respiratory system bof

8/11/2019 Respiratory System BOF

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Respiratory System

A 67-year-old retired man has been complaining of a 6-month history of increasing

shortness of breath, dull right-sided chest pain, loss of appetite and night sweats. Heworked all his life in the ship-building industry where he was eposed to asbestos. He

has ne!er smoked in his life. "n eamination he is slightly cyanosed but there is no

clubbing. #amination of the lungs re!ealed dullness to percussion and reduced air

entry at the right base. $hat is the most likely diagnosis%

A &"'(

) )ronchial carcinoma

& Recurrent pulmonary embolism

( *alignant mesothelioma

# +uberculosis*alignant mesothelioma arising from the pleura was first recognised in the /s,

and during the 6/s much e!idence accumulated indicating a strong link between the

condition and eposure to asbestos. +he risk is a function of the concentration of

fibres and duration of eposure. #posure is greatest in those in!ol!ed in mining or

0uarrying the material, and in those who handle the raw fibres. *any workers

engaged in the ship-building industry during the 1/s and /s were eposed to

asbestos, and more recently it has been in widespread use in the building industry. 2t is

rare for mesotheliomas to de!elop within 3/ years of eposure and most patients were

initially eposed 4/ or more years before clinical presentation. 2n the 5nited

ingdom, although the risk was first recognised in the 6/s, it was not until the mid-

7/s that there was a significant reduction in eposure to asbestos. +he age ofpresentation is usually between / and 7/, although the incidence is increasing in

older patients. +here is a male predominance, reflecting the greater likelihood of

pre!ious occupational eposure, which should be sought with a careful lifetime

occupational history. Symptoms due to local disease are mainly those of pain and

breathlessness. 'ain may be pleuritic in nature, but is often a dull ache due to direct

in!ol!ement of the chest wall. Shortness of breath is usually associated with a pleural

effusion, although as the tumour progresses it gradually encases the lung. Systemic

symptoms include tiredness, anoreia, weight loss and fe!er, and occasionally

drenching sweats. inger-clubbing has been recorded but is rare. 'hysical findings in

the chest are those of a pleural effusion, but with ad!anced disease there is

progressi!e reduction in chest wall mo!ement. (irect etension through the chest wall

can result in a palpable mass, and this may de!elop at the site of pre!ious biopsy.

A 31-year-old medical student 8height 6 cm, weight 79 kg: has been complaining of

a few days; history of shortness of breath on eertion and of coughing up blood once.

She is a few days away from her final eamination and smokes 3/ cigarettes per day.

She takes no medication ecept for the oral contracepti!e pill. $hat is the most likely

diagnosis%

A Hyper!entilation syndrome due to stress

) +uberculosis& Recurrent pulmonary embolism


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( Sarcoidosis

# and

prognosis of a cigarette smoker with spirometric e!idence of moderate &"'(%

A +obacco-smoking cessation

) re0uent use of antibiotics for acute bacterial eacerbations of chronic bronchitis

& (aily use of salmeterol to impro!e #>

( ?ong-term oygen therapy at 3 l@min

# (aily use of ipratropium bromide to impro!e #>+here is no treatment that has been shown to significantly slow or alter the

progression of &"'( ecept smoking cessation. +he single best thing patients with

&"'( can do for themsel!es is to stop smoking. All other treatments are largely for

symptom relief.&hronic obstructi!e pulmonary disease is a common chronic

respiratory illness. 2t is steadily progressi!e and carries a large burden of mortalityand morbidity. 2t causes about 4/,// deaths per year in the 5. +he morbidity

burden this raises for the HS is huge. "f all emergency medical admissions, 3= are

due to acute respiratory infections and &"'( eacerbations comprise o!er half this

total. +he cost in hospital care for these patients is about B// million. Housing

changes and alterations add to the social costs of this disease. &"'( is caused by

tobacco smoking, hea!y eposure to occupational dusts and chemicals, air pollution,

cannabis smoking 8which is now being recognised: and a-antitrypsin deficiency.

A /-year-old smoker was diagnosed with a non-small-cell carcinoma. 2n!estigation

re!ealed the presence of a 1 cm C 4 cm C 3 cm tumour on the left side in the lower

lobe of his lung that has in!aded the !isceral pleura. +he ipsilateral hilar lymph node

is also in!ol!ed, but there is no metastatic in!ol!ement of any distal organ. $hat is

the stage of disease in this patient%

A +1/*/

) +3/*/

& +3*/

( +4*/

# +1*/2t is important to remember the criteria for staging carcinoma of the lung. As the

tumour is more than 4 cm in the greatest dimension and has only in!aded the !isceralpleura, it is designated +3. *etastasis to the ipsilateral peribronchial and@or ipsilateral


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hilar lymph nodes makes the nodal stage . Absence of distal metastasis is called */.

2t would be useful to go through the staging in detail for other possible combinations.

A 44-year-old man is found to ha!e strongly positi!e aspergillus precipitins in his

blood. $hat is the most likely diagnosis%

A Allergic bronchopulmonary aspergillosis 8A)'A:

) &olonising aspergillosis

& 2n!asi!e aspergillosis

( Asperger;s syndrome

# +ype 2 hypersensiti!ity toAspergillus fumigatus

Aspergillus precipitins are 2g< antibodies typically found in colonising aspergillosis

8aspergilloma:, which occurs in areas of damaged lungs, eg ca!ities. +ype 2

hypersensiti!ity toAspergillus fumigatusoccurs in A)'A. 2n!asi!e aspergillosis

occurs in immunocompromised patients. Asperger;s syndrome has nothing to do with

aspergillus infection.

A 4/-year-old woman who is a non-smoker comes to clinic with a 3-year history of a

dry cough. *ore recently she has had episodes of flushing. #amination is normal,

but her chest radiograph shows a smooth lesion at the origin of her right lower lobe

bronchus. &+ scan confirms this and is otherwise normal. Dou perform the

bronchoscopy and see a smooth red tumour. $hat would you do net%

A )iopsy the tumour

) (iscuss her with the thoracic surgeons with a !iew to biopsy

& (iscuss her with the thoracic surgeons with a !iew to tumour resection

( (iscuss her with the oncologists with a !iew to chemotherapy

# Repeat the chest E-ray in 4 months

+his woman has a pulmonary carcinoid tumour, which is an uncommon

neuroendocrine primary lung tumour, accounting for F3= of all lung tumours. +hey

are slow growing and benign, although there are more aggressi!e subtypes which can

metastasise. &arcinoid syndrome occurs without metastases. &arcinoids are typically

located endobronchially, so can cause wheeGe and cough. +hey can bleed profusely on

biopsy, so this is not ad!ised. A person with an isolated pulmonary carcinoid should

be referred for tumour resection, and histology may not be necessary prior to surgery

if the clinical picture is typical. &hemotherapy can be used for metastatic carcinoids.

