infiltrates. as well as allergic bronchopulmonary aspergillosis. higher than it would be with asthma alone.and medium-vessel necrotising vasculitis. despite inhaled steroids. discharge and sinus pain. with associated eosinophilia. She is known to have asthma. She has also had problems with nasal irritation. sinus disease or extravascular eosinophils on biopsy findings. Eosinophil levels in the blood are tightly regulated. although a biopsy should be sought for pathological confirmation. It is diagnosed on finding four out of the following: asthma. which has recently been poorly controlled.bacilli or other specimens. a positive skin-prick test to . blood eosinophilia > 10%. Eosinophils accumulate in allergic or hypersensitivity disease. Churg–Strauss syndrome is an eosinophilic granulomatous inflammation of the respiratory tract with small.
D-Dimers should not be measured. pa(O2) 7. 167. A V/Q scan is unlikely to be helpful in view of her asthma. A chest radiograph is normal. which has been well controlled on a low dose of inhaled corticosteroids and long-acting ß-agonist. She is tachycardic (132 beats/min) and an ECG shows sinus tachycardia. for which the clinical probability is high. and was discharged as she was doing well. She underwent left hemiarthroplasty 12 days ago.6 kPa.aspergillus and flitting consolidation on the chest X-ray. Therefore a CT pulmonary angiogram would be the imaging procedure of choice in this case. the flow-volume loop is different in shape to normal A mid-expiratory flow rate between 25% and 75% of expired vital capacity is not indicative of airway obstruction Your answer . after starting low molecular weight heparin. 168. A small pneumothorax. not apparent on the inspiratory chest radiograph. She is started on oxygen. The symptoms and findings point towards a pulmonary embolism (PE). pa(CO2) 3. A 72-year-old woman is admitted with a sudden-onset. Her chest is clear on auscultation. is also unlikely since it would not cause marked hypoxia. left-sided pleuritic chest pain with shortness of breath. and request CT pulmonary angiography Request a chest radiograph in expiration Your answer Her PEF rate is only mildly reduced (75% best).5 kPa. Regarding the value of lung function tests The peak expiratory flow rate is not dependent on age In a restrictive disease. It is unlikely that this patient’s symptoms are due to an exacerbation of her asthma. There is no associated sinus disease. and request a V/Q scan Start low molecular weight heparin suspecting PE. Arterial blood gases are as follows: pH 7. 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. She is being treated for asthma. since the result would not alter the need for definitive investigation: because she has had a recent operation it would be high anyway. D-Dimers should only be measured when the probability of PE is low and further investigations would not be pursued.34. Her peak expiratory flow (PEF) rate is 300 l/min (best 400 l/min).
She is known to have moderate asthma and normally takes fluticasone 750 µg salmeterol twice a day and salbutamol as needed. PEFR readings are an objective measure of airway obstruction and in any child able to do PEFR. She is now unable to speak in sentences. 169. her peak flow is less than 150 l/min and her pulse rate is 130/minute. She has been given highflow oxygen. Her peak flow is usually 450. repeated nebulised salbutamol and Atrovent. She has been deteriorating over the past 3 days despite increasing her fluticasone and starting 40 mg oral prednisolone daily. it is advisable to do them regularly to assess lung function. so does not need iv hydrocortisone. and this would be the next step in the management of this woman. In a restrictive pattern. Saturations should be maintained above 95% with oxygen and close monitoring essential. Intravenous aminophylline is safe.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.5 kPa. She has had adequate doses of oral steroids. the f–v loop is reduced in size but looks similar in shape to normal. Which of the following 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 nonpregnant patient. A mid-expiratory flow rate (between 25% and 75% of the expired vital capacity) is a good measure of airways obstruction. It is of paramount importance to stabilise her and an emergency . Saturations are 96% and you hear a widespread wheeze on examination. A 23-year-old woman who is 34 weeks’ pregnant is admitted to the emergency department with shortness of breath. although levels need monitoring. cough and wheeze. Her p(O2) is 15 kPa and p(CO2) 4.
