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Question 1:
A 72-year-old woman who smokes 5–10 cigarettes per day and has a past history of whooping cough presents with chronic cough and recurrent chest infections for review. She admits to producing frequent amounts of purulent sputum and of intermittently suffering night sweats for a number of months. There have also been occasional episodes of haemoptysis. Chest X-ray reveals hyperinflation, crowded lung markings and small, cyst- like spaces at the lung bases. What is the most likely underlying pathology?
Options:
- Asthma
- Bronchial carcinoma
- Bronchiectasis
- Chronic lung abscess
- Tuberculosis
Correct Answer: Bronchiectasis
Explanation:
Correct Answer: C- Bronchiectasis Explanation Bronchiectasis The past history of whooping cough and smoking, coupled with the X-ray changes, are very suggestive of bronchiectasis. Non-pharmacological management involves self-physiotherapy and adequate hydration. Chronic intermittent oral antibiotic therapy is used by some physicians, although it might encourage the development of multi-drug resistance and its use is not universally endorsed. Influenza and pneumococcal vaccinations are strongly recommended. Surgical referral might be recommended for patients with chronic severe localised infection that fails to resolve after intravenous antibiotic therapy. Asthma Asthma is incorrect. The predominant symptom of asthma is wheeze, which is not mentioned here. Asthma is not associated with chronic productive cough, haemoptysis or night sweats. Bronchial carcinoma Bronchial carcinoma is incorrect. Bronchial carcinoma causing a lobar airway obstruction and subsequent recurrent infectons is a reasonable differential here. However, the history of whooping cough and the chest radiograph appearances point more towards a diagnosis of bronchiectasis. Chronic lung abscess Chronic lung abscess is incorrect. A chronic lung abscess would be seen on the chest radiograph. The chest radiograph appearances described in this case are most consistent with bronchiectasis. Tuberculosis Tuberculosis is incorrect. The duration of symptoms coupled with the history of whooping cough and chest radiograph appearances are more consistent with bronchiectasis. In tuberculosis, you would expect a shorter duration of symptoms before presentation and chest X-ray would typically show upper lobe consolidation +/- lymphadenopathy.
Question 2:
A 71-year-old man comes to the Respiratory Clinic for review. He has a history of chronic obstructive pulmonary disease (COPD) managed with high-dose Seretide and tiotropium, and right heart failure for which he takes ramipril and bumetanide. He has an exercise tolerance of 80 m and has had two COPD exacerbations in the past year. On examination his BP is 135/85 mmHg; pulse is 75/min and regular. Auscultation reveals bilateral poor air entry and wheeze. He has bilateral pitting oedema to just above the ankles. His BMI is 23. Investigations: Hb 13.8 g/dl WCC 9.3 × 109/l PLT 189 × 109/l Na+ 138 mmol/l K+ 4.3 mmol/l Bicarbonate 32 mmol/l Creatinine 122 μmol/l pH 7.44 pO2 7.8 kPa (7.7 kPa 3 months earlier) pCO2 6.5 kPa Which of the following is the most important argumentation justifying prescription of long- term oxygen therapy (LTOT) in this patient?
Options:
- Exercise tolerance 80 m
- pCO2 6.5 kPa and right heart failure
- pO2 7.8 kPa and right heart failure
- Presence of right heart failure irrespective of pO2
- Two exacerbations in the past year
Correct Answer: pO2 7.8 kPa and right heart failure
Explanation:
Correct Answer: C- pO2 7.8 kPa and right heart failure Explanation
pO2 7.8 kPa and right heart failure O2 is the main driver for LTOT prescription. Guidelines state that LTOT should be offered to patients with PaO2 less than 7.3 kPa when stable, or greater than 7.3 kPa and less than 8 kPa when stable, who also have secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension. CO2 retention is a driver for pulmonary hypertension, and the presence of right heart failure allows the less stringent threshold for O2 prescription to be used, as here. Exercise tolerance 80 m Exercise tolerance 80 m is incorrect. Although exercise tolerance is associated with poorer prognosis, it is not a driver for oxygen prescription.
pCO2 6.5 kPa and right heart failure
pCO2 6.5 kPa and right heart failure is incorrect. It is the degree of hypoxia, not hypercapneoa that dictates the need for long-term oxygen therapy. Presence of right heart failure irrespective of pO2 Presence of right heart failure irrespective of pO2 is incorrect. LTOT only confers a survival benefit in patients with right heart failure with a pO2 < 8 kPa when stable. It would therefore be inappropriate to prescribe LTOT in a patient with a pO2 greater than this, even in the presence of heart failure. Two exacerbations in the past year Two exacerbations in the past year is incorrect. Although increased exacerbations are associated with poorer prognosis, they are not a driver for oxygen prescription.