Radiotherapy is not used.

A 33-year-old man presented with shortness of breath, an increase in sputum

production and a temperature of 47. &. He suffers from recurrent chest infections

three or four times a year. +his young man regularly produces copious amounts of

sputum, more so in the morning. A slow, progressi!e clumsiness and instability set in

during early childhood and he has been wheelchair-bound since the age of 3 years.

He grew up in foster care but found out that his uncle died young, wheelchair-bound.

+here are coarse crackles bilaterally and a chest E-ray shows signs of bronchiectasis.

$hat is the cause of this%

A &ystic fibrosis) Hypogammaglobulinaemia in ataia telangiectasia


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& Hereditary spinocerebellar degeneration

( $illiamsF&ampbell syndrome

# *ounierFuhn syndrome

'atients are typically progressi!ely ataic from an early age, with oculomotor apraia

and chorioathetosis de!eloping later. 2t is inherited as an autosomal-recessi!e. +he

clinical diagnosis is based on identification of the symptoms and multipletelangiectasia seen particularly in the conIuncti!a. a-etoprotein le!els may be raised.

&ell defects and humoral immunity with 2gA and 2g# deficiencies and defecti!e (A

repair results in recurrent infections and tumour susceptibility. (eath in the late teens

or twenties from bronchiectasis is typical.2n the $illiamsF&ampbell syndrome there

is a deficiency of the bronchial cartilage. +he *ounierFuhn syndrome or

tracheobronchomegaly is the Jadult e0ui!alent; of the congenital deficiency of

bronchial cartilage.

$hich of the following reflects the !alue of lung function tests%

A 'eak epiratory flow rate is not dependent on age

) 2n a restricti!e disease, the flow-!olume loop is different in shape to normal

& *#3F7 8l@min: is a poor measure of airway obstruction

( Are not needed as a routine in the management of asthma

# +hey cannot differentiate between different causes of wheeGe

+he most accurate correlation of the '#R is with height. 2n a restricti!e pattern, the

fF! loop is reduced in siGe but looks similar in shape to normal. *id-epiratory flow

8*#: rate 8between 3= and 7= of the epired !ital capacity: is a good measure of

airway obstruction. '#R readings are an obIecti!e measure of airway obstructionK

therefore it is ad!isable for any child to perform regular '#Rs to assess lung

function, pro!iding they can do it properly.

A reduced forced epiratory flow of 3F7 units 8l@min: is an indicator of which of

the following%

A Asthma

) )ronchial carcinoma

& yphoscoliosis

( )ronchiectasis

# $hooping cough

+his is an indicator of small-airways disease.

A 1-year-old woman presents to the Accident L #mergency department with a

sudden onset of pleuritic chest pain and breathlessness. A chest radiograph re!eals a

large right-sided pneumothora. 'leural aspiration fails to result in ade0uate re-

epansion of the lung and you therefore insert an intercostal tube connected to an

underwater seal. After 31 hours of intercostal drainage the lung has not re-epanded

despite the drain still swinging with respiration. $hat would you do net%

A $ait another 31 hours

) egati!e suction should be started at F to F3 cmH3"& High-!olume@low-pressure suction should be used


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( Refer for immediate surgical inter!ention

# Reposition chest drain

2f, at 19 hours, a pneumothora fails to re-epand or there is a persistent air leak

8bubbling present: then you should refer the patient to a respiratory specialist as

negati!e suction may be re0uired. ormal intrapleural pressure is F4.1 cmH 3" during

epiration, rising to F9 cmH3" during inspiration. +his should be started at F/ to F3/cmH3" 8F to F3 k'a M F7. to F mmHg: using a high-!olume@low-pressure suction

system. 2f high-!olume@high-pressure suction is used then high-airflow suction may

be generated, which can lead to air stealing, hypoaemia and@or the persistence of air

leaks. 2f appropriate suction fails to result in ade0uate re-epansion by F7 days in

those without pre-eisting lung disease 8earlier if lung disease: then referral to a

thoracic surgeon is indicated.

$hich of the following is the best predictor for obstructi!e sleep apnoea%

A eck siGe

) &hest siGe

& Abdominal girth

( $aist to hip ratio

# 5!ulopalatal distance

eck siGe is the best predictor of "SA, with N 14 cm 8N7 inches: being associated

with an increased risk. +he mass loading from the obese or muscular neck

o!erwhelms the residual dilator muscle action of the pharyn when the patient is

asleep, causing airway obstruction and subse0uent apnoea. 'atients may also ha!e a

small or set back mandible, which predisposes them to "SA as well. +ypically,

patients also ha!e upper body obesity, which is the typical male fat pattern.

A 6-year-old woman with rheumatoid arthritis is referred with a history of recurrent

chest infections, intermittent wheeGe and production of half an eggcup-full of phlegm

daily, on occasions with a streak of blood. She is a retired secretary and has ne!er

smoked. "n eamination she had coarse crepitations on both the bases. $hat is the

most likely diagnosis%

A &hronic bronchitis

) (iffuse interstitial lung fibrosis

& &arcinoma of the lung

( +uberculosis# )ronchiectasis

)ronchiectasis is associated with rheumatoid arthritis, occurring in 4F1= of patients

with this condition. As with all other causes of bronchiectasis, it presents with

recurrent chest infections and ecessi!e phlegm. Recurrent haemoptysis is a common

feature. &hronic obstructi!e pulmonary disease 8&"'(: and lung cancer are unlikely

in a non-smoker. +uberculosis should be ecluded as it can cause bronchiectasis and

haemoptysis. Although interstitial fibrosis occurs in up to 3/= of patients with

rheumatoid arthritis, it is not associated with sputum production or haemoptysis

8unless there is an associated cancer:. +his woman should undergo pulmonary

function tests to assess the presence of airway obstruction, which is associated with

bronchiectasis. A high-resolution computed tomography 8HR&+: scan of the lungs isthe in!estigation of choice to confirm the presence of bronchiectasis.


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A 69-year-old man with bronchiectasis is found to ha!e acid-fast bacilli in his sputum.

+he microbiology report suggests this may be an opportunistic or atypical

mycobacterium. $hich of the following is the least likely infectious agent%

A Mycobacterium kansasii

) Mycobacterium malmoense& Mycobacterium xenopi

( Mycobacterium leprae

# Mycobacterium avium intracellulare

Mycobacterium lepraeis the causati!e organism of leprosy, whereas the rest are all

Jopportunistic; mycobacteria, ie they may colonise structurally abnormal lung such as

seen in patients with ca!itary disease, bronchiectasis or &"'(. Such patients may not

always re0uire treatment. Howe!er, if treatment is re0uired, then it is usually for

longer than the standard 6 months needed to treat pulmonary +) F but 8for the *R&'

eam: you do not need to worry about comple treatment regimens.