A 47-year-old man presents to hospital with acute breathlessness.section would not be in her best interests. She has features of acute severe asthma. There is minimal evidence at present to support the use of non-invasive ventilation in acute asthma (see British Guideline on the Management of Asthma 2003. 171.5 kPa (65 mmHg) and a pa(CO2) of 5.5–2.8) = 14 kPa Therefore.6/0. 1). A 62-year-old man presents with flushing and wheezing. but may respond to iv aminophylline and the nebulisers and not require intubation. although the clinical history of breathlessness does make hypoventilation seem an unlikely answer. Which of the following is the least likely explanation for this abnormality? Ventilation/perfusion (VQ) mismatch Right-to-left shunting Hypoventilation Diffusion abnormality Anaemia Your answer The Alveolar–arterial (A–a) oxygen gradient is one way to find the answer to this question.5 kPa (42 mmHg). A mass is seen on his chest radiograph.58. the normal being approximately 0. Hypoventilation causes hypoxaemia with a normal A–a gradient and is therefore the most unlikely explanation in this case. or she tires or becomes drowsy.0 kPa (< 15 mmHg). A–a gradient = 14 – 8.5 mmHg) whilst breathing room air. pA(O2) = FiO2 – (pa(CO2)/0. if her blood gases deteriorate. but which one of the following would be unusual with this diagnosis? Histological appearance similar to that of a small-cell carcinoma Highly vascular appearance Unlikely to be seen at bronchoscopy A low percentage develop carcinoid syndrome Your answer .6 kPa (42. His arterial blood gases show a pa(O2) of 8. Thorax. VQ mismatch. with hypoxia and hypercapnia. You suspect he may have a carcinoid tumour. she would need to be transferred to intensive care for intubation and ventilation.8) = 21 – (5. However.Suppl.5 = 5. diffusion abnormalities and right-to-left shunting all cause widening of the A–a gradient. 170.
Double lung transplant is usually performed because of the risk of chronic infection in the remaining lung. Histologically. A PEFR diary shows no nocturnal dips. Her doctor has tried various types of inhalers with no benefit. Typically. 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. With surgery the 5-year survival is 90% and 10-year survival is 75%.90% 5–year survival post-surgery Carcinoid tumours make up 1% of all lung tumours and 60% are visible in the bronchial tree. A chest X-ray shows a reticulonodular pattern. they are very vascular structures that on bronchoscopy appear as cherry-red balls that tend to bleed easily. night sweats or weight loss. No underlying cancer or serious systemic disease should be present. The chest of the donor should be slightly less than the recipient. She is on a maintenance dose of 15 mg of prednisolone. Examination is unremarkable apart from the skin changes of SLE. 173. cramp. She has never smoked. There is no history of fever. diarrhoea and wheezing). Only a small percentage develops carcinoid syndrome (flushing. Donor is matched for the ABO grouping and the rhesus blood group compatibility is not essential. A 25-year-old male patient with cystic fibrosis is to undergo lung transplantation. They originate from the APUD cell line. Which of the following is NOT true about the lung transplant in this patient? Donor-selection parameters include age under 40 years Donor’s chest measurements should be slightly smaller than those of the recipient It 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 transplant Your answer Indications for the treatment are patient under 60 years with life expectancy of less than 18 months. they may resemble small-cell carcinoma. and according to her she developed an unproductive cough and dyspnoea three months ago. 172. What is the most likely diagnosis? Asthma . Donor should have good cardiac and lung function and should be under the age of 40.
SLE. viral infection. It presents as a dry cough and dyspnoea. The prognosis is poor. Physical examination is unremarkable. 174. mineral-dust exposure.Bronchiectasis Bronchiolitis obliterans Your answer Tuberculosis Fungal infection ‘Bronchiolitis obliterans’ is the term used to describe fibrous scarring of the small airways. It is seen following: toxic-fume inhalation. The diagnosis can be confirmed by lung biopsy. and as a side-effect of penicillamine. tachypnoea and hypoxaemia that occur in patients deficient in . Which one of the following features is MOST accurate regarding Pneumocystis jiroveci pneumonia (PCP)? Occurs exclusively in AIDS Pleural effusion is frequently bilateral Auscultation of the lungs usually reveals no abnormality Your 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 by dyspnoea. Patients rarely respond to steroids. heart–lung and lung transplantation. Expiratory wheeze may be audible. bone marrow. mycoplasma and legionella infection. rheumatoid arthritis. The chest X-ray findings can vary from normal to a reticular or reticulonodular pattern.