Question 3:
A 52-year-old patient from a chemical factory presents with cough and is found to have a squamous lung carcinoma. He is quite sure that it is work related. He smoked five cigarettes per day until he was aged 34, having started smoking at the age of 16. What is the most likely cause?
Options:
- Aromatic amines
- Coal dust
- Isocyanates
- Polyvinyl chloride
- Smoking
Correct Answer: Isocyanates
Explanation:
Correct Answer: C- Isocyanates Explanation Isocyanates Isocyanates are a recognised risk factor for the development of non-small-cell lung cancer. Other aetiological factors include smoking, asbestos exposure and exposure to polycyclic hydrocarbons or the products of coal burning. Exposure to isocyanate fumes occurs in chemical workers, particularly those who work in the rubber industry, and this exposure is most likely to be associated with squamous-cell carcinoma of the bronchus. Most squamous-cell carcinomas present as obstructive lesions, which can manifest as infection. Around 10% of cases present with cavitating lesions, but widespread metastases occur relatively late. Aromatic amines Aromatic amines is incorrect. Aromatic amines are associated with bladder carcinoma. Coal dust Coal dust is incorrect. There is nothing in the history to suggest coal dust exposure. Polyvinyl chloride Polyvinyl chloride is incorrect. Exposure to vinyl chloride is associated with angiosarcoma of the liver. Smoking Smoking is incorrect. He has a relatively low smoking exposure in terms of patient years; as such, it is isocyanates which are likely to have had a larger impact on his lung cancer risk.
Question 4:
A 32-year-old black woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially on climbing stairs. She reports intermittent fevers of up to 39 °C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and her serum antinuclear antibody (ANA) is negative. On examination there are red nodules over her lower legs. What is the most likely diagnosis?
Options:
- Adenocarcinoma of the lung
- Goodpasture syndrome
- Histoplasmosis
- Sarcoidosis
- Systemic lupus erythematosus
Correct Answer: Sarcoidosis
Explanation:
Correct Answer: D- Sarcoidosis Explanation Sarcoidosis Sarcoidosis is most common in black women, but the aetiology is unknown. It is characterised by the presence of non-caseating granulomas in at least two organs. Pulmonary involvement has been described in more than 90% of patients and the lymph nodes and the lung parenchyma can both be involved. Clinical manifestations include:
• Dry cough • Dyspnoea • Arthralgias • Erythema nodosum • Systemic symptoms, including:
• Fever • Weight loss • Fatigue Adenocarcinoma of the lung Adenocarcinoma of the lung is incorrect. Malignancy would be a differential diagnosis however, the presence of intermittent fevers, arthralgia and rash suggestive of erythema nodosum is more consistent with sarcoidosis. Patients with adenocarcinomas are often non-smokers. Goodpasture syndrome Goodpasture syndrome is incorrect. Goodpasture syndrome is associated with pulmonary haemorrhage and renal impairment with nephritis which are not described here therefore, this diagnosis is unlikely. Histoplasmosis Histoplasmosis is incorrect. Histoplasmosis is a fungal infection which, in severe infections, can be associated with fever, headace, myalgia, dry cough, chest pain, arthralgia, rash and weight loss – all of which are described in this case. However, there is nothing mentioned in the history to suggest risk factor for histoplasmosis. There is no history of immunosuppression and there is no mention of a potential risk factor (e.g. farming, poultry keeping, construction work, roofing, gardening). Sarcoidosis is more likely here. Systemic lupus erythematosus Systemic lupus erythematosus is incorrect. Systemic lupus erythematosus is also a reasonable differential diagnosis however the lack of cytopenias, negative ANA and rash suggestive of erythema nodosum means sarcoidosis is more likely.
Question 5:
An 81-year-old woman who had consulted her GP with symptoms of flu 2 weeks earlier now presents to the Emergency Department. For the past few days she has had increasing cough, associated with purulent sputum and haemoptysis. Her daughter visited and noticed that she had become acutely confused and arranged an ambulance. On arrival to the department she is found to be agitated, with a respiratory rate of 35/min. Blood gases reveal that she is hypoxic, her white blood cell count is 20 — 109/l, predominantly neutrophils. Her creatinine concentration is 250 µmol/l. Chest X-ray reveals patchy areas of consolidation, with necrosis and empyema formation. What diagnosis best fits this clinical picture?