$hich pulmonary function test is the same in both restricti!e lung disease and

obstructi!e lung disease%

A Residual !olume

) +idal !olume

& +otal lung capacity

( orced epiratory !olume in second@forced !ital capacity 8#>@>&: ratio

# orced epiratory !olume in second 8#>:

+idal !olume M the amount of gas inspired or epired with each breath.Residual

!olume M the !olume of air remaining in the lung after a maimal epiration 8cannotbe measured with spirometry:.+otal lung capacity M the !olume of air remaining in the

lung after a maimal inspiration.+otal lung capacity 8and more so, the residual

!olume: is increased in obstructi!e lung disease due to air trapping. +he #>@>&

ratio is O 7/= in obstructi!e lung disease and N 7/= in restricti!e lung disease.

A 6-year-old retired man who smoked was diagnosed with smear-positi!e

mycobacterium tuberculosis. He used to work as a stonemason. 2f there is an

increased occupational risk of getting the infection, what is the cause%

A 'neumoconiosis

) Asbestosis& Silicosis

( ?ead poisoning

# )erylliosis

Stonemasons, fettlers and slate-miners@-workers are at risk of de!eloping silicosis.

Silica acts as a toin to macrophages, and so impairing their function. +his results in

an increased risk of contracting a mycobacterium tuberculosis infection.

A 6/-year-old patient was referred with a -year history of persistent cough

producti!e of mucopurulent sputum throughout the year. He has been treated by his


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( +he organism responsible is Coxiella pneumoniae

# +he organism is usually inhaled from infected dust &orrect answer

Q fe!er is due to Coxiella burnetiiand is ac0uired through contact with animals. +he

organism is !ery resistant to drying and is inhaled from infected dust. 2t is not

notifiable, but can occur in outbreaks in farming communities and in abattoirs. A chest

E-ray may show multi-lobar consolidation. +reatment is with prolonged courses oftetracyclines. Rarely, infection can be persistent leading to chronic symptoms

including fatigue, malaise and sweats. 2n cases of chronic disease, culture-negati!e

endocarditis should be suspected. ?engthy antibiotic courses can be curati!e.

A 16-year-old cardiologist attended a local conference last weekend and fell ill with a

fe!er of up to 1/ & that lasted for 3 days. He had associated shortness of breath and

dry cough. 2n addition, he had loose motions for a day. His blood results showed

deranged ?+s and hyponatraemia. His $)& count was /.3 C /@l. )ibasal

consolidation was seen on his E-ray. $hat would be the most effecti!e treatment for

his condition%

A Amoicillin

) &efuroime

& &larithromycin

( lucloacillin

# &iprofloacin

+his is a case of legionella pneumonia and the preferred treatment is with the

macrolide, clarithromycin. &iprofloacin can also be effecti!e and rifampicin can be

used. ?egionella outbreaks are seen in pre!iously fit indi!iduals staying in hotels or

institutions where the shower facilities and@or the cooling system are contaminated

with the organism. +he incubation period is 3F/ days. lu-like symptoms, fe!er,malaise and myalgia typically precede a dry cough and dyspnoea. #trapulmonary

symptoms include anoreia, diarrhoea and !omiting, hepatitis, renal failure, confusion

and coma. A chest E-ray shows bibasal consolidation, sometimes with a small pleural

effusion. )lood results show lymphopenia without significant lymphocytosis,

hyponatraemia and deranged ?+s. 5rinalysis may show haematuria. (iagnosis is by

the urinary antigen test, which is highly specific. 2t is important to remember that the

organism does not show up on @Q scan


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+his is a woman who has a high clinical probability of ha!ing had a massi!e

pulmonary embolus 8'#:. She has respiratory and cardio!ascular compromise from

this '# and is likely to die without treatment. 2n!estigation with either

echocardiogram showing pulmonary hypertension or &+ showing a clot8s:, would be

reasonable to confirm the diagnosis, but this woman is rapidly deteriorating. She is

not well enough for a >@Q scan. She has had i! fluids and unfractionated heparinalready, with no effect. +hrombolysis can be used for acute pulmonary emboli causing

circulatory collapse and there is emerging e!idence to support this treatment. +he

risk@benefit analysis must be considered, but in a patient who is at imminent risk of

arrest@death, gi!e alteplase // mg o!er . hours peripherally. 8see )+S guidelines

for the management of suspected acute pulmonary embolism. Thorax

3//4,986:,17/:.

A 67-year-old patient with lung cancer complains of difficulty breathing, coughing

and swelling of his face, neck, upper body and arms. Superior !ena ca!a syndrome is

diagnosed. $hich of the following treatments is most likely to be successful%

A &orticosteroids

) Radiotherapy

& Surgery

( &hemotherapy

# Antihypertensi!e drugs

Superior !ena ca!a syndrome 8S>&S: is a collection of symptoms caused by the

partial blockage of the !ein that carries blood from the head, neck, chest and arms to

the heart. Symptoms that may indicate this syndrome include difficulty breathing,

coughing and swelling of the face, neck, upper body and arms. 2n rare instances,

patients may complain of hoarseness, chest pain, difficulty swallowing and coughingup blood. 'hysical signs of S>&S include swelling of the neck or chest !eins,

collection of fluid in the face or arms and rapid breathing. +he syndrome of superior

!ena ca!a obstruction is relie!ed in about 9/= of sufferers, but usually re0uires a

more con!entional course of F/ fractions of radiotherapy. 'ain from bone

secondaries can be relie!ed in more than /= of sufferers by a single fraction of 9


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+he other three answers would all gi!e a picture of Jetrapulmonary restriction; with a

restricti!e ratio, low +?&" but normal@high &" 8same cardiac output going through

smaller al!eolar !olume:.

A 36-year female i! drug user presents with a producti!e cough and fe!er of 3F4

days; duration She had flu last week. "ther than a leucocytosis and high &R', herblood results are normal. A chest E-ray shows bilateral ca!itating pneumonia. $hat is

the most probable cause of her pneumonia%

A 'neumococcal pneumonia

) Staphylococcal pneumonia

& Pneumocystis cariniipneumonia

( lebsiella pneumonia

# ungal pneumonia

2n general, staphylococcal pneumonia follows a !iral infection F usually with flu-like

symptoms. +his type of pneumonia is fre0uently seen in i! drug abusers and patientswith central line. 2t is also common in those patients with an underlying disease, eg

leukaemia, lymphoma or cystic fibrosis. E-rays show bilateral ca!itating

bronchopneumonia. 'neumothora, effusion and empyema are fre0uent. 2ntra!enous

antibiotics should be administered properly. +he drug of choice is flucloacillin.

Klebsiella spp. also cause ca!itating pneumonia, particularly of the upper lobes, and

most commonly in the elderly.