On examination patients usually show signs of respiratory distress (tachypnoea. which. Echocardiography may show right ventricular dilatation and evidence of pulmonary hypertension. The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study emphasised the poor predictive value of scans reported as intermediate probability. The vast majority of adult patients have AIDS. A 20-year-old woman complains of a sudden onset of dyspnoea associated with pleuritic chest pain. it can also occur in those who received chemotherapy for haematological malignant disease or organ transplant. it remains the diagnostic reference test for pulmonary embolism. The trophozoite does not enter the blood. the organism is identified in pulmonary secretions obtained by bronchopulmonary lavage or lung biopsy and stained by methenamine silver or Giemsa stain. dyspnoea). It can also occur in malnourished or premature infants. Clinical examination is unremarkable. 175.immunoglobulin G and M. and patients deficient in cellular mediated immunity. A negative D-dimer test is useful for excluding pulmonary embolism in patients who are clinically thought to be at low risk. His chest X-ray shows bilateral hilar enlargement and mediastinal widening. a common occurrence in routine clinical practice. 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% of patients. may strengthen the clinical impression that a pulmonary embolism has occurred. Auscultation of the lung usually reveals no abnormalities. Pentamidine isethionate or cotrimoxazole is the recommended treatment (metronidazole is not effective in the treatment of PCP). What is the most likely diagnosis? Tuberculosis . but a ‘positive’ result does not establish the diagnosis. however. in the proper clinical setting. 176. A 64-year-old mechanic and lifelong smoker noticed haemoptysis a few days after he had a cold.
which then moves paradoxically on sniffing. with the tumour itself often being obscured in the process. Rarely. Involvement of the phrenic nerve may lead to paralysis and elevation of the hemidiaphragm. as is a tumour situated behind the heart. The common appearance of a tumour arising from the main central airways (70% of all cases) is enlargement of one or other hilum. Coned views of the ribs may help where rib invasion is suspected clinically. Collapse of the left lower lobe is often hard to identify. and if there is any suspicion. Apically located masses or superior sulcus tumours (Pancoast tumours) may be misdiagnosed as pleural caps. but such an abnormality may be secondary to infection beyond obstruction caused by a central tumour. and patients often have a long history of pain in the distribution of the brachial nerve roots. Loss of the head of the first. However. Consolidation and collapse distal to the tumour may have occurred by the time the patient presents. Tumour spreading to the pleura causes effusion. .Bronchial carcinoma Your answer Lymphoma Hilar metastases Lung abscess The value of the chest X-ray in the diagnosis and management of pulmonary neoplasm needs no emphasis. second or third rib is not unusual. Even experienced observers sometimes have difficulty in deciding whether or not a hilar shadow is enlarged. The ribs and spine should be carefully examined for the presence of metastases. No initial examination is complete without a lateral film. investigation by bronchoscopy and/or CT should be pursued. Spread of tumour from mediastinal nodes peripherally along the lymphatics gives the characteristic appearance of lymphangitis carcinomatosa – bilateral hilar enlargement with streaky shadows fanning out into the lung fields on either side. the finding of a normal X-ray of the chest does not exclude bronchial carcinoma as patients presenting with haemoptysis and a normal chest X-ray are sometimes found to have a central tumour on bronchoscopy. The mediastinum may be widened by enlarged nodes. localised obstructive emphysema may be observed.
Which is the most likely diagnosis? Histiocytosis X Histoplasmosis Churg–Strauss syndrome Berylliosis Polyarteritis nodosa (PAN) Your answer Histiocytosis X (eosinophilic granuloma) is a disease of young adults with widespread nodules in the lungs. 178. granulomas are absent. eg cavities. He has a business working as a builder. PAN affects mediumsized arteries (cf small arteries in Churg–Strauss syndrome) and the infiltrate is composed of neutrophils but granulomas are absent. which occurs in areas of damaged lungs. particularly involved in renovating farm houses and barns. 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. Churg– Strauss syndrome is characterised by a prodromal phase of asthma. Fibrosis appears early and may progress to respiratory failure and death. Type I hypersensitivity to Aspergillus fumigatus occurs in ABPA. transfer factor for carbon monoxide) and transfer coefficient (KCO).177. a second phase of tissue and peripheral eosinophilia and a final phase of systemic vasculitis. A 49-year-old man with unexplained cough undergoes bronchoscopy and transbronchial biopsy. What is the most likely diagnosis? Allergic bronchopulmonary aspergillosis (ABPA) Colonising aspergillosis Invasive aspergillosis Asperger’s syndrome Type I hypersensitivity to Aspergillus fumigatus Your answer Aspergillus precipitins are IgG antibodies typically found in colonising aspergillosis (aspergilloma). Histoplasmosis is the commonest fungal infection in North America and has both acute (usually self-limiting) and chronic (those with previous lung disease) forms. A 33-year-old man is found to have strongly positive aspergillus precipitins in his blood and complains of a cough with intermittent bloody sputum. 179. Invasive aspergillosis occurs in immunocompromised patients. Asperger’s syndrome has nothing to do with aspergillus infection. Which of the following is the most likely explanation for this abnormality? . Berylliosis has features similar to sarcoid. Histology shows evidence of neutrophil infiltrate.
