Respiratory Medicine 151. A 32-year-old patient with asthma has been stable with inhaled salbutamol when required.

Recently she had to use her inhaler more frequently and also at night. What is the next step in her therapy? Inhaled 2-agonist at maximum dose Regular inhaled budesonide, inhaled salbutamol when required Addition of oral corticosteroids Addition of oral leukotriene-receptor antagonist Addition of oral theophylline

Your answer

This patient needs step 2 in the management of chronic asthma because she needs her 2agonist inhaler more than once a day and also complains of night-time symptoms. Step 2 therapy consists of a regular standard-dose inhaled corticosteroid and an additional inhaled short-acting 2-agonist as required. Oral leukotriene-receptor antagonists and theophylline are indicated in step 3 if the asthma is still not controlled. Oral corticosteroids should be added in step 5.

152. A 50-year-old man patient was referred by his GP because of a long-standing history of persistent cough productive of mucopurulent sputum. He also noticed increasing shortness of breath. The patient has been treated several times for recurrent chest infections. What is the most likely diagnosis? Lung cancer Bronchiectasis Your answer Chronic cardiac failure Extrinsic allergic alveolitis Asthma Bronchiectasis should be suspected when there is a history of persistent cough productive of mucopurulent or purulent sputum throughout the year. Patients have frequently been treated for recurrent chest infections and labelled as

bronchitic, often despite the absence of a history of smoking. Patients may produce mucoid sputum early in their disease, developing purulent sputum when they suffer an exacerbation associated with a viral upper respiratory tract infection. Such exacerbations may be associated with pleuritic chest pain, haemoptysis, fever and sometimes wheeze. Those presenting as adults often recall a chesty cough or wheezy bronchitis associated with upper respiratory tract infections in childhood, followed by complete resolution of symptoms in the teens and early adult life before these return after a viral trigger. Upper respiratory tract symptoms such as nasal drip are common, and in about 30% of cases there is a history of chronic sinusitis. Patients with bronchiectasis also suffer from undue tiredness, which many find more troublesome than the productive cough.

153. A 25-year-old basketball player is brought to the accident and emergency department with a history of sudden onset of right-sided chest pain and breathlessness. On examination, tachycardia is noted. Decreased breath sounds are heard on the right side. What is the probable diagnosis? Rupture of subpleural tuberculous focus Rupture of a subphrenic abscess through the diaphragm Rupture of apical subpleural blebs Pulmonary embolism Lobar pneumonia

Your answer

Rupture of subpleural tuberculous focus is a rare cause, particularly in the UK. Rupture of a subphrenic abscess through the diaphragm may cause empyema, not pneumothorax. Primary spontaneous pneumothorax is due to rupture of apical pleural blebs. The incidence of pneumothorax is highest in males aged 15-30 years where smoking, height and the presence of apical subpleural blebs appear to be the most important aetiological factors. Height may be a significant factor in this case as the patient is a basketball player. Lobar pneumonia usually presents with a history of cough, fever and malaise. The majority of patients with pulmonary embolism present with pleurisy, shortness of breath and haemoptysis. 75% of pulmonary emboli derive from deep vein thrombosis in the lower limb. There does not appear to be any risk factor for venous thromboembolism in this case. 154. A 78-year-old man, who worked as a plumber, presents with a unilateral pleural effusion. He has felt unwell for some time and spends much of the day sitting in a chair. Pleural biopsies taken at thoracoscopy have shown malignant mesothelioma and extensive tumour on all pleural surfaces was noted. Having explained the diagnosis to him, which would be the most appropriate treatment to consider next?

Radical surgery alone Radical surgery combined with chemotherapy and radiotherapy Chemotherapy alone Radiotherapy to the hemithorax Radiotherapy to the thoracoscopy tract site Your answer Radical surgery (extraparietal pneumonectomy) involves removing the lung, parietal pleura, diaphragm and pericardium. It is suitable only for fit patients with a low tumour volume. Used alone, it does not improve survival, but studies are underway using it as part of trimodality treatment with chemotherapy and radiotherapy. These suggest it may improve survival, although it is not curative. It has a perioperative morbidity of up to 50% and mortality of up to 8%. Chemotherapy, as yet, has not been found to have any impact on survival, although 30% of patients have an objective tumour response. Radiotherapy to the entire pleural surface is technically difficult and associated with a high risk of radiation pneumonitis, hepatitis and pericarditis. Results are disappointing. Radiotherapy to chest instrumentation-tract sites is effective at preventing tumour seeding and growth (see Boutin et al 1995. Chest,108(3),754-8) and is recommended after pleural procedures. This is routine practice, along with providing symptomatic treatment.

155. A 70-year-old man with chronic bronchitis is admitted with dyspnoea and peripheral cyanosis. On auscultation, there are scattered rhonchi but no wheeze or evidence of consolidation. Arterial blood-gas determinations show a pH of 7.38, pa(O2) 40 mmHg and pa(CO2) 45 mmHg. 40% oxygen is given by facemask. Within 10 minutes his cyanosis worsens and his respiratory rate falls. A repeat arterial blood-gas estimation shows a pH of 7.24, pa(O2) 72 mmHg, pa(CO2) 63 mm Hg. What is the next step in his management?