A 4/-year-old asylum seeker has been complaining of cough, fe!er and weight loss.

+he chest E-ray shows a large, upper lobe lesion, the sputum shows acid-fast bacilli

that are confirmed asMycobacterium tuberculosisby polymerase chain reaction

8'&R:. (rug therapy with isoniaGid, rifampicin, ethambutol and pyraGinamide hasbeen started under directly obser!ed therapy 8("+:. (uring the net 1 weeks the

disease is still progressing. $hat is the most likely reason%

A 2nfection with multi-resistant tuberculosis

) 2nfection with atypical mycobacteriae

& 5nderlying bacterial pneumonia

( &arcinoma of the lung

# Aspiration pneumonia

*ultidrug-resistant tuberculosis is defined as resistance to rifampicin and isoniaGid

with or without resistance to other anti-+) drugs. +he treatment of patients with drug-resistant tuberculosis should only be carried out by specialist physicians with

appropriate eperience in the management of such cases. 2nitial drug resistance is

uncommon 8O 3=: in pre!iously untreated $hite patients born in the 5. Higher

le!els of resistance occur in ethnic minority groups, particularly those of the 2ndian

subcontinent and )lack-African ethnic origin, with isoniaGid resistance occurring in

1F6= of such patients. H2>-positi!ity, independent of ethnic group, is also a marker

for increased drug resistanceP a positi!e H2> result increases at least fourfold the

chances of single- or multiple-drug resistance compared with an H2>-negati!e

indi!idual.+reatment is comple, time-consuming and demanding for both the patient

and the physician. Such treatment should only be carried out by physicians with

substantial eperience in managing comple resistant cases, and only in hospitals withappropriate isolation facilities. +his may re0uire transfer of the patient to an


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appropriate unit. +reatment of such patients has to be planned on an indi!idual basis

and needs to include reser!e drugs. Such treatment must be closely monitored because

of increased toicity, but, more importantly, full compliance is essential to pre!ent the

emergence of further drug resistance. +herefore all such treatment must be directly

obser!ed throughout, both on an in-patient and an out-patient basis. +reatment should

start with fi!e or more drugs to which the organism is, or is likely to be, susceptibleand continue until sputum cultures become negati!e. (rug treatment then has to be

continued with at least three drugs to which the organism is susceptible on in !itro

testing for a minimum of a further months and perhaps up to or beyond 31 months,

depending on the in !itro drug-resistance profile, the a!ailable drugs and the patient;s

H2> status. &onsideration may also ha!e to be gi!en to resection of pulmonary

lesions under drug co!er.

A 6/-year-old man who has a 4/-pack year smoking history comes to clinic with

worsening shortness of breath o!er the last 6 months. He works as a baker and keeps

racing pigeons. "n eamination, he is clubbed, has saturations of = on air and has

widespread fine inspiratory crepitations. His chest radiograph shows reticulonodularshadowing and his &+ scan confirms reticulation, mainly subpleural and some

honeycombing. $hat is the diagnosis%

A 'ulmonary sarcoidosis

) 5sual interstitial pneumonitis

& Hypersensiti!ity pneumonitis

( "ccupational asthma

# ?angerhans; cell histiocytosis

(yspnoea, clubbing and inspiratory crepitations are the classic features of usual

interstitial pneumonitis. &hest E-ray will show reticulation, which is classicallysubpleural in distribution on &+. 'ulmonary sarcoidosis does not gi!e clubbing and

crepitations would be associated with end-stage fibrotic disease. +he &+ appearances

would be those of nodularity, including fissural nodularity. +he &+ in hypersensiti!ity

pneumonitis showsP ground-glass shadowing, with reticular and nodular patternsK in

occupational asthma, possibly non-specific features of air trappingK and in

?angerhans;cell histiocytosis it shows nodules and cystic lesions.

A 1-year-old woman has been admitted with haemoptysis and epistais, the chest E-

ray shows multiple rounded lesions with al!eolar shadowing. Serum is c-A&A

positi!e. $hat is the most likely diagnosis%

A +uberculosis

) &arcinoma of the lung

& #chinococcosis

( $egener;s granulomatosis

# Systemic lupus erythematosus

Almost all the patients so diagnosed ha!e e!idence of granulomatous lung disease at

presentation, which is often accompanied by al!eolar capillaritis. +he bronchi can also

be affected and bronchial stenoses occur as late manifestations. Symptoms include

cough, dyspnoea, haemoptysis and chest pain, which can be pleuritic. Signs on chest

eamination depend on the nature of the pulmonary lesions and include finecrepitations and bronchial breathing or, less commonly, pleural rubs and signs of


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pleural effusions. 'ulmonary granulomas are usually diagnosed from chest E-ray and

&+ scans. +hey may appear as single or multiple rounded lesions, which can ca!itate.

)ronchoscopy often re!eals granulomatous inflammation and the diagnosis can

sometimes be made from bronchial biopsies.

A 6-year-old man who has a 1/-pack year history of smoking is referred to the clinicwith haemoptysis. He has no other symptoms. His chest radiograph shows an ill-

defined 3-cm opacity at the periphery of his left lower lobe. After checking his routine

blood tests and spirometry in clinic, which test would you arrange net%

A )ronchoscopy

) &+ scan of the chest

& '#+ scan

( Repeat chest radiograph in month from now

# Sputum cytology

?ung cancer is the most likely diagnosis in this man. A &+ scan is the best test toperform initially to locate, characterise and stage the lesion if it is cancer. Histological

confirmation would then be sought, with either a bronchoscopy if the lesion is

proimal or a &+ or ultrasound-guided biopsy if it is peripheral. A positron-emission

tomography 8'#+: scan would determine whether there are distant metastases and is

performed after the &+. Sputum cytology can be used to pro!ide a histological

diagnosis, but a tissue biopsy is fa!oured by the pathologists. 'neumonia can cause

haemoptysis and chest radiograph abnormalities, but it can also be associated with a

proimal carcinoma. Dou should ha!e a low threshold for performing a &+ scan

initially in a high-risk patient.

Dou are called to see a /-year-old woman who is ha!ing difficulty breathingfollowing a laparoscopic cholecystectomy. She is making a lot of noisy inspiratory

effort. Dou notice she is taking warfarin long term for thromboembolic disease,

salbutamol and inhaled steroids for asthma and penicillamine for rheumatoid arthritis.

$hich test might be the most helpful in diagnosing her current problem%

A 'eak flow

) Spirometry with transfer factor measurement

& Spirometry with flow !olume loops

( &hest E-ray

# &+ chest+his woman has stridor due to cricoarytenoid arthritis. +his is seen in studies in up to

7= of patients with rheumatoid arthritis. 2t can cause sore throat, hoarse !oice and

stridor, but is often asymptomatic. Howe!er, symptoms may be worse in the

postoperati!e period. 2t is unrelated to any lung fibrosis. low !olume loop can be

abnormal, as can direct laryngoscopy and HR&+ 8high-resolution &+ scan: of the

laryn. 2t may need urgent tracheostomy and steroids, both oral and Ioint inIection.