WBC 10. A skin test for inhaled antigens.) in weight. ESR 110 mm in first hour. A serological screen for parasitic infection was negative. The disease responds to steroid treatment. He had began to become wheezy after a tooth extraction procedure 5 months ago and also had an associated troublesome cough. The IgE level is normal unlike fungal and parasitic hypersensitivity.2 kg (7 lb. including Aspergillus fumigatus . lymphocytes 30%. and about half of them have features of asthma. normal U&E. raised eosinophils noted) . which needs to be . He used to smoke 15 cigarettes per day but gave up smoking about 2 months ago. weight loss. was negative. Pulmonary function was within normal limits. Nothing was mentioned about atopy or extrapulmonary involvement in the scenario. low TLCO but normal/high KCO (same cardiac output going through smaller alveolar volume). There was no history of recent foreign travel and no significant past illness. fever and a raised ESR. eg vasculitis. What is the probable diagnosis? Pneumocystis pneumonia Loffler’s syndrome Asthma Cryptogenic pulmonary eosinophilia Churg-Strauss Syndrome Your answer This patient has eosinophilia and associated definite pulmonary signs. normal urine dipstick. Recently he had been unwell: he had had a fever and had lost about 3. A 49-year-old homosexual accountant came to the clinic with increased breathlessness. In fibrosing alveolitis you would also expect to see decreased lung volumes with a restrictive ratio (> 80%) on spirometry. There is no indication of drug involvement or malignancy.Fibrosing alveolitis Pulmonary vascular disease Severe thoracic skin thickening Pleural involvement Respiratory muscle weakness Your answer Isolated decreases in gas transfer are typical of pulmonary vascular disease. When the disease is self-limiting and lasts less than a month it is Loeffler’s syndrome.2 × 109/l (neutrophils 53%. The other three answers would all give a picture of ‘extrapulmonary restriction’ with a restrictive ratio. Churg–Strauss syndrome is unlikely. Salbutamol and beclometasone inhalers poorly controlled his symptoms. His serum IgE was normal. Tests showed: Hb 14.6 g/dl. Chest X-ray showed extensive symmetrical homogenous shadowing affecting all the peripheral lung field. recurrent pulmonary embolism (PE). Oxygen saturations are 97% and there is no desaturation on exerciese. he had a temperature of 37. 180. On examination. Patients may have systemic features of malaise.2 °C and occasional rhonchi on both sides.