Obtain a chest X-ray Do a ventilation/perfusion scan Decrease the fraction of inspired oxygen Initiate mechanical ventilation Administer intravenous aminophylline

Your answer

Patients with advanced COPD are at risk of developing acute respiratory failure. Oxygen therapy is effective in reversing the hypoxaemia of respiratory failure. However, oxygen administration may lead to hypercapnia as these patients have lost their sensitivity to hypercapnia. When the hypoxaemia is corrected, they lose their stimulus to breathe and develop carbon dioxide narcosis. Oxygen administration therefore has to be decreased prior to initiating mechanical ventilation.

156. An 18-year-old woman presents with an acute pulmonary embolism in the ninth week of pregnancy. No obvious factors contributed to the risk of pulmonary embolus. What is the most appropriate treatment for this patient throughout her pregnancy? Aspirin Intravenous unfractionated heparin Subcutaneous low molecular weight heparin Your answer Subcutaneous unfractionated heparin Warfarin

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

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

157. A 49-year-old woman has been admitted with haemoptysis and epistaxis, the chest Xray shows multiple rounded lesions with alveolar shadowing. Serum is c-ANCA positive. What is the most likely diagnosis? Tuberculosis Carcinoma of the lung Echinococcosis Wegeners granulomatosis Systemic lupus erythematosus

Your answer

Almost all the patients so diagnosed have evidence of granulomatous lung disease at presentation, which is often accompanied by alveolar capillaritis. The bronchi can also be affected and bronchial stenoses occur as late manifestations. Symptoms include cough, dyspnoea, haemoptysis and chest pain, which can be pleuritic. Signs on chest examination 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. Pulmonary granulomas are usually diagnosed from chest X-ray and CT scans. They may appear as single or multiple rounded lesions, which can cavitate. Bronchoscopy often reveals granulomatous inflammation and the diagnosis can sometimes be made from bronchial biopsies.

158. A 24-year-old thin man complains of constant daytime sleepiness. He mentions involuntary naps, often in the middle of activity, which occur suddenly and without warning. He also caused an accident when he fell asleep while driving home from work. The patient works as an office manager and has no history of exposure to chemicals. Which of the following treatments would be indicated? Nortriptyline Fluoxetine Diazepam Modafinil Continuous positive airway pressure-breathing device

Your answer

This patient has narcolepsy: a sleep disorder causing hypersomnia, which usually starts in adolescence or young adulthood. Treatment involves the use of central nervous system stimulants such as modafinil to allow daytime functioning. Continuous positive airway pressure-breathing devices are used in the treatment of sleep apnoea. A typical patient with sleep apnoea is usually older, obese and there will be a long history of gradually worsening snoring with apnoeas, possibly witnessed by the spouse, who will probably have moved out of the bedroom because of the noise. There is usually a history of fairly high alcohol intake and smoking.

159. An 82-year-old man living alone in a bungalow came to the clinic complaining of feeling generally unwell for about the last 34 months and of losing about 9.5 kg (21 lbs) in weight during this period. On further enquiry he said he had been having night sweats for the last month. He also has a past history of angina and arthritis and was on medication. On examination he did not look well. He was pyrexic and without lymphadenopathy. Bibasal crepitus on the lower zone was heard on chest auscultation. He had hepatosplenomegaly and clubbing. Investigations showed WBC 12.3 106/l (neutrophils 52%, lymphocytes 39%), Hb 9.1 g/dl, with all other routine investigations being normal. A chest X-ray showed 12 cm diameter miliary shadows all over the lung field. The Mantoux test was negative. No bacteria grew in a sputum culture. What is the probable cause of the illness and the X-ray finding? Sarcoidosis Mycoplasma pneumonia Staphylococcal pneumonia Miliary tuberculosis Bacterial endocarditis

Your answer

This is a case of miliary tuberculosis, which is caused by a diffuse disseminated spread of tubercle bacilli via the bloodstream. In older patients it is difficult to diagnose. It presents with a gradual onset of vague ill health, loss of weight and then fever. It can also present as tubercular meningitis. Hepatosplenomegaly is seen in advanced disease. Choroidal tubercles are seen in the eyes. Initially, a chest X-ray may be normal. Later, chest X-ray reveals the presence of small 12 cm lesions. CT scanning may show a lung parenchymal abnormality at an early stage. The Mantoux test may be negative in up to half of the patients with severe disease. A transbronchial biopsy is positive at an early stage. Biopsy of liver and bone marrow may be required. If untreated miliary tuberculosis is universally fatal.