A 4-year-old woman who was pre!iously fit and well presents with breathlessness

that has been getting worse o!er 4 or 1 months. Her sister died a few years ago with a

lung disease. "n eamination, her Iugular !enous pressure is raised and she has a

palpable hea!e at the left sternal edge. $hat would be your pro!isional diagnosis%


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A amilial primary pulmonary hypertension

) +ricuspid regurgitation

& &hronic pulmonary thromboembolism

( &onstricti!e pericarditis

# 'ulmonary !enous hypertension

'rimary pulmonary hypertension presents with breathlessness, fatigue, angina 8due to

right !entricular ischaemia: or presyncope@syncope. About 6= of all patients with

primary pulmonary hypertension ha!e a family history of the condition, which

ehibits an autosomal-dominant pattern of inheritance with incomplete penetrance.

'hysical signs include ele!ated >', left parasternal hea!e, pansystolic murmur

8tricuspid regurgitation: and right !entricular S1, peripheral oedema. An important

differential diagnosis of primary pulmonary hypertension is chronic pulmonary

thromboembolism.

A 4/-year-old man from the Russia is seen in the emergency department. He was

diagnosed with pulmonary tuberculosis 1 months ago in Russia and is takingrifampicin and isoniaGid. He comes because of a producti!e cough, fe!ers, weight loss

and malaise. $hat would you like to do net%

A Send a sputum sample and arrange to see him in out-patients

) Admit him to hospital, send a sputum sample and start him on amoicillin

& Admit him to hospital, send a sputum sample and start him on pyraGinamide

(Admit him to hospital, send a sputum sample and start him on amoicillin and

pyraGinamide

#Admit him to hospital, send a sputum sample and start him on pyraGinamide,

amikacin and ethambutol

+he concern with this man is one of multidrug-resistant tuberculosis. He is failing on

his current regime and has clinical features of acti!e tuberculosis. +reatment failure is

usually due to poor compliance, which can lead to the de!elopment of drug resistance.

"ther risk factors for resistant disease areP pre!ious anti-+) treatment, H2> infection

and contact with drug-resistant +). Although he may ha!e a superimposed simple

bacterial infection, this should not deter from in!estigating and treating him for +), as

most of the antibiotics used for +) will co!er the usual bacterial chest pathogens. A

single drug should ne!er be added to a failing +) regime. Add two or three, ideally

ones to which the organism is known to be sensiti!e and which the patient has not

pre!iously taken. Send sputum for culture and polymerase chain reaction 8'&R:

testing before starting further treatment. 2f he has confirmed multidrug-resistant +),ensure he is on fi!e or more drugs to which the organism is likely to be susceptible.

A 31-year-old thin man complains of constant daytime sleepiness. He mentions

in!oluntary naps, often in the middle of acti!ity, which occur suddenly and without

warning. He also caused an accident when he fell asleep while dri!ing home from

work. +he patient works as an office manager and has no history of eposure to

chemicals. $hich of the following treatments would be indicated%

A ortriptyline

) luoetine

& (iaGepam


14/27

( *odafinil

# &ontinuous positi!e airway pressure-breathing de!ice

+his patient has narcolepsyP a sleep disorder causing hypersomnia, which usually

starts in adolescence or young adulthood. +reatment in!ol!es the use of central

ner!ous system stimulants such as modafinil to allow daytime functioning.&ontinuous

positi!e airway pressure-breathing de!ices are used in the treatment of sleep apnoea.A typical patient with sleep apnoea is usually older, obese and there will be a long

history of gradually worsening snoring with apnoeas, possibly witnessed by the

spouse, who will probably ha!e mo!ed out of the bedroom because of the noise.

+here is usually a history of fairly high alcohol intake and smoking.

A 6-year-old woman, who is known to suffer from rheumatoid arthritis, complains

she has had recurrent haemoptysis for o!er years. She has ne!er smoked and only

takes a non-steroidal anti-inflammatory agent. According to her, she coughs up

phlegm e!ery day and at times this contains streaks of fresh blood. She has no known

respiratory disease, but tends to get fre0uent chest infections that are relie!ed by a

course of antibiotics. $hat is the most likely diagnosis%

A ?ung cancer

) )ronchiectasis

& +uberculosis

( 'ulmonary embolism

# Atypical pneumonia

Some 4F1= of patients with rheumatoid arthritis de!elop bronchiectasis. +his is

characterised by recurrent haemoptysis. +he history of epectorating phlegm on most

days and fre0uent chest infections are suggesti!e of the diagnosis. A high-resolution

computed tomography 8&+: scan of her lungs will establish the diagnosis.

A 7-year-old man with a )*2 of 4 presents with a history of worsening

breathlessness and cough of about -week duration. He is a smoker and still smoked

3/ cigarettes per day until he became ill this time. His arterial blood gases in room air

are as followsP pH 7.31,pa8"3: 6.3 k'a,pa8&"3: .9 k'a, bicarbonate 44 mmol@l.

$hich of the following is the most likely diagnosis%

A 'ulmonary embolus

) Acute asthma

& "bstructi!e sleep apnoea 8"SA:( Acute eacerbation of chronic obstructi!e pulmonary disease 8&"'(:

# 'ulmonary oedema

+his patient is in chronic type-3 respiratory failure. Although "SA can cause chronic

respiratory failure, it is unusual to suffer chronic type-3 respiratory failure ecept in

combination with some other illness like &"'(. His blood gas results are most

compatible with a patient who has se!ere &"'( with an acute eacerbation. 2n se!ere

asthma the picture is mostly of type- respiratory failure. His history of smoking

points more to &"'(.

A 4-year-old woman with end-stage renal failure de!elops pulmonary tuberculosis.

$hich one of the following drugs should be used in a reduced dose%


15/27

A Rifampicin

) 2soniaGid

& 'yraGinamide

( #thambutol

# 'yridoine

#thambutol is renally ecreted and therefore dose adIustment is necessary to minimise

the risk of toic effects, ie optic neuropathy. 'yridoine is a !itamin supplement gi!en

with isoniaGid to minimise the risk of peripheral neuropathy. +he remaining drugs are

mainly metabolised in the li!er and may be gi!en in normal doses in renal failure.