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 shows generalised tenderness. reduced cardiac output and hypoxaemia. There is no relation to the patient’s sexual orientation and Pneumocystis jiroveci secondary to HIV is unlikely. The clinical status is striking. It is thought to result from the operation of a one-way valve system. However. 181.continued for about one year. The patient rapidly becomes distressed with rapid laboured respiration. 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. and the clinical scenario of tension pneumothorax may correlate poorly with chest X-ray findings. and is frequently missed in the ICU setting. Advanced Trauma Life Support guidelines recommend the use of a 3–6 cm long cannula to perform needle thoracocentesis for life-threatening tension pneumothorax. usually in the second anterior intercostal space mid-clavicular line. The cannula should be left in place until bubbling is confirmed in the underwater-seal system to confirm proper function of the intercostal tube. A few minutes later she develops cyanosis. It should be particularly suspected in those on mechanical ventilators or nasal non-invasive ventilation who suddenly deteriorate or develop EMD arrest. It is therefore recommended that a cannula length of at least 4. If a tension pneumothorax occurs. The development of tension pneumothorax is often. sweating and tachycardia. heralded by a sudden deterioration in the cardiopulmonary status of the patient related to impaired venous return. cyanosis. What is the diagnosis? Myocardial infarction Tension pneumothorax Ectopic pregnancy Pulmonary embolism Acute pancreatitis Your answer If a tension pneumothorax is present. the patient should be given high-concentration oxygen and a cannula should be introduced into the pleural space. drawing air into the pleural space during inspiration and not allowing it out during expiration. 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. .5 cm should be used in needle thoracocentesis of tension pneumothoraces. in 57% of patients with tension pneumothorax the thickness of the chest wall has been found to be greater than 3 cm. but not always. After a tennis match. The development of tension in a pneumothorax is not dependent on the size of the pneumothorax. Tension pneumothorax occurs when the intrapleural pressure exceeds the atmospheric pressure throughout inspiration as well as expiration.
How long would you continue warfarin therapy in these circumstances? 4–6 weeks 3 months 6 months 1 year Lifelong Your answer This young woman’s only risk factor given is the long-haul flight. There appears to be increased resonance over the upper right side of the chest. The risk of bleeding needs to be balanced against the risk of further emboli. There are no other associated symptoms and no signs to suggest acute infection. they tend to be recurrent when linked to emphysema. The standard duration of anticoagulation is: 4–6 weeks for temporary risk factors. Other. rarer causes of pneumothorax include asthma. 3 months for first idiopathic. The sudden onset of shortness of breath associated with pleuritic chest pain in this case makes pneumothorax more likely than COPD exacerbation. which is only a temporary risk factor. underlying carcinoma. pneumothoraces occurring in relation to COPD should be managed conservatively or with needle air-aspiration depending on their size. Unfortunately. Which is the most likely diagnosis in this case? An exacerbation of COPD A spontaneous pneumothorax Acute-onset pneumonia Empyema Pulmonary embolism Your answer Underlying chronic obstructive pulmonary disease (COPD) is the usual cause of pneumothorax in patients of this age group. . A 26-year-old woman arrives in the UK from Australia. A pulmonary embolus is confirmed radiologically and she is commenced on warfarin. 183. A few days later she presents to hospital with pleuritic chest pain and breathlessness. at least 6 months for other. She is not on the oral contraceptive pill and has no family or personal history of DVT/PE. lung abscess and severe pulmonary fibrosis with cyst formation.182. Formal chest drain may be required where the size is > 50% or there is significant respiratory compromise. A 74-year-old man with previously stable emphysema presents to A&E with rightsided pleuritic chest pain and sudden increase in shortness of breath. If possible.
BP 100/70 mmHg and pulse 130/min.184. He also complains of right-sided chest pain on inspiration. Which one of the following features is MOST characteristic of cystic fibrosis? Inherited as autosomal dominant Pancreatic insufficiency is almost always identified in adult patients In patients with recurrent chest infections Pseudomonas cepacia is the most frequent organism isolated from sputum Family members who carry the gene are at risk of developing mild recurrent bronchitis Patients typically have reduced levels of sodium and chloride in the sweat Your answer . fatigue and asthenia. 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 variable presence of sputum production. 185. Examination of the lung might reveal decreased vesicular breath sounds. A 36-year-old lorry driver who smokes heavily presents with a 2-day history of cough associated with fever. respiratory rate 38/min. Most patients have constitutional symptoms such as malaise. He has basal crepitations and dullness to percussion at the right lung base. On examination he is slightly cyanosed. dyspnoea and pleurisy. The chest X-ray is a pivotal test for the confirmation of pneumonia. dullness to percussion and sometimes a bronchial wheeze. and many also have gastrointestinal symptoms. His temperature is 38 °C. localised foci of crepitations.