Options:
- Chlamydia psittaci pneumonia
- Haemophilus influenzae pneumonia
- Mycoplasma pneumonia
- Staphylococcus aureus pneumonia
- Streptococcus pneumoniae pneumonia
Correct Answer: Staphylococcus aureus pneumonia
Explanation:
Correct Answer: D- Staphylococcus aureus pneumonia Explanation Staphylococcus aureus pneumonia In general, staphylococcal pneumonia only occurs after a preceding viral illness. Patchy areas of consolidation occur that eventually break down into abscesses. Pneumothorax, pleural effusion and empyema are common in staphylococcal pneumonia. Clinical features of severe pneumonia include a respiratory rate > 30/min, diastolic blood pressure < 60 mmHg, confusion, involvement of more than one lobe, low albumin concentration, white cell count > 20 × 109/l or less than 1 × 109/l, and renal dysfunction. Treatment: fulminant staphylococcal pneumonia, as in this case, carries a high mortality. Standard therapy would be intravenous cefuroxime and clarithromycin, with added flucloxacillin for suspected Staphylococcus aureuspneumonia. Chlamydia psittaci pneumonia Chlamydia psittaci pneumonia is incorrect. Chlamydia psittaci pneumonia was originally described in people who kept the psittacine family of birds (eg parrots). The peak age at presentation is 30–60 years and it has an equal sex distribution. Mortality is low (0.7%). The incubation period is 1–2 weeks, but the illness can follow a protracted course over a number of months. Symptoms usually include increasing tiredness, high fevers at night, cough and myalgia, and liver function tests might show mild abnormalities in up to 50%. The chest X-ray can show segmental or diffuse consolidation. Diagnosis is confirmed by enzyme immunoassay. Treatment is with macrolide or tetracycline antibiotics. Haemophilus influenzae pneumonia Haemophilus influenzae pneumonia is incorrect. Haemophilus influenzae pneumonia produces classical symptoms of pneumonia with cough, fever and shortness of breath. Most patients will have significant underlying comorbidities such as alcohol dependence, chronic obstructive pulmonary disease (COPD), or diabetes mellitus. The overall mortality rate for adults is high at 30–60% and is probably related to the severe comorbid conditions affected patients tend to have along with the pneumonia itself. Complications can include lung abscess, empyema, meningitis, arthritis, pericarditis, epiglottitis, and, in children, otitis media. The fact that this lady had symptoms of influenza preceding the illness makes staphylococcal pneumonia more likely. In addition, although Haemophilus influenzae pneumonia can lead to lung abscesses and empyema, these are more commonly seen with staphylococcal pneumonias. Mycoplasma pneumonia Mycoplasma pneumonia is incorrect. Mycoplasmal infections occur in epidemics every 4–5 years, more commonly among close-knit populations such as those in schools and colleges. Mycoplasmal infection is not associated with exposure to birds. The peak age of presentation of mycoplasmal pneumonia is 5–20 years, and Mycoplasma pneumonia accounts for about 7% of all community- acquired pneumonias. Cold agglutinins are associated in up to 50% of cases and muscle tenderness is reported to occur in up to 50%. The X-ray appearances are usually much worse than would be suggested by the clinical examination of the respiratory system. Treatment consists of a 2-week course of erythromycin or clarithromycin. X-ray resolution is complete by week 8 in around 90% of patients. Streptococcus pneumoniae pneumonia Streptococcus pneumoniae pneumonia is incorrect. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia and produces classical symptoms such as cough, fever, dyspnoea and malaise. The most common complication is pleural effusion, which can progress to empyema in severe cases. Herpetic ulcers often predate the development of symptoms but are not mentioned in this case. Although a viral illness can precede a streptococcal pneumonia, a history suggestive of recent influenza is most classically associated with staphylococcal pneumonia, making pneumonia secondary to Staphylococcus aureus more likely.
Question 6:
A 50-year-old retired boilermaker with shortness of breath comes to the Respiratory Clinic. He has smoked ten cigarettes per day for the past 30 years. The GP wonders if he has obstructive lung disease and the man arrives with his spirometry results, which show: forced expiratory volume in 1 s (FEV1) 1.74 l (predicted 3.0 l), forced vital capacity (FVC) 2.5 l (predicted 2.8 l); post- salbutamol FEV1 1.81 l, post-salbutamol FVC 2.7 l; transfer factor 55%. Which of the following is the most likely diagnosis?
Options:
- Asbestos-related pleural plaque disease
- Asthma
- Emphysema
- Pulmonary embolism
- Pulmonary fibrosis
Correct Answer: Emphysema
Explanation:
Correct Answer: C- Emphysema Explanation Emphysema The forced vital capacity (FVC) is only slightly reduced, but the ratio of the forced expiratory volume in 1 s (FEV1) to the FVC (FEV1/FVC) is more significantly reduced. Transfer factor is also reduced at 55%. With reversibility of less than 10% post-salbutamol, the most likely diagnosis here is chronic obstructive pulmonary disease (COPD). Stopping smoking is the key initial measure, with trials also indicating that high-dose inhaled steroids combined with long-acting ß2-agonists might reduce exacerbation rates and improve quality of life in comparison with other options. Asbestos-related pleural plaque disease Asbestos-related pleural plaque disease is incorrect. Asbestos-related pleural plaque disease is not associated with abnormal lung function. Asthma Asthma is incorrect. There is less than 10% reversibility in this man’s FEV1 following salbutamol, which means that COPD is more likely. Pulmonary embolism Pulmonary embolism is incorrect. There are no risk factors for pulmonary emboli (PE) mentioned. He has no pleuritic chest pain or leg swelling suggesting deep venous thrombosis. Spirometry in a lone diagnosis of PE would likely be normal. Pulmonary fibrosis Pulmonary fibrosis is incorrect. Pulmonary fibrosis is associated with a restrictive pattern of spirometry.