A 3-year-old office secretary has been suffering from intermittent pain and

tenderness affecting her elbows, wrist and ankles for last 3 years. Symptomatic relief

had being obtained from SA2(s. or last 4 months she has been increasingly

unwell, and with night sweats, fe!er and a weight loss of about 6.1 kg 81 lbs:. She

also de!eloped a non-producti!e cough and left-sided pleuritic chest pain. She

smoked 4/ cigarettes per day. "n eamination she had temperature of 47.9 &. +hesyno!ium was palpable o!er her wrist Ioints. "n respiratory eamination her left

lower Gone was dull to percussion with decreased breath sounds. A chest E-ray

confirmed a left-sided pleural effusion in addition to some fibrotic patches on both the

upper Gones. Aspiration showed a straw-coloured fluid with a protein concentration of

16 g@l and a glucose concentration of .6 mmol@l. +he fluid contained many

lymphocytes but no malignant cells. A culture was sterile on the fifth day. $hat is the

probable cause of the pleural effusion%

A Sarcoidosis

) Rheumatoid pleural effusion

& +uberculosis

( 'leural effusion secondary to lung malignancy

# ?ymphoma

+wo main points for the diagnosis are the unilateral pleural effusion and upper Gone

shadowing. Rheumatoid effusions are unusual in the young and are small and

asymptomatic. +his woman may ha!e rheumatoid disease but this is not the cause of

her effusion. ?ymphocyte predominance suggests lymphoma, carcinoma or

tuberculosis. A low glucose concentration fa!ours an infection, malignancy or a

rheumatoid condition. )ut the fibrotic shadow of the upper Gone clinches the

diagnosis in this case and is typical of post-primary tuberculosis. Sarcoidosis shows

upper Gone fibrosis with pleural effusion at end-stage only, and it is rare. o otherfeature fa!ours the diagnosis.

A 3/-year-old woman complains of a sudden onset of dyspnoea associated with

pleuritic chest pain. $hich assessment is the most accurate to confirm your diagnosis

of pulmonary embolism%

A d-(imer

) #chocardiography

& >entilation@perfusion scan

( &ontrast-enhanced spiral computed tomography

# 'ulmonary angiography


16/27

Although pulmonary angiography is associated with serious complications in about

= of patients, it remains the diagnostic reference test for pulmonary embolism.A

negati!e d-dimer test is useful for ecluding pulmonary embolism in patients who are

clinically thought to be at low risk, but a Jpositi!e; result does not establish the

diagnosis. #chocardiography may show right !entricular dilatation and e!idence of

pulmonary hypertension, which, in the proper clinical setting, may strengthen theclinical impression that a pulmonary embolism has occurred. +he 'rospecti!e

2n!estigation of 'ulmonary #mbolism (iagnosis 8'2"'#(: study emphasised the

poor predicti!e !alue of scans reported as intermediate probability, a common

occurrence in routine clinical practice.

$hich lung disease is associated with the clinical obser!ations Jpink puffer; and Jblue

bloater;%

A &ystic fibrosis

) 'ulmonary fibrosis

& &"'(

( Small-cell lung cancer

# +uberculosis

'ink puffers ha!e a good respiratory dri!e.

eatures includeP purse-lip breathing with intense dyspnoea, patient is often thin and

elderly, little sputum produced, oedema and o!ert heart failure are rare complications.

2n!estigationsP blood gases are near normal until pre-terminally there is !ery se!ere

airways obstruction, total lung capacity is increased, there is a reduction in transfer

factor.

)lue bloaters ha!e a poor respiratory dri!e.eatures includeP 0uite mild dyspnoea, patient often obese, large !olumes of sputum

produced, infecti!e eacerbations, patient often oedematous, may de!elop cor

pulmonale.

2n!estigationsP blood gases F hypercapnia, hypoaemia, ele!ated plasma bicarbonate,

se!ere nocturnal hypoaemia, airways obstruction may only be moderate, transfer

factor approimately normal.

A young adult was referred because of cough and shortness of breath. An etrinsic

allergic al!eolitis was diagnosed. )eside reduction of eposure to the allergen, which

other therapy is most likely to be successful%

A Antibiotics

) on-steroidal anti-inflammatory drugs

& 2mmunoglobulins

( &orticosteroids

# (esensitisation

*anagement of the patient centres on reducing any further eposure to a minimum,

but first the diagnosis must be secure. (esensitisation has no beneficial effect. 2deally,

affected indi!iduals change their rele!ant working, domestic and recreational

en!ironment completely, but this may mean a profound loss of income or greatepense, and is often unrealistic. or is it fully Iustified on purely medical grounds


17/27

since continued eposure does not ine!itably lead to progressi!e disease. Affected

indi!iduals who continue to work in the occupation responsible for their disease can

often reduce their eposure substantially by changing the pattern of their particular

duties. An alternati!e is to use industrial respirators, which filter out 9F= of

respirable dust from the ambient air. +hese are especially !aluable when eposures are

intermittent and short, but they may be uncomfortably hot when worn for long periodsor when there is hea!y work, and so compliance with their use may be poor. $hate!er

course is followed, continuing eposure should be accompanied by regular medical

sur!eillance. 2f there is no progression, it is reasonable for some eposure to continue.

$hen there is progressi!e disease, eposure should cease. +his may in!ol!e a loss of

earnings, and may entitle the affected worker to compensation. "ccasionally,

indi!iduals with progressi!e disease may refuse to change their occupation or hobby,

and their physician must weigh the possible ad!antages of long-term corticosteroid

therapy against the risks

Restricti!e lung diseases include which of the following%

A #mphysema

) Asthma

& &ystic fibrosis

( Se!ere scoliosis

# Sarcoidosis

#mphysema, asthma, cystic fibrosis and sarcoidosis J8can produce a mied

obstructi!e@restricti!e pattern F better to choose another disease:; present an

obstructi!e pattern with a low '#R. Se!ere scoliosis compromises respiratory

muscle action and can present as a restricti!e pattern in pulmonary function tests.

JRe!ise;

A 61-year-old woman is referred to the medical team from the orthopaedic ward. She

underwent a right total-hip replacement si days ago. She is known to suffer from

mild &"A( and is on regular inhaled steroids and a short-acting 3-agonist. She now

complains of left-sided chest pain and is also dyspnoeic. Dour clinical diagnosis is

pulmonary embolism 8'#:. $hich one of the following is not a feature of '#%

A (yspnoea

) +achypnoea

& ew-onset atrial fibrillation( e!er

# )radycardia

)radycardia is not a feature of '#. +achypnoea 8respiratory rate N 3/@min: is the

commonest feature occurring in 9= of patients. e!er is a fre0uent finding 841-

/=:. +achycardia occurs in 4/= of patients. Atrial flutter, fibrillation and premature

beats are known to occur in patients with '#.