Pseudomonas cepacia occurs in 5–10% of cases. He smokes 10–15 cigarettes a day.Cystic fibrosis (CF) is an autosomal recessive disease affecting both eccrine and exocrine gland function. he does not need oxygen Once the pneumothorax has resolved he can go back to work. 186. The patient is not breathless and his oxygen saturation on air is 95%. an asymptomatic patient with a small. left-sided chest pain. Smoking increases the chances of a . Recurrent chest infections are usually caused by Pseudomonas aeruginosa and Staphylococcus aureus. Which of the following statements is true? Simple aspiration is the first-line treatment if the patient is symptomatic If admitted for observation. It is caused by abnormal viscid secretions from mucous glands leading to chronic pulmonary disease and pancreatic insufficiency. A chest X-ray confirms a small leftsided pneumothorax. high-flow oxygen increases the absorption of air from the pleural cavity. heterozygotes are clinically normal. characterised by elevated levels of sodium and chloride in the sweat. A 26-year-old. naval officer is admitted to the hospital with a sudden-onset. A pneumothorax can be classed as small or large depending on the presence of a visible rim of < 2 cm or ≥ 2 cm between the lung margin and the chest wall. primary spontaneous pneumothorax can be discharged with the advice to return if he becomes symptomatic. which will be evident in more than 95% of adult cases. previously healthy. apart from in the prevention of COPD in later life He should be treated with a small (10–14 F)-sized chest drain Your answer A small pneumothorax in a person with no previous chest disease should be aspirated if the patient is breathless. The carrier rate is 5% in the Caucasian population. If a patient is admitted for observation. Ideally. including resuming his diving duties Smoking cessation has no role in management.
Whatever course is followed. and so compliance with their use may be poor. which filter out 98–99% of respirable dust from the ambient air. and may entitle the affected worker to compensation. A young adult was referred because of cough and shortness of breath. exposure should cease. which other therapy is most likely to be successful? Antibiotics Non-steroidal anti-inflammatory drugs Immunoglobulins Corticosteroids Desensitisation Your answer Management of the patient centres on reducing any further exposure to a minimum. Desensitisation has no beneficial effect. 188. but this may mean a profound loss of income or great expense. but first the diagnosis must be secure. Ideally. An alternative is to use industrial respirators. When there is progressive disease. Beside reduction of exposure to the allergen. but they may be uncomfortably hot when worn for long periods or when there is heavy work. 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. affected individuals change their relevant working. and is often unrealistic. Diving is contraindicated unless the patient has undergone pleurectomy. and their physician must weigh the possible advantages of longterm corticosteroid therapy against the risks. continuing exposure should be accompanied by regular medical surveillance. An extrinsic allergic alveolitis was diagnosed. 187. This may involve a loss of earnings. it is reasonable for some exposure to continue. individuals with progressive disease may refuse to change their occupation or hobby. Which of the following conditions is most likely to be associated with a decreased DLCO? Polycythaemia Anaemia Pulmonary embolism Exercise Your answer . If there is no progression. Nor is it fully justified on purely medical grounds since continued exposure does not inevitably lead to progressive disease. domestic and recreational environment completely. Occasionally. These are especially valuable when exposures are intermittent and short.recurrence.
she has been more breathless than usual when taking her evening walk. 190. Bilateral reticular shadowing. 189. best seen in the basal region.4 kg (14 lbs) during the last year. Other than an occasional paracetamol for her headache. A 60-year-old hairdresser complains that. Horner’s syndrome is caused by an apical lung tumour. and has also felt short of breath when climbing the stairs. Respiratory . She has had pain in her right shoulder for some months. Her JVP was not raised and heart sounds were normal.Acute poliomyelitis DLCO. only 3-5% are said to be due to small cell tumours. which leads to spinal cord damage between spinal levels C8 and T1. She has lost about 6. Her husband has noticed that her pupil is constricted and her right eyelid is drooping. She has become concerned that she has a cardiac problem. the diffusion capacity in the lung for carbon monoxide. which her GP has described as 'probable rheumatism'. On examination she was apyrexic and had bilateral clubbing. Examples include pulmonary embolism and emphysema in which the alveolar surface area is reduced. What is the most likely diagnosis in this case? Eaton-Lambert Syndrome Horner’s syndrome caused by Pancoast’s tumour Small-cell carcinoma Tuberculosis Aspergilloma Your answer Eaton-Lambert syndrome is a paraneoplastic syndrome associated with proximal myopathy. It is associated with SIADH in 510% of cases. after an attack of flu last year. A 73-year-old woman presents with weight loss and a chronic cough. No pedal oedema was seen. she is on no regular medication. Symptoms are pupil constriction. No lymphadenopathy was seen. Her HRCT showed peripheral reticular ground-glass opacification. is decreased in any condition that reduces the effective alveolar surface area or affects the alveolar membrane. related to a deficient action of cholinergic neurones. except for an ESR of 35 mm in the first hour. Pancoast’s tumours are mostly squamous or adenocarcinomas. ptosis and facial anhydrosis. was seen on chest X-ray. mostly on the bases. Routine bloods were normal. this is because small-cell carcinoma of the bronchus is more likely to occur centrally and so wouldn’t be expected to present like this. She has smoked 20 cigarettes per day for 45 years but does not drink alcohol. Bibasal inspiratory crepts were audible. Unfortunately her chest x-ray reveals a mass in the right lung apex with possible lymphadenopathy at the right hilum.