Question 7:
A 60-year-old woman presents with chronic progressive shortness of breath and bibasal crepitations. Which of the following is the most likely diagnosis?
Options:
- Extrinsic allergic alveolitis
- Idiopathic pulmonary fibrosis
- Progressive massive fibrosis
- Sarcoidosis
- Tuberculosis
Correct Answer: Idiopathic pulmonary fibrosis
Explanation:
Correct Answer: B- Idiopathic pulmonary fibrosis Explanation Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is characterised by an inflammatory cell infiltrate. The main symptoms are dry cough, exertional dyspnoea and malaise. Signs include cyanosis, finger clubbing and fine end-inspiratory crepitation at the bases and in the axillae. Bilateral lower- zone reticulonodular shadows are seen on chest X-ray. Lung damage is often irreversible but pirfenidone is recommended between 50% and 80% predicted. Lung transplantation may be considered. Overall, the median survival is 2–3 years following diagnosis. Extrinsic allergic alveolitis Extrinsic allergic alveolitis is incorrect. Extrinsic allergic alveolitis shows a predilection for the upper zones,
although, when severe, can affect all zones. Progressive massive fibrosis Progressive massive fibrosis is incorrect. Progressive massive fibrosis describes a stage of a number of occupational lung diseases which are caused by mineral dusts – silicosis and coal-worker’s pneumoconiosis. When the irregular or linear opacities become large shadows late in the course of these diseases this is then called ‘progressive massive fibrosis’. Sarcoidosis Sarcoidosis is incorrect. Sarcoidosis affects upper zones and midzones, although, when severe, it can affect all zones. Tuberculosis Tuberculosis is incorrect. Tuberculosis shows a predilection for the upper zones, although, when severe, it can affect all zones.
Question 8:
Surgical resection in carcinoma of the lung is most likely to be contraindicated in the presence of which one of the following?
Options:
- Adenocarcinoma
- Forced expiratory volume in 1 s 25% of predicted
- Ischaemic heart disease
- Pulmonary artery involvement
- Superior vena cava obstruction
Correct Answer: Forced expiratory volume in 1 s 25% of predicted
Explanation:
Correct Answer: B- Forced expiratory volume in 1 s 25% of predicted Explanation Forced expiratory volume in 1 s 25% of predicted Pulmonary function assessment does not provide clear- cut answers to the Question: of operability, but there are some simple rules for performing a thoracotomy. The
physician should keep in mind that the extent of resection can be determined only at operation, and pneumonectomy might be needed. The functional criteria for pneumonectomy are therefore:
• Forced expiratory volume in 1 s (FEV1) of > 1.5 l •
FEV1 > 50% of the observed forced vital capacity • Normal partial pressure of arterial CO2 (Paco2) with the patient at rest Taking a 50-year-old man as an example, he would have a predicted FEV1 of 5 l. As such 25% of 5 l equals 1.25 l, below the likely requirement of 1.5 l. Adenocarcinoma Adenocarcinoma is incorrect. Localised adenocarcinoma may be surgically resected. Ischaemic heart disease Ischaemic heart disease is incorrect. Presence of ischaemic heart disease will increase surgical risk and decisions would be made on a case by case basis depending on severity of coronary disease and cardiac function. Lung cancer resection woud be contraindicated within 30 days of acute myocardial infarction due to increased risk of perioperative mortaility. Pulmonary artery involvement Pulmonary artery involvement is incorrect. Pulmonary artery involvement is not a contraindication to surgery. Superior vena cava obstruction Superior vena cava obstruction is incorrect. Superior vena cava obstruction may be extrinsic; as such, there is still a very small chance that resection may be possible.
Question 9:
A 22-year-old student attends the clinic for his 6-week check after admission with pneumonia. Which of the following complications of pneumonia is most likely to be a chronic rather than an acute complication of the infective process?
