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. He
worked 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
6ingdom, 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 of
presentation 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. 7inger-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
( Sarcoidosis
# <oodpasture;s syndrome
'ulmonary embolism can present in di!erse ways. +he syndrome of pleuritic pain or
haemoptysis, in the absence of circulatory collapse, is the most fre0uent mode of
presentation of acute pulmonary embolism. 2t occurred in 6/= of patients recruited in
a collaborati!e in!estigation, the 'rospecti!e 2n!estigation of 'ulmonary #mbolism
(iagnosis 8'2"'#(:. A syndrome of dyspnoea in the absence of haemoptysis or
pleuritic pain or circulatory collapse occurred in 3.=. &irculatory collapse 8systolic
blood pressure less than 9/ mmHg or loss of consciousness: was an uncommon mode
of presentation, occurring in ,.=. "besity and a high oestrogen content in oral
contracepti!es ha!e been linked to thromboembolic e!ents. *ost patients with
pulmonary embolism had smoked at one time or continued to smoke at the time of
their pulmonary embolism.
$hich of the following inter!entions is most likely to impro!e the 7#>
,
and
prognosis of a cigarette smoker with spirometric e!idence of moderate &"'(%
A +obacco-smoking cessation
) 7re0uent use of antibiotics for acute bacterial eacerbations of chronic bronchitis
& (aily use of salmeterol to impro!e 7#>
,
( ?ong-term oygen therapy at 3 l@min
# (aily use of ipratropium bromide to impro!e 7#>
,
+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 mortality
and morbidity. 2t causes about 4/,.// deaths per year in the 56. +he morbidity
burden this raises for the AHS 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
A
/
*
/
) +
3
A
/
*
/
& +
3
A
,
*
/
( +
4
A
,
*
/
# +
1
A
,
*
/
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 !isceral
pleura, it is designated +
3
. *etastasis to the ipsilateral peribronchial and@or ipsilateral
hilar lymph nodes makes the nodal stage A
,
. 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 to Aspergillus 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 to Aspergillus fumigatus occurs 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.- H&. 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
& Hereditary spinocerebellar degeneration
( $illiamsF&ampbell syndrome
# *ounierF6uhn 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 multiple
telangiectasia seen particularly in the conIuncti!a. a-7etoprotein le!els may be raised.
&ell defects and humoral immunity with 2gA and 2g# deficiencies and defecti!e (AA
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 *ounierF6uhn 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
& *#7
3.F7.
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 '#7R 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*#7: rate 8between 3.= and 7.= of the epired !ital capacity: is a good measure of
airway obstruction. '#7R readings are an obIecti!e measure of airway obstructionK
therefore it is ad!isable for any child to perform regular '#7Rs to assess lung
function, pro!iding they can do it properly.
A reduced forced epiratory flow of 3.F7. units 8l@min: is an indicator of which of
the following%
A Asthma
) )ronchial carcinoma
& 6yphoscoliosis
( )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
) Aegati!e suction should be started at F, to F3 cmH
3
"
& High-!olume@low-pressure suction should be used
( 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. Aormal intrapleural pressure is F4.1 cmH
3
" during
epiration, rising to F9 cmH
3
" during inspiration. +his should be started at F,/ to F3/
cmH
3
" 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 Aeck siGe
) &hest siGe
& Abdominal girth
( $aist to hip ratio
# 5!ulopalatal distance
Aeck siGe is the best predictor of "SA, with N 14 cm 8N,7 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 is
the in!estigation of choice to confirm the presence of bronchiectasis.
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 leprae is 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
( 7orced epiratory !olume in , second@forced !ital capacity 87#>
,
@7>&: ratio
# 7orced epiratory !olume in , second 87#>
,
:
+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 8cannot
be 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 7#>
,
@7>&
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
<' for recurrent chest infections. $hat is the most likely diagnosis%
A 7ibrosing al!eolitis
) &arcinoma of the lung
& Sarcoidosis Dour answer
( )ronchiectasis &orrect answer
# Allergic asthma
)ronchiectasis should be suspected when there is a history of persistent cough
producti!e of mucopurulent or purulent sputum throughout the year. 'atients ha!e
fre0uently been treated for recurrent chest infections and labelled as Jbronchitic;,
often despite the absence of a history of smoking. 'atients may produce mucoid
sputum early in their disease, de!eloping purulent sputum when they suffer an
eacerbation associated with a !iral upper respiratory tract infection. Such
eacerbations may be associated with pleuritic chest pain, haemoptysis, fe!er and
sometimes wheeGe. +hose presenting as adults often recall a Jchesty cough; or
JwheeGy bronchitis; associated with upper respiratory tract infections in childhood,
followed by complete resolution of symptoms in their teens and early adult life before
the symptoms return after a !iral trigger. 5pper respiratory tract symptoms such as
postnasal drip are common, and in about 4/= of cases there is a history of chronic
sinusitis. 'atients with bronchiectasis also suffer from undue tiredness, which many
find more troublesome than the producti!e cough.