0). Azathioprine or cyclophosphamide may be added to the treatment and a single lung transplant may be offered.3-12. The best evidence relates to exacerbations of chronic obstructive pulmonary disease (COPD). An open-lung biopsy showed an exudate of intra-alveolar macrophages with patchy interstitial fibrosis. Bronchoalveolar lavage showed an increased number of cells – neutrophils and macrophages – but no malignant cells. Physiological responses (heart and respiratory rate. what is the most likely diagnosis? Pulmonary embolus Aspirin overdose . All other causes should be excluded before diagnosing cryptogenic fibrosing alveolitis. Given these blood gas results. 191. and a carbon dioxide tension of 8. Median survival time is approximately 5 years. What is the likely diagnosis? Cryptogenic fibrosing alveolitis Extrinsic alveolitis Lymphangitis carcinomatosis Chronic left heart failure Sarcoidosis Your answer Cryptogenic fibrosing alveolitis is the group of disease consisting of interstitial pneumonia with differing amounts of cellularity and fibrosis. Intubation is also less frequently required.5kPa (4. In which of the following emergency medical presentations is non-invasive ventilation an established treatment? Tension pneumothorax Acute asthma Acute exacerbation of COPD ARDS Pulmonary oedema Your answer Non-invasive ventilation (NIV) is currently being evaluated in an number of emergency situations. 192.6). An arterial blood sample from a 48-year-old male patient with progressive dyspnoea has an oxygen tension of 8. Patients with desquamative histology have a favourable response to treatment with prednisolone.function test showed restrictive ventilatory defect.76.5 kPa (11. this type of therapy is effective in patients with decompensated type-2 respiratory failure. In particular. and arterial blood gases) improve more quickly with NIV in these patients compared to standard treatment.
Silicosis is characterised by shortness of breath. Which of the following is not a common symptom of lung cancer on presentation? Cough Chest pain Cough and chest pain Coughing blood . 193. His chest X-ray is abnormal with small rounded opacities and irregular upper zone fibrosis. and unfortunately he is suffering from silicosis.A 58-year-old memorial stonemason presents to the chest clinic. There is hilar lymphadenopathy with ‘eggshell’ calcification.Ankylosing spondylitis Viral pneumonitis Lobar pneumonia Your answer This is type II respiratory failure. Pulmonary function testing reveals a restrictive picture and there is mild hypoxia. kyphoscoliosis (and similar musculoskeletal disorders) and end-stage muscle. Over the past few years he has noted a gradual increase in shortness of breath. but accelerated forms and continued exposure are associated with respiratory failure over a few years. screening for and treatment of tuberculosis if found in association and supportive measures such as bronchodilators and oxygen therapy. He is a non-smoker and has no other past history of note. Pathogenesis is related to activation of alveolar macrophages via ingestion of silica dust. Chronic silicosis may not progress. Which diagnosis best fits with this clinical picture? Silicosis Asthma Idiopathic pulmonary fibrosis Tuberculosis Byssinosis Your answer This man’s job is likely to have exposed him to silica dust. neurological and airways disorders. wheeze and cough with lung function tests and chest X-ray suggestive of irregular fibrosis. 194. releasing a number of proteolytic enzymes and inflammatory cytokines. with cough and occasional wheeze. Management involves removal of exposure. Lobar pneumonia causes hypoxia but a normal/low pa(CO2) (type I respiratory failure) unless exhaustion supervenes when the patient may start to retain carbon dioxide. pa(CO2) rises due to hypoventilation and this can occur acutely due to drug overdose or more chronically with gross obesity.