Options:
- Bronchiectasis
- Bronchopleural fistula
- Empyema
- Lung abscess
- Organising pneumonia
Correct Answer: Bronchiectasis
Explanation:
Correct Answer: A- Bronchiectasis Explanation Bronchiectasis This is a ‘know it or you don’t’ question. The diagnosis of bronchiectasis can only be made after the illness because temporary or reversible bronchial dilatation is sometimes seen during the acute illness. Bronchopleural fistula Bronchopleural fistula is incorrect. Bronchopleural fistula is an acute complication of the infective process. Empyema Empyema is incorrect. Empyema is an acute complication of the infective process. Lung abscess Lung abscess is incorrect. Lung abscess is an acute complication of the infective process. Organising pneumonia Organising pneumonia is incorrect. Organising pneumonia is an acute complication of the infective process.
Question 10:
A 54-year-old man who has a suspicious area on his chest X-ray, thought to be a tumour on CT scanning, is referred for PET imaging. Which of the following is the usual tracer used for PET imaging in lung cancer?
Options:
- Alanine
- Aspartame
- Fluorodeoxyglucose
- Fluorodopa
- Metomidate
Correct Answer: Fluorodeoxyglucose
Explanation:
Correct Answer: C- Fluorodeoxyglucose Explanation Fluorodeoxyglucose Rapidly dividing tumour cells of course require large amounts of glucose to satisfy their energy needs. As such it is avidly taken up by tumour cells and phosphorylated by hexokinase, which then allows it to be visualised on PET scanning. Alanine Alanine is incorrect. Alanine is not a tracer used for PET imaging in lung cancer. Aspartame Aspartame is incorrect. Aspartame is not a tracer used for PET imaging in lung cancer. Fluorodopa Fluorodopa is incorrect. Fluorodopa (FDOPA) is a tracer used in the imaging of adrenal tumours. Metomidate Metomidate is incorrect. Metomidate is a tracer used in the imaging of adrenal tumours.
Question 11:
A 65-year-old man complains of lethargy, fever, dry cough, headache, chest pain and increasing shortness of breath. He returned from a cruise 2 days ago. His chest X-ray shows bilateral infiltrates, the Po2 is 8.35 kPa. What is the most appropriate therapy?
Options:
- Amphotericin B
- Ampicillin
- Erythromycin
- Intravenous corticosteroids
- Isoniazid
Correct Answer: Erythromycin
Explanation:
Correct Answer: C- Erythromycin Explanation Erythromycin This patient has Legionella pneumonia. The most relevant factor in treatment is the ability of the antibiotic to penetrate intracellularly into alveolar macrophages where the Legionellaorganism hides and divides. A macrolide antibiotic, such as erythromycin or clarithromycin, is at present recommended as the drug of first choice, in dosages of 500–1000 mg every 6 hours for erythromycin and 500 mg twice daily for clarithromycin, being given intravenously if required. In-vitro and animal experiments and clinical experience support the efficacy of rifampicin and fluoroquinolones. Rifampicin is often recommended as additional therapy to erythromycin, in a dose of 600 mg once or twice daily in patients with severe infection or who are deteriorating. General supportive measures are particularly important, with attention to adequate hydration and correction of hypoxaemia with the early use of assisted ventilation for advancing respiratory failure. The most important principle to follow is to avoid holding water at temperatures between 20 °C and 45 °C, which is the range in which Legionella multiplication occurs. Other preventive measures should be taken, such as:
• Minimisation of colonisation, growth and release of Legionella organisms into the atmosphere •
Physical or chemical treatment of water to kill the bacteria • Protection of maintenance personnel who work on contaminated systems. Amphotericin B Amphotericin B is incorrect. Amphoterecin B would be appropriate in severe fungal infection, not in Legionella pneumonia. Ampicillin Ampicillin is incorrect. Ampicillin would not treat Legionella pneumonia adequately. Intravenous corticosteroids Intravenous corticosteroids is incorrect. Intravenous steroids are not an appropriate treatment for severe Legionella pneumonia and would immunosuppress the patient, leaving him at risk of disseminated infection/sepsis. Isoniazid Isoniazid is incorrect. Isoniazid is an appropriate therapy for tuberculosis, not for Legionellapneumonia.
Question 12:
A 29-year-old woman with brittle asthma is admitted to the Emergency Department with a viral exacerbation of her asthma. Her usual peak flow is around 490 l/min and she is managed with a high-dose Seretide® inhaler. On examination her blood pressure is 145/80 mmHg, pulse 105 bpm and regular. She has a respiratory rate of 40/min and looks exhausted. On auscultation you can hear wheeze and decreased air entry. Her peak flow is measured at 180 l/min. Investigation: Hb 13.1 g/dl WCC 8.1 x 109/l PLT 249 x 109/l Sodium 141 mmol/l Potassium 3.9 mmol/l Creatinine 110 µmol/l paO2 10.5 kPa pCO2 6.4 kPa Her peak flow has not improved 30 min after admission despite salbutamol and Atrovent® nebulisers and intravenous hydrocortisone. You arrange review by the Intensive Therapy Unit registrar. While you are waiting for her visit, which of the following is the most appropriate next management step?