An anious, 3.-year-old saleswoman presented with mild shortness of breath on
eertion, which had come on gradually o!er se!eral months. +he symptom was
intermittent and seemed to get worse in the e!ening. She has also been on treatment
for depression o!er the last 3 months. "n eamination she looked depressed and there
was no positi!e physical finding in any of the systemic eaminations. Dou now ha!e
the results of the in!estigationsP bloods, normalK chest E-ray and lung function tests,
normalK #&<, normal. $hat is the likely diagnosis%
A Angina
) #atonF?ambert syndrome Dour answer
& *yasthenia gra!is &orrect answer
( Somatisation disorder
# +2A
+his is a case of myasthenia gra!is. *uscle weakness may not be apparent on a single
eamination, so the eamination should be repeated. *ost affected is the ocular and
shoulder-girdle muscle. Respiratory and proimal lower limb muscles may be
in!ol!ed early in the disease. )reathlessness may de!elop early and cause sudden
death. Swallowing problems, slurred speech and difficulty in chewing may be caused
by bulbar in!ol!ement. Asymmetrical in!ol!ement of the eternal ocular muscle may
mimic cranial ner!e palsy. 'upillary refle is normal. *ild ptosis and weak facial
muscles make patients appear depressed. +halamic enlargement may be seen in Iust
,.= of patients. *yasthenia gra!is is autoimmune in origin.
A 16-year-old meat-factory worker is found to ha!e Q fe!er pneumonia. $hich of the
following statements is correct%
A He re0uires high-dose penicillin for his treatment Dour answer
) His occupation is not important for the diagnosis
& +here is no long-term se0uel of the disease
( +he organism responsible is Coxiella pneumoniae
# +he organism is usually inhaled from infected dust &orrect answer
Q fe!er is due to Coxiella burnetii and 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 of
tetracyclines. 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/ H& 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 ?7+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
( 7lucloacillin
# &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. 7lu-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 ?7+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 <ram-staining.
Dou are fast-bleeped to see a ./-year-old woman on the medical ward. She was
admitted earlier that day with a swollen lower leg following her return from a holiday
in Australia. Her d-dimers were raised and she was started on subcutaneous
unfractionated heparin. She is now short of breath, pale, clammy, bradycardic and
hypotensi!e. Her #&< shows sinus tachycardia. +he house officer has gi!en her i!
fluids, but her blood pressure is continuing to fall. $hat would you consider doing
net%
A 2ntra!enous heparin
) 7urther i! fluids
& +hrombolysis
( #chocardiogram
# >@Q scan
+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 heparin
already, 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 coughing
up 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 <y,
often gi!en at the same time as a clinic !isit. )rain metastases generally respond
poorly to radiotherapy. A 19-hour trial of deamethasone, 1 mg orally four times
daily, is recommended as initial management.
A 46-year-old woman with systemic sclerosis de!elops breathlessness on eertion.
Her pulmonary function tests show normal spirometry but a decreased gas transfer
factor 8+?&", transfer factor for carbon monoide: and transfer coefficient 86&":.
$hich of the following is the most likely eplanation for this abnormality%
A 7ibrosing al!eolitis
) 'ulmonary !ascular disease
& Se!ere thoracic skin thickening
( 'leural in!ol!ement
# Respiratory muscle weakness
2solated decreases in gas transfer are typical of pulmonary !ascular disease, eg
!asculitis, recurrent pulmonary embolism 8'#:. 2n fibrosing al!eolitis you would also
epect to see decreased lung !olumes with a restricti!e ratio 8N 9/=: on spirometry.