In less than 5% of cases they present with other symptoms: shortness of breath. weight loss. right ventricular enlargement. hoarseness.Shortness of breath Your answer Cough is the commonest symptom (about 41% of patients) at presentation. Which of the following is a poor prognostic factor in patients suffering from pneumonia? White cell count (WCC) 17 × 109/l Blood pressure 110/70mmHg Respiratory rate 35/min Rigors Temperature 39°C Your answer 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. Mismatched defects are classical of PE. hypoxia with a low pa(CO2) and a low transfer factor. Only 7% of patients present with the symptom of coughing up blood. followed by chest pain in 22% of patients who have later been diagnosed to have lung carcinoma. 196. 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 alveolar–arterial (A–a) gradient on exercise Your answer Recurrent pulmonary emboli (PE) should always be considered in cases of progressive SOB with no obvious cause. About 15% of patients present with both cough and chest pain. Possible clues include pulmonary hypertension. A 36-year-old woman is under follow up for recurrent pulmonary thrombo-embolic disease. malaise and distant spread. . 195. Widening of the lveolar–arterial (A–a) gradient on exercise is likely to be found.
his temperature spiked and he developed a productive cough with a yellow-greenish sputum. It also causes hospital-acquired infections. particularly on the ITU or after surgery. What is the most probable cause of his pneumonia? Pneumococcal pneumonia Aspiration pneumonia Pseudomonas pneumonia Staphylococcal pneumonia Haemophilus pneumonia Your answer Pseudomonas is a common pathogen in patients with bronchiectasis and cystic fibrosis. Blood results showed leucocytosis. CT has confirmed the mass and has also shown enlarged 1-cm short-axis hilar and paratracheal nodes. 198. A 65-year-old man known to have COPD presented with progressive respiratory failure. What are they likely 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 . ceftazidime. A chest X-ray revealed a right-sided middle and lower lobe pneumonia. Treatment is with anti-pseudomonal penicillin. A fit 50-year-old man with a 20-pack year smoking history presents with haemoptysis and a 3-cm right upper lobe mass on his chest radiograph. On the second day on the ward. meropenem or ciprofloxacin. Nosocomial or hospital-acquired infections should be suspected in patients with an onset of symptoms at least 48 hours after admission to the hospital. He is discussed at the lung-cancer multidisciplinary team meeting. The sputum colour also gives a clue to the most likely diagnosis.197. He was treated in ITU with mechanical ventilation and improved. Bronchoscopy has shown this is a squamous-cell carcinoma. After extubation he was transferred to the ward.
which predisposes them to OSA as . In a PET scan. and this can be done with mediastinoscopy or a positron-emission tomography (PET) scan. If his cancer is inoperable. radiolabelled glucose is injected peripherally and is taken up by metabolically active tissues. but these could be removed with pneumonectomy. He has enlarged hilar nodes. causing airway obstruction and subsequent apnoea. The mass loading from the obese or muscular neck overwhelms the residual dilator muscle action of the pharynx when the patient is asleep. such as the brain and any cancer. Chemotherapy could also be considered. with > 43 cm (>17 inches) being associated with an increased risk. which if they were cancerous. but he also has enlarged mediastinal nodes.Refer to the palliative care team This is a man with potentially operable non-small-cell lung cancer. It would show metastases from the primary cancer. 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. palliative radiotherapy can be given to the mass. Palliative care team referral would be appropriate if he does not want interventions or has troublesome symptoms. would make the cancer resection non-curative. Patients may also have a small or set back mandible. to try and control the haemoptysis. However CT is not great at assessing whether enlarged nodes are inflammatory or malignant. 199. He therefore needs further assessment of his mediastinal nodes prior to surgery.
patients also have upper body obesity. or pa(O2) of 7.0 kPa when stable and also an additional risk feature like secondary polycythaemia. What are the indications for home oxygen? Low forced expiratory colume in 1 s (FEV1) Low p(CO2) Cor pulmonale Low p(O2) Ischaemic heart disease Your answer 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 less than 7.3 kPa when stable. 200. nocturnal hypoxaemia. . which is the typical male fat pattern. Oxygen should be used for at least 15 h a day.well. Typically. peripheral oedema or pulmonary hypertension.3–8.
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