Options:
- Inhaled helium/oxygen mixture
- Intravenous aminophylline
- Intravenous magnesium
- Intravenous salbutamol
- Non-invasive positive-pressure ventilation
Correct Answer: Intravenous magnesium
Explanation:
Correct Answer: C- Intravenous magnesium Explanation Intravenous magnesium A Cochrane meta-analysis showed some benefit from intravenous magnesium in acute asthma, and for this reason it is recommended in acute severe asthma that has not responded to inhaled bronchodilator therapy. Her
Pco2 is just outside the upper limit of normal, so she requires urgent admission to the Intensive Therapy Unit. Inhaled helium/oxygen mixture Inhaled helium oxygen mixture is incorrect. Inhaled helium/oxygen mixture is used in the treatment of vocal cord dysfunction. Intravenous aminophylline Intravenous aminophylline is incorrect. In acute asthma, IV aminophylline is not likely to result in any additional bronchodilation compared to standard care with inhaled bronchodilators and steroids. Side effects such as stomach pain/cramping and vomiting are increased if IV aminophylline is used. Therefore, it is not recommended routinely and should only be used in specific patients after consultation with senior staff. Intravenous salbutamol Intravenous salbutamol is incorrect. Intravenous salbutamol should be reserved for individuals in whom inhaled salbutamol cannot be used reliably. Non-invasive positive-pressure ventilation Non-invasive positive-pressure ventilation (NIPPV) is incorrect. NIPPV should not be used to treat acute asthma. Ventilation, if required should be invasive.
Question 13:
A 62-year-old woman is admitted with confusion and increased respiratory rate. She has been managed by her GP for shortness of breath and is taking ramipril and indapamide for hypertension and has a salbutamol inhaler. She came to the Emergency Department with her daughter because of concerns that she was getting worse. On examination her blood pressure is 112/62 mmHg and she has a pyrexia of 37.8 °C. The pulse is 75 bpm and regular and the heart sounds are normal. Auscultation of the chest reveals scattered crackles and wheeze. Investigations show: Hb 13.1 g/dl WCC 9.2 x 109/l Platelets 201 x 109/l Sodium 138 mmol/l Potassium 4.5 mmol/l Bicarbonate 24 mmol/l Creatinine 130 μmol/l Po2 9.1 kPa Pco2 7.2 kPa pH 7.2 Which of the following is the most likely diagnosis?
Options:
- Acute on chronic respiratory acidosis
- Acute respiratory acidosis
- Chronic respiratory acidosis
- Metabolic acidosis
- Mixed metabolic and respiratory acidosis
Correct Answer: Acute respiratory acidosis
Explanation:
Correct Answer: B- Acute respiratory acidosis Explanation Acute respiratory acidosis This woman is hypercapnic with decreased pH. This has occurred too quickly for metabolic compensation to occur via renal bicarbonate reabsorption, which takes 3– 5 days to occur. It is therefore an acute event such as a chronic obstructive pulmonary disease (COPD) exacerbation that is most likely to have led to her deterioration in symptoms. Aggressive management is therefore likely to return her to a reasonable level of function. Acute on chronic respiratory acidosis Acute on chronic respiratory acidosis is incorrect. This woman is hypercapnic with decreased pH. This has occurred too quickly for metabolic compensation to occur via renal bicarbonate reabsorption, which takes 3– 5 days to occur. It is therefore an acute event such as COPD exacerbation that is most likely to have led to her deterioration in symptoms. Chronic respiratory acidosis Chronic respiratory acidosis is incorrect. This woman is hypercapnic with decreased pH. This has occurred too quickly for metabolic compensation to occur via renal
bicarbonate reabsorption, which takes 3–5 days to occur. It is therefore an acute event such as COPD exacerbation that is most likely to have led to her deterioration in symptoms. Metabolic acidosis Metabolic acidosis is incorrect. Bicarbonate would be low in metabolic acidosis. Mixed metabolic and respiratory acidosis Mixed metabolic and respiratory acidosis is incorrect.
Bicarbonate would be low in metabolic acidosis.
Question 14:
A 50-year-old woman comes to the clinic complaining of breathlessness on exertion, which has been worsening for 1 year. This is accompanied by wheeze which worsens with exercise, and during the course of the summer when she also has severe hayfever. She has never smoked. The chest X-ray shows mild hyperinflation but is otherwise unremarkable. Her lung function test results are shown below: Test Result Predicted FEV1 (l) 1.1 1.7-3.0 FVC (l) 2.7 2.0-3.5 FRC (l) 4.2 1.7-3.4 TLC (l) 6.5 3.6-5.6 Tlco (mmol/min per kPa) 5.86 5.7-9.5 Kco (mmol/min per kPa per l) 1.63 1.66 What is the most likely diagnosis?