+he other three answers would all gi!e a picture of Jetrapulmonary restriction; with a
restricti!e ratio, low +?&" but normal@high 6&" 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', her
blood 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 carinii pneumonia
( 6lebsiella pneumonia
# 7ungal 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 patients
with 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 as Mycobacterium tuberculosis by polymerase chain reaction
8'&R:. (rug therapy with isoniaGid, rifampicin, ethambutol and pyraGinamide has
been 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 56. 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 with
appropriate isolation facilities. +his may re0uire transfer of the patient to an
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, susceptible
and 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 reticulonodular
shadowing 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 classically
subpleural 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-AA&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 fine
crepitations and bronchial breathing or, less commonly, pleural rubs and signs of
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 clinic
with 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 to
perform 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 breathing
following 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. 7low !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%
A 7amilial 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 R>', 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 taking
rifampicin 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 Aortriptyline
) 7luoetine
& (iaGepam
( *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, p
a
8"
3
: 6.3 k'a, p
a
8&"
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%
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 ASA2(s. 7or last 4 months she has been increasingly
unwell, and with night sweats, fe!er and a weight loss of about 6.1 kg 8,1 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 H&. +he
syno!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. Ao other
feature 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
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 the
clinical 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.
7eatures 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.
7eatures 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
) Aon-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 great
epense, and is often unrealistic. Aor is it fully Iustified on purely medical grounds
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 periods
or 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 '#7R. 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 S
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
& Aew-onset atrial fibrillation
( 7e!er
# )radycardia
)radycardia is not a feature of '#. +achypnoea 8respiratory rate N 3/@min: is the
commonest feature occurring in 9.= of patients. 7e!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
( 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, <ram-
positi!e organisms cause an eacerbation of chronic bronchitis. Aminophylline and
theophylline are indicated in patients with re!ersible chronic obstructi!e pulmonary
disease 8&"'(: only if nebulised bronchodilators and steroids are ineffecti!e.
"ygen therapy should aim for a p8"
3
: of 6/ mmHg, particularly for Jblue bloaters;
8with type-22 respiratory failure:. Any further increase will result in carbon dioide
retention. #tensorFplantar responses are seen in &"'( due to carbon dioide
retention, which results in carbon dioide narcosis.
A 47-year-old man who speaks little #nglish comes to the +) clinic. His notes are
missing but he is able to tell you that he has been on treatment for almost , year. $hat
is the most likely reason he has been treated for this length of time%
A 'ulmonary +)
) ?ymph-node +)
& +) meningitis
( )ony +)
# 'leural +)
2n the 56, all fully sensiti!e +) is treated for 6 months ecept for +) affecting the
central ner!ous system, which is treated for ,3 months. *ulti-drug resistant +)
8*(R+): will re0uire longer courses of treatment, usually with a combination of less
commonly used anti-+) drugs.
(ecreased (?&" is seen in which of the following%
A Heart failure
) Anaemia
& 'ulmonary embolism
( #ercise
# Acute poliomyelitis
(?&", the diffusion capacity in the lung for carbon monoide, is decreased in any
condition that reduces the effecti!e al!eolar surface area or affects the al!eolar
membrane. #amples include pulmonary embolism and emphysema in which the
al!eolar surface area is reduced.
A 1--year-old woman has been admitted with haemoptysis and epistais, the chest E-
ray shows multiple rounded lesions with al!eolar shadowing. ?aboratory parameters
show a leucocytosis without eosinophilia but with microhaematuria, proteinuria as
well as antineutrophil cytoplasmic antibodies 8c-AA&A:. $hich drug treatment is the
most appropriate%
A #rythromycin
) Ampicillin
& &yclophosphamide in combination with corticosteroids
( &iclosporin
# 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@m
3
body 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 7#>
,
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%
A
His 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
& 7ollowing the rehabilitation programme, his lung function should impro!e
( 7ollowing the rehabilitation programme, his walking distance should impro!e
#
2f his eercise tolerance did impro!e following pulmonary rehabilitation, this
would 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%
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 S
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
S
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 S
3
-agonist as re0uired. "ral leukotriene-receptor
antagonists and theophylline are indicated in step 4 if the asthma is still not
controlled. "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 AA&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, <oodpasture;s syndrome or
microscopic polyangiitis. He needs urgent admission and assessment. He may ha!e
renal failure, he may de!elop respiratory failure and he may need to start urgent
immunosuppression if a diagnosis of !asculitis is made. +his diagnosis is best made
by biopsyP either of the kidneys, or an open lung biopsy, or of any skin lesion@nose
lesion if present. 2deally, he should ha!e a tissue diagnosis before starting
immunosuppressi!e treatment.