$hich of the following is a feature in acute eacerbation of chronic bronchitis%

A Respiratory acidosis is associated with a lowering of bicarbonate le!els

) #acerbation is usually due to anaerobic infection

& Aminophylline@theophylline combinations form the first line of management


18/27

( An etensorFplantar response is common

# "ygen therapy should be continued until the symptoms subside

2n respiratory acidosis, bicarbonate and hydrogen le!els are usually raised due to

carbon dioide retention and the renal retention of bicarbonate. &ommonly,


19/27

# Aciclo!ir

+he combination of prednisolone and cyclophosphamide is now established as the

standard induction therapy for patients with generalised $egener;s granulomatosis or

microscopic polyangiitis. +here is consensus on how corticosteroids should be used,

but less so for cyclophosphamide. 'rednisolone is gi!en in doses of around mg@kg

per day initially, after which the dose is reduced rapidly, typically at weekly inter!als.&ontrolled trials show that the addition of pulses of methylprednisolone is unlikely to

confer additional benefit. +raditionally, patients recei!ed daily oral cyclophosphamide

83 mg@kg per day:, but latterly intra!enous boluses ha!e pro!ed increasingly popular,

gi!en in doses of /.F/.7 g@m3body surface area at inter!als of 3 weeks 8at least for

short periods: to 3 months.

A characteristic manifestation of cystic fibrosis includes which of the following%

A )lockage of fallopian tubes

) Rectal prolapse

& Restricti!e pattern of lung function tests

( (iabetes mellitus in later life

# &irrhosis

)lockage of the spermatic tubules and ducts results in subfertility. +he female fertility

rate is diminished but the fallopian tubes are not affected. Rectal prolapse may occur

secondary to malnutrition. An obstructi!e pattern is common in lung function tests

due to airway in!ol!ement. ?ess than /= of patients de!elop diabetes secondary to

pancreatic dysfunction 8eocrine function is affected more commonly:. &irrhosis

occurs in less than = of cases.

A 7/-year-old man attends clinic. He is an e-smoker of / pack years. He has &"'(,with an #>of 1/= predicted and minimal bronchodilator re!ersibility. He is

breathless after walking // metres and was keen to be referred to discuss the

possibility of pulmonary rehabilitation. $hat do you tell him%

AHis eercise tolerance is too poor to be considered for the rehabilitation

programme

) Rehabilitation will make little difference to the length of any future hospital stays

& ollowing the rehabilitation programme, his lung function should impro!e

( ollowing the rehabilitation programme, his walking distance should impro!e

# 2f his eercise tolerance did impro!e following pulmonary rehabilitation, thiswould be a long-lasting impro!ement

+here ha!e been many randomised controlled trials to establish the effects of

pulmonary rehabilitation. +his is a programme of aerobic lower etremity training

combined with education, which has been found to pro!ide significant impro!ements

in functional eercise, although little change in lung function testing. 'atients who

ha!e completed pulmonary rehabilitation ha!e no fewer hospital admissions because

of chest problems, but their hospital stays are likely to be shorter. (ecline in eercise

tolerance and heath status occurs between 6 and 3 months after the completion of a

course. +he effect of sustained impro!ement with ongoing rehabilitation has yet to be

e!aluated.

$hich of the following is not a common symptom of lung cancer on presentation%


20/27

A &ough

) &hest pain

& &ough and chest pain

( &oughing blood

# Shortness of breath

&ough is the commonest symptom 8about 1= of patients: at presentation, followed

by chest pain in 33= of patients who ha!e later been diagnosed to ha!e lung

carcinoma. About = of patients present with both cough and chest pain. "nly 7=

of patients present with the symptom of coughing up blood. 2n less than = of cases

they present with other symptomsP shortness of breath, hoarseness, weight loss,

malaise and distant spread.

A 43-year-old patient with asthma has been stable with inhaled salbutamol when

re0uired. Recently she had to use her inhaler more fre0uently and also at night. $hat

is the net step in her therapy%

A 2nhaled 3-agonist at maimum dose

) Regular inhaled budesonide, inhaled salbutamol when re0uired

& Addition of oral corticosteroids

( Addition of oral leukotriene-receptor antagonist

# Addition of oral theophylline

+his patient needs step 3 in the management of chronic asthma because she needs her

3-agonist inhaler more than once a day and also complains of night-time symptoms.

Step 3 therapy consists of a regular standard-dose inhaled corticosteroid and an

additional inhaled short-acting 3-agonist as re0uired. "ral leukotriene-receptor

antagonists and theophylline are indicated in step 4 if the asthma is still notcontrolled. "ral corticosteroids should be added in step .

A /-year-old man attends clinic with haemoptysis and a -week history of dyspnoea.

#amination is unremarkable, but his chest radiograph shows bilateral fluffy shadows.

5rine dipstick is positi!e for blood and protein. $hat would you do net%

A Send a serum A&A and arrange to see him in clinic in week

) 'erform pulmonary function tests and see him in week for repeat tests

& Arrange an out-patient renal ultrasound

( Admit him to the ward, check his renal function and send blood for autoantibodies

# Admit him to the ward and start i! cyclophosphamide

+he fluffy shadows on the chest E-ray could represent pulmonary oedema, interstitial

lung disease, !asculitic lung disease or pulmonary haemorrhage. &+ may help to

differentiate between these possibilities. &ombined with the positi!e urine dipstick,

this man could ha!e an acti!e !asculitis with pulmonary haemorrhage and renal

disease. He could ha!e $egener;s granulomatosis,


21/27

A 9-year-old smoker with chronic bronchitis was successfully treated with

antibiotics for a right upper lobe bronchopneumonia. After 6 weeks he was readmitted

to hospital. +he chest E-ray shows signs of a pneumonia in the same place. $hat is

the most likely reason%

A &andida pneumonia) 2mmunodeficiency

& )ronchial carcinoma with post-stenotic pneumonia

( Sarcoidosis

# +uberculosis

on-resol!ing pneumonia is an indication of bronchogenic carcinoma. An ill-defined

homogeneous or patchy consolidation in a segmental or non-segmental distribution

may be an indication of bronchogenic carcinoma. 'atients with these findings are

often initially treated for pneumoniaK the lack of response to antibiotic therapy

suggests the diagnosis of a malignancy. +he opacity may contain air bronchograms

and air al!eolograms. +his presentation is often seen with adenocarcinoma andbronchoal!eolar carcinoma. )ronchial stenosis and post-stenotic changes are

commonly seen because most nonFsmall-cell carcinomas demonstrate intraluminal

growth. arrowing of the main bronchi or a complete cut-off can be identified on

chest E-rays. An endobronchial lesion commonly leads to partial or complete

atelectasis and is the commonest sign of bronchogenic carcinoma. &omplete

endobronchial obstruction can sometimes produce distal mucoid impaction, which

may be !isible on plain chest E-rays as a tubular or branching opacity.

+he nurses on the ward ask you to look at a chest drain that has been inserted in a

patient for a pneumothora. +hey are concerned about whether it is still working.