Options:
- Asthma
- Bronchiectasis
- Chronic obstructive pulmonary disease
- Interstitial lung disease
- Pulmonary haemorrhage
Correct Answer: Asthma
Explanation:
Correct Answer: A- Asthma Explanation Asthma This woman has obstructive spirometry, with raised lung volumes. This is suggestive of asthma or chronic obstructive pulmonary disease (COPD). She has never smoked and has a normal transfer factor and so she is more likely to have asthma. Bronchiectasis Bronchiectasis is incorrect. Bronchiectasis can lead to a mild obstructive defect, but would not tend to show such marked hyperinflation. History would usually include a chronic productive cough. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease is incorrect. Non- smokers can develop COPD, but they tend to have a heavy passive smoke exposure and be older. Interstitial lung disease Interstitial lung disease is incorrect. Interstitial lung disease would lead to a restrictive defect with a reduced transfer factor. Pulmonary haemorrhage Pulmonary haemorrhage is incorrect. There are no features in the history to suggest pulmonary haemorrhage, which would have a much shorter history plus potentially coexistent symptoms of vasculitis or renal failure. Pulmonary haemorrhage would lead to a raised Tlco and Kco (transfer factor and transfer coefficient for carbon monoxide).
Question 15:
A 54-year-old man with a 40-pack-year smoking history presents to the Respiratory Clinic complaining of a chronic cough and haemoptysis. He has lost 4 kg in weight recently. He has an abnormal chest X-ray, consistent with bronchial carcinoma. Investigations: Hb 11.0 g/dl WCC 6.1 x 109/l PLT 352 x 109/l ESR 65 mm in 1 hour Sodium 132 mmol/l Potassium 3.9 mmol/l Creatinine 130 µmol/l Bronchoscopy with transbronchial biopsy reveals adenocarcinoma of the bronchus. You arrange computed tomography of the thorax. Which of the following would tend to rule out the possibility of a surgical cure?
Options:
- Forced expiratory volume in 1 s (FEV1) 1.6 l
- Horner syndrome
- Ipsilateral mediastinal lymph node involvement
- Malignant pleural effusion
- Superior vena caval obstruction
Correct Answer: Malignant pleural effusion
Explanation:
Correct Answer: D- Malignant pleural effusion Explanation Malignant pleural effusion Pleural effusion implies pleural involvement and this would preclude a surgical cure. Forced expiratory volume in 1 s (FEV1) 1.6 l Forced expiratory volume in 1 s (FEV1) 1.6 l is incorrect. A forced expiratory volume in 1 s (FEV1) of less than 1.5 l precludes surgery for bronchial carcinoma because there is not enough lung reserve. Horner syndrome Horner syndrome is incorrect. Horner syndrome is attributable to local nerve involvement and therefore does not exclude successful surgical excision of the primary tumour. Ipsilateral mediastinal lymph node involvement Ipsilateral mediastinal lymph node involvement is incorrect. Contralateral lymph node involvement implies distant spread and again precludes surgery. Superior vena caval obstruction Superior vena caval obstruction is incorrect. Superior vena caval obstruction is not an absolute contraindication to surgery.
Question 16:
A 40-year-old man presents with a 2-month history of cough and breathlessness. He has also noted haemoptysis, which he says has gradually worsened. On examination he has bilateral basal crepitations. His chest X-ray shows diffuse shadowing. He has moderate renal failure. What is the most likely diagnosis?