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
Aon-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 and
bronchoal!eolar carcinoma. )ronchial stenosis and post-stenotic changes are
commonly seen because most nonFsmall-cell carcinomas demonstrate intraluminal
growth. Aarrowing 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 in
the tube mo!es up and down. $hat does this mean%
A Air and fluid are draining from the pleural space
) 7luid 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 draining
from 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, the p8"
3
: is 9.4. k'a. $hat is the most appropriate
therapy%
A 2ntra!enous corticosteroids
) 2soniaGid
& 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, is
at 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. <eneral
supporti!e measures are particularly important, with attention to ade0uate hydration
and correction of hypoaemia with the early use of assisted !entilation for ad!ancing
respiratory failure.'re!entionP +he most important principle to follow is to a!oid
holding water at temperatures between 3/ and 1. H&, which is the range in which
legionella multiplication occurs. "ther pre!enti!e measures should be taken, ieP
minimise colonisation, growth and release of legionellae into the atmosphereK
physically or chemically treat water to kill the bacteriaK protect maintenance personnel
who work on contaminated systems.
$hich of the following statements applies to the peak epiratory flow rate%
A
2t is a less sensiti!e parameter for assessing impro!ement to therapy in patients
with acute bronchial asthma
) 2t measures small-airway resistance
& 2t is more related to age than height
(
?ess than ./= of normal is an indication for aminophylline therapy in those with
acute asthma
# 2t is effort-dependent
'#7R is a sensiti!e measurement of small-airway obstruction, although the maimal
mid-epiratory flow rate is more changed in mild disease. +he ease of performing the
'#7R at the bedside has made it more rele!ant in clinical practice. 2t is more related
to height than age, and is effort-independent if the proper techni0ue is used.
2n which of the following respiratory disease is clubbing not a feature%
A Asbestosis
) 7ibrosing al!eolitis
& ?ung abscess
( )ronchitis
# )ronchial carcinoma
?oss of the natural angle between the nail and the nailbed is seen in clubbing. An
increased cur!ature of the nail de!elops later. &lubbing is seen in suppurati!e diseases
such as long-standing bronchiectasis, acute lung abscesses and empyema. Howe!er,
clubbing is not seen in uncomplicated bronchitis. &lubbing is also found in fibrosing
al!eolitis and asbestosis, in malignant disease, particularly carcinoma of the bronchus
and in pleural malignancy. 2f finger clubbing is associated with hypertrophic
pulmonary osteoarthropathy, a painful osteitis of the distal ends of the long bones of
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 regular
and 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 Aa, ,1/
mmol@lK 6, 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 <oodpasture;s syndrome
) *icroscopic polyangiitis
& $egener;s granulomatosis
( 'AA
# +uberculosis
+he patient is suffering a pulmonary haemorrhage, as shown on the chest E-ray.
Associated renal in!ol!ement is present. +he changes can be caused by microscopic
polyangiitis, $egener;s or <oodpasture;s syndrome. +he larger !essel !asculitides do
not present in this way. *icroscopic polyangiitistends to recur more often than the
other two, making this the probable diagnosis.
A 33-year-old student is admitted to the emergency department, ha!ing been found by
her flatmates to be unsteady on her feet and ha!ing problems with her memory. +hey
tell you they ha!e been using old-fashioned gas fires as it has been so cold and you
are wondering whether she could ha!e carbon monoide poisoning. $hich test will
be the most helpful in determining this%
A &linical eamination
) 'ulse oimetry
& Arterial blood oygen le!el
( #haled breath test
# &hest radiograph
)reath carbon monoide le!els can be measured using de!ices intended for smoking
cessation work. +hey can also be measured on a co-oimeter, measuring
carboyhaemoglobin le!els. &linical eamination is unhelpful, as patients are not
cyanosed, but a cherry-red colour. 'ulse oimetry appears normal, due to
carboyhaemoglobin ha!ing similar absorption spectra to oyhaemoglobin. Arterial
oygen le!els may be normal, as may a chest radiograph. +reatment for carbon
monoide poisoning is to gi!e high le!els of inspired oygen, by !entilation 8or
hyperbaric means if necessary:, to displace the carbon monoide and increase the
amount of dissol!ed oygen.
$hat is the most common cause of haemoptysis%
A 2nfecti!e eacerbation of &"'(
) 'ulmonary infarction
& +uberculosis
( <oodpasture;s syndrome
# )ronchial carcinoma
+he most common cause of haemoptysis is acute infection, in eacerbation of &"'(
in particular. )ut other causes should be ecluded while in!estigating. )ronchial
carcinoma, pulmonary infarction and tuberculosis are common causes. *assi!e
haemoptysis of more than 3// ml of blood is present in cases of bronchiectasis and
tuberculosis. 'ulmonary haemosiderosis, <oodpasture;s syndrome, microscopic
polyangiitis, and trauma are some of the rarer causes worth remembering.