$hen the patient coughs, nothing happens. $hen he breathes in and out, the fluid inthe tube mo!es up and down. $hat does this mean%

A Air and fluid are draining from the pleural space

) luid alone is draining from the pleural space

& Air is no longer draining from the pleural space as the drain is blocked

( Air is no longer draining from the pleural space, but the drain is still working

# He needs to commence suction to the drain

+he fluid le!el rising and falling in the drain Jswinging; shows it is still in contact

with the pleural space and the fluid le!el is mo!ing with respiration. Air is not

bubbling out of the drain when the patient coughs, as the air has stopped drainingfrom the pleural space and the lung has re-inflated. 2f a drain does not bubble or

swing, then it is blocked or kinked and is not working. $ith a simple pneumothora,

there would be minimal fluid drainage from the chest. Suction is necessary if the drain

is still bubbling, but the lung has not fully re-inflated on the chest E-ray.

A 6-year-old man complains of lethargy, fe!er, dry cough, headache, chest pain and

increasing shortness of breath. He returned from a cruise 3 days ago. His chest E-ray

shows bilateral infiltrates, thep8"3: is 9.4 k'a. $hat is the most appropriate

therapy%

A 2ntra!enous corticosteroids) 2soniaGid


22/27

& Ampicillin

( Amphotericin )

# #rythromycin

+his patient has ?egionella pneumonia. +he most rele!ant factor is the ability of the

antibiotic to penetrate intracellularly into al!eolar macrophages where the legionella

organism hides and di!ides. A macrolide, such as erythromycin or clarithromycin, isat present recommended as the drug of first choice, in dosages of //F/// mg e!ery

6 h for erythromycin and // mg twice daily for clarithromycin, being gi!en

intra!enously if re0uired. 2n !itro and animal eperiments and clinical eperience

support the efficacy of rifampicin and fluoro0uinolones. Rifampicin is often

recommended as additional therapy to erythromycin, in a dose of 6// mg once or

twice daily in patients with se!ere infection or who are deteriorating.


23/27

the lower arms and legs, it is designated grade 2>. *alignancy is associated in = of

these cases.

A 37-year-old woman presented in AL# with a 3-week history of haemoptysis and a

4-day history of red-coloured urine. She had a similar problem 3 years ago but

reco!ered fully. She looked pale and was tachycardic, her pulse was 39 and regularand her )' was /@6 mmHg. )ilateral crackles were present on auscultation.

?aboratory testing ga!e the following resultsP

Hb, 7. g@dlK $)&, 4 C /6@lK 'latelets, 19/ C /6@lK &lotting, normalK a, 1/

mmol@lK , 6.7 mmol@lK 5rea, 16 mmol@lK &reatinine, 6/ mmol@l.

5rine showed blood and protein. +he chest E-ray showed patchy interstitial

shadowing in both lung fields. $hat is the probable diagnosis%

A


24/27

A 2nfecti!e eacerbation of &"'(

) 'ulmonary infarction

& +uberculosis

( @>& ratio. $hat is the most likely diagnosis%


25/27

A ibrosing al!eolitis

) &arcinoma of the lung

& &"'(

( +uberculosis

# )ronchiectasis

&ryptogenic fibrosing al!eolitis may occur in any decade of life but is most

commonly seen between the ages of / and 6/ yearsK it is slightly more fre0uent in

males than females. A history of progressi!e breathlessness on eertion in the absence

of wheeGe is typical. A dry cough may be present, but sputum production is unusual

until the later stages of the disease. Haemoptysis is uncommon, but should suggest the

de!elopment of lung malignancy that occurs with a 7- to 1-fold relati!e risk in

patients with cryptogenic fibrosing al!eolitis. &hest pain is uncommon. &onstitutional

symptoms such as weight loss and lethargy are recognised. ?ung function tests show a

restricti!e picture.

$hich one of the following statement is true about the #3=F7=8forced epiratoryflow rate between 3= and 7= of the forced !ital capacity: in pulmonary function

tests%

A 2t reflects the status of the small airways

) 2t is not impaired in bronchiolitis obliterans

& 2t is effort-dependent

( 2t is not affected in smokers

# 2t is useful to identify tracheal obstruction

+he #3=F7=primarily reflects the status of the small airways. 2t is more sensiti!e

than the #>for identifying early airway obstruction. 2t is effort-independent. 2t isimpaired in bronchiolitis obliterans, smokers and reIection reactions in bone marrow,

lung and heart transplants.

Dou are asked to re!iew a patient with known asthma on the haematology ward. He is

neutropenic from chemotherapy for Hodgkin;s lymphoma. He has a cough and a low-

grade fe!er, sparse crepitations on chest eamination and his chest E-ray shows

diffuse pulmonary shadowing. He has been on broad-spectrum antibiotics for week

with no impro!ement. His sputum has shown a few hyphae, but is culture-negati!e.

)lood cultures ha!e been negati!e. Aspergillus precipitins are negati!e, as is an

aspergillus skin-prick test. $hat is the diagnosis%

A Allergic bronchopulmonary aspergillosis

) 2n!asi!e aspergillosis

& Aspergilloma

( 'neumocystis pneumonia

# Systemic candidosis

+his man has in!asi!e aspergillosis, due to his immunosuppression. He has fungal

hyphae in his sputum and a corresponding clinical and radiological picture. He is

unable to mount an immune response and so precipitin and skin-prick tests are

negati!e. Aspergilloma is a fungal ball in an area of pre!iously damaged lung tissue,

such as old +). 2t causes high le!els of aspergillus antibody so precipitins are high,although the skin-prick test is negati!e as there is no 2g#-mediated allergy to


26/27

aspergillus. Allergic bronchopulmonary aspergillosis has high 2g# and antibodies to

aspergillus, so the skin-prick is positi!e and precipitins are high. 'neumocystis

pneumonia 8'&': does not cause hyphae in the sputum. &andida can be identified and

cultured from the sputum. 2t rarely causes obIecti!e e!idence of lung in!asion and is

not recognised as ha!ing specific radiological features

A 34-year-old woman with a lifelong history of atopy, hay fe!er and mild asthma

attends her


27/27

pneumonia ha!e an ele!ated serum lactic dehydrogenase, but this may also occur with

other pulmonary diseases.

$hich drug therapy is indicated for a young adult with mild intermittent asthma 8no

night-time symptoms, no trigger: as re0uired medication%

A )udesonide inhaler

) Salbutamol inhaler

& Salmeterol inhaler

( "ral cromoglycate

# "ral leukotriene-receptor antagonists

"ccasional-relief bronchodilators are indicated in step in the treatment of chronic

asthma, if relief is only needed once daily, if there are no night-time symptoms or no

impaired lung function. Regular inhaled corticosteroids are added in step 3. Regular

inhaled long-acting 3-agonists 8salmeterol: are added in step 4. "ral leukotriene-

receptor antagonists can also be added in step 4 if the asthma is still not controlled.

respiratory system bof

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