Options:
- Bronchial carcinoma
- Goodpasture syndrome
- Legionella pneumonia
- Pulmonary embolism
- Tuberculosis
Correct Answer: Goodpasture syndrome
Explanation:
Correct Answer: B- Goodpasture syndrome Explanation Goodpasture syndrome Goodpasture described a case of a man with renal failure, glomerulonephritis and pulmonary haemorrhage. Goodpasture syndrome consists of diffuse pulmonary haemorrhage and glomerulonephritis with linear deposition of antibodies (90% of which are directed against the α3 chain of type IV collagen) along the glomerular basement membrane (GBM). In practice, glomerulonephritis proves to be a much more common threat to survival than lung haemorrhage, and the diagnosis of Goodpasture syndrome is reached more conveniently by serological testing (for anti-GBM antibodies) and from kidney rather than lung biopsy. In some cases, lung disease dominates the clinical picture. The majority of these patients are male smokers and some report a recent exposure to volatile hydrocarbons. In addition, case reports have identified recent exposure to chlorine and smoked cocaine as relevant factors. This suggests that, when there is susceptibility, inhaled toxic agents enhance pulmonary endothelial damage and allow the initiation of autoimmunity or the ready access of existing autoantibody to basement membrane. Respiratory presentation is with cough, breathlessness and haemoptysis, which is intermittent and ranges from occasional streaks to massive fatal bleeding. Systemic symptoms of fever, joint pains or weight loss are unusual. The chest X-ray shows patchy or diffuse shadowing due to intra-alveolar blood, usually resolving over the course of 2 weeks unless there is further bleeding. At the time of bleeding there may be arterial hypoxaemia and reduced lung volumes. Serial measurement of carbon monoxide (CO) diffusing capacity or transfer factor (Tlco) can be used to monitor progression, and prolonged bleeding can lead to iron deficiency anaemia. The Tlco is widely used as a simple test of the integrity of the alveolar capillary membrane and of the overall gas-exchanging function of the lungs. It has good sensitivity but poor specificity, as impairment can result from a variety of pathological processes. Renal function can be normal initially but then deteriorates over days to weeks. Steroids, other immunosuppressant drugs (cyclophosphamide in particular) and plasmapheresis are all used (in some circumstances) to control renal disease, and are additionally helpful in treating pulmonary haemorrhage. Patients should not smoke and should avoid hydrocarbon exposure. Bronchial carcinoma Bronchial carcinoma is incorrect. Bronchial carcinoma is a reasonable differential diagnosis in view of his history of cough, breathlessness and haemoptysis. However, the examination and X-ray findings are not classical of bronchial carcinoma and, in conjunction with the presence of renal failure, a diagnosis of vasculitis, namely Goodpasture syndrome, is more likely. Legionella pneumonia Legionella pneumonia is incorrect. The 2-month history of symptoms makes a pneumonia an unlikely cause of this man’s symptoms. Haemoptysis in legionella pneumonia is uncommon and legionella pneumonia is not directly associated with renal failure. Pulmonary embolism Pulmonary embolism is incorrect. The clinical examination and chest X-ray findings, along with the presence of renal failure, are not in keeping with pulmonary embolism. Clinical examination of the chest is usually normal in pulmonary embolism and chest X- ray is typically also normal, although an area of lung infarction may be seen with large emboli. Tuberculosis Tuberculosis is incorrect. Miliary tuberculosis could potentially present with the symptoms described in this history, but if miliary tuberculosis was present then the classical ‘millet seed’ appearance on chest X-ray would likely be seen and there would also almost certainly be bilateral hilar lymphadenopathy. The absence of these findings, in addition to the fact that classical infective symptoms such as fevers, night sweats and purulent sputum are not mentioned here and there is no suggestion of risk factors for tuberculosis, makes vasculitis a more likely diagnosis.
Question 17:
A 28-year-old woman comes to the clinic for review 4 weeks after discharge from the ward following an asthma attack. She was diagnosed with asthma at the age of 7 years and has been taking inhaled beclometasone 400 μg and salbutamol as required since then. She tells you that since discharge she has been using her salbutamol three times a day and has been waking two or three times a night with coughing. On examination, her peak flow is 340 l (predicted is 570 l). She has scattered wheeze throughout both lung fields on examination. She had a good inhaler technique with volumatic as assessed in the clinic. Investigation: Hb 13.1 g/dl WCC 6.5 x 109/l PLT 231 x 109/l ESR 12 mm in 1 hour Sodium 140 mmol/l Potassium 4.9 mmol/l Creatinine 80 µmol/l The chest X-ray shows no evidence of consolidation. Which of the following is the most appropriate management plan for her?
Options:
- Add low-dose oral theophylline to her regimen
- Add omalizumab
- Add oral montelukast to her regimen
- Add twice-daily inhaled salmeterol to her regimen
- Change her to 800 μg of fluticasone
Correct Answer: Add oral montelukast to her regimen
Explanation:
Correct Answer: C- Add oral montelukast to her regimen Explanation Add oral montelukast to her regimen Adding oral montelukast is now recommended as a trial in patients who have failed to gain control on low dose inhaled corticosteroids by NICE 2017 guidelines. Add low-dose oral theophylline to her regimen Add low-dose oral theophylline to her regimen is incorrect. Low-dose oral theophylline is an option after addition of salmeterol. Add omalizumab Add omalizumab is incorrect. Omalizumab, an anti-IgE antibody, is reserved for patients with severe allergic asthma in whom other treatments have been unsuccessful and require at least four acute courses of corticosteroids per year. Add twice-daily inhaled salmeterol to her regimen NICE guidelines 2017 now recommend a trial of Montelukast before moving to the addition of a long- acting beta agonist (LABA) in patients who are not controlled on lower doses of inhaled corticosteroids. Change her to 800 μg of fluticasone Change her to 800 μg of fluticasone is incorrect. Fluticasone is twice as potent as beclomethasone, so this option is significantly increasing the amount of steroid medication. This option could be considered after addition of monteleukast or LABA.