$hich form of lung disease de!elops typically in people with a
,
-antitrypsin
deficiency%
A Atelectasis
) 'neumonitis
& #mphysema
( 2nterstitial fibrosis
# )ronchiectasis
+he association of a
,
-antitrypsin with the de!elopment of premature emphysema has
led to the wider conclusion that emphysema results from an imbalance between
proteases and antiproteases within the lung. +he elastase and a
,
-antitrypsin balance
clearly illustrates the processes in!ol!ed in the de!elopment of emphysema and the
interplay between the en!ironmental and genetic factors that determine its onset.
'atients usually present with increasing dyspnoea and weight loss, with cor pulmonale
and polycythaemia occurring late in the course of the disease. &hest E-rays typically
show bilateral basal emphysema with paucity and pruning of the basal pulmonary
!essels.
$hich of the following is the best agent for treating chlamydia pneumonia%
A &larithromycin
) 'iperacillin
& &lindamycin
( Ampicillin
# 2mipenem
*acrolide antibiotics 8eg clarithromycin or erythromycin: are the treatment of choice
for chlamydia and other atypical pneumonias. +he most fre0uent side-effects are
nausea, !omiting and diarrhoea. 2t should be kept in mind that treatment is likely to be
most effecti!e when gi!en o!er a long rather than a short time, suboptimal doses are
a!oided and compliance is strict.
A 6/-year-old man presents to the clinic complaining of a 6-month history of
dyspnoea on eertion and a non-producti!e cough. "n eamination there is clubbing,
and crepitations are heard at the lung bases. ?ung function tests show a reduced !ital
capacity and an increased 7#>
,
@7>& ratio. $hat is the most likely diagnosis%
A 7ibrosing 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 7#7
3.=F7.=
8forced epiratory
flow 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 7#7
3.=F7.=
primarily reflects the status of the small airways. 2t is more sensiti!e
than the 7#>
,
for identifying early airway obstruction. 2t is effort-independent. 2t is
impaired 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
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 <'. "!er the last 4 months she has been waking in the early morning
coughing and wheeGing, and it is slowly getting worse. She is taking inhaled
salbutamol se!en times a day and is also using inhaled steroids 1// g twice a day.
Her predicted peak flow rate is .// l@min and it is now 4./ l@min. $hat would you
ad!ise her <' to do%
A &all an ambulance and admit her to hospital
) Start an oral leukotriene-receptor antagonist, such as montelukast
& Start her on oral theophylline
( Start an inhaled long-acting S
3
-agonist
# ?end her a nebuliser to use at home
+his is a woman with features of inade0uately controlled asthma. She has no features
of an acute or life-threatening attack, so does not re0uire hospital admission. She is
already taking a moderate dose of inhaled steroids, but needs add-on therapy. +he
)ritish <uidelines on the *anagement of Asthma 8see Thorax 3//4, .98Suppl. ,::
recommend commencing a long-acting S
3
-agonist, such as salmeterol, if the patient is
regularly taking an inhaled steroid. 2f they do not impro!e with this, or if additional
therapy is still re0uired, oral theophylline or a leukotriene-receptor antagonist can
then be tried. A nebuliser is not recommended in place of increasing her other
therapies.
A 31-year-old patient with haemophilia A has been complaining of fe!er and dry
cough. An interstitial pneumonia was diagnosed. After 7 days; treatment with
doycycline 3// mg@day his temperature was still 4- H& and a chest E-ray showed
increased interstitial infiltrates. $hich is the most likely diagnosis%
A &andida pneumonia
) *ycoplasma pneumonia
& Pneumocystis carinii pneumonia
( "rnithosis
# #trinsic allergic al!eolitis
Pneumocystis carinii pneumonia typically presents with gradually increasing
dyspnoea and cough o!er weeks, but sometimes as an acute illness with rapid
deterioration o!er a few days. 'atients with haemophilia A were more susceptible to
H2> due to fre0uent blood transfusions that were not screened in the past. +he chest
E-ray usually re!eals diffuse ground-glass opacities, which strongly suggests the
diagnosis, but it sometimes shows nodular opacities, lobar consolidation, or e!en a
normal film. &ystic abnormalities and spontaneous pneumothoraces in patients with
known or suspected H2> infection are usually caused by Pneumocystis carinii
pneumonia. Pneumocystis carinii pneumonia is unlikely in a patient who has had a
&(1T cell count abo!e 3// cells@Ul in the preceding 3 months in the absence of other
H2>-associated symptoms. Approimately -/= of patients with Pneumocystis carinii
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 S
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.