160. A 26-year-old man presents with fever, headache and a moderate productive cough. The chest X-ray shows increased interstitial markings. Laboratory examination shows an elevated LDH and anaemia with the presence of cold agglutinins. What is the most likely diagnosis? Non-Hodgkins lymphoma Pneumocystis jiroveci pneumonia Mycoplasma pneumonia Exogene allergic alveolitis Chlamydia pneumonia

Your answer

Acute, cold autoimmune haemolytic anaemia is commonly seen in adolescents and young adults following infection with Mycoplasma pneumoniae. Haemolysis occurs approximately 12 weeks following infection and is most commonly associated with a rise in polyclonal anti-I IgM antibodies with Mycoplasma pneumonia. The typical patient is usually a young adult who experiences a respiratory tract infection accompanied by headache, myalgia, cough and fever, and with a chest X-ray that shows bronchopneumonia. The cough is often non-productive, but when sputum is obtained it is mucoid, shows predominantly mononuclear cells and no dominant organism. A characteristic feature is the relatively high frequency of extrapulmonary complications such as rash, neurological syndromes (aseptic meningitis, encephalitis, neuropathies), myocarditis, pericarditis and haemolytic anaemia. The diagnosis should be suspected in those patients with a relatively mild form of pneumonia, particularly in previously healthy young adults. With regard to treatment, the pathogen lacks a cell wall and hence is not susceptible to penicillin, cephalosporins or other cell wall-active antibiotics. The usual therapeutic agents are macrolides such as erythromycin, clarithromycin, azithromycin or doxycycline. 161. Which of the following treatments have been shown to prolong life in patients with COPD? Anticholinergics 2-agonists Inhaled corticosteroids Long-term oxygen therapy Lung volume reduction surgery

Your answer

The only treatment shown to prolong life in COPD is long-term oxygen therapy. It must be taken in excess if 16 h per day. It is thought that by relieving hypoxia there is a reduction in pulmonary arterial pressure and hence prolongation of life. Suitable candidates are patients with an FEV1 < 1.5 litres and a pa(O2) < 7.3 kPa when well on two occasions some weeks apart.

162. A 60-year-old man who has a 30-pack year smoking history comes to clinic with worsening shortness of breath over the last 6 months. He works as a baker and keeps racing pigeons. On examination, he is clubbed, has saturations of 91% on air and has widespread fine inspiratory crepitations. His chest radiograph shows reticulonodular shadowing and his CT scan confirms reticulation, mainly subpleural and some honeycombing. What is the diagnosis? Pulmonary sarcoidosis Usual interstitial pneumonitis Your answer Hypersensitivity pneumonitis Occupational asthma Langerhans cell histiocytosis

Dyspnoea, clubbing and inspiratory crepitations are the classic features of usual interstitial pneumonitis. Chest X-ray will show reticulation, which is classically subpleural in distribution on CT. Pulmonary sarcoidosis does not give clubbing and crepitations would be associated with end-stage fibrotic disease. The CT appearances would be those of nodularity, including fissural nodularity. The CT in hypersensitivity pneumonitis shows: ground-glass shadowing, with reticular and nodular patterns; in occupational asthma, possibly non-specific features of air trapping; and in Langerhanscell histiocytosis it shows nodules and cystic lesions.

163. Which of the following statements fits best with 1-antitrypsin (AAT) deficiency? AAT deficiency is never associated with asthma and bronchiectasis AAT is an autosomal co-dominant condition Emphysema with a late presentation is the major respiratory complication Severe deficiency affects the lungs and kidney predominantly The main function of AAT is to neutralise eosinophil elastase in the lung Your answer

AAT deficiency is an autosomal co-dominant condition with the gene located on the long arm of chromosome 14. AAT neutralises neutrophil elastase thereby preventing lung destruction. Deficiency (Pi ZZ homozygotes) results in premature emphysema. Asthma and bronchiectasis do occur but less frequently than emphysema.

164. A 48-year-old woman is admitted with a couple of days history of fever with rigors and breathlessness. On examination she looks extremely unwell and is confused, cyanosed, has a respiratory rate of 36/min and a systolic blood pressure of 86 mmHg. There is dullness on percussion and bronchial breathing at her right base. The chest radiograph reveals consolidation. Which of the following would be the most appropriate antibiotic regimen to use? Oral amoxicillin Oral amoxicillin and oral clarithromycin Intravenous cefotaxime and intravenous clarithromycin Intravenous ceftazidime and intravenous vancomycin Intravenous amoxicillin and intravenous clarithromycin

Your answer

This woman has severe pneumonia as defined by the British Thoracic Society guidelines. It requires any two of the following features: confusion, urea > 7 mmol/l, respiratory rate > 30/min and hypotension (SBP < 90 mmHg, DBP < 60 mmHg). Appropriate treatment (as recommended by the British Thoracic Society) is with intravenous antimicrobials: coamoxiclav 1.2 g three times daily or cefuroxime 1.5 g three times daily or cefotaxime 1 g three times daily or ceftriaxone 2 g once daily plus erythromycin 500 mg four times daily or clarithromycin 500 mg twice daily.

165. A 24-year-old patient presents with anorexia, fever and hot flushes. The chest X-ray shows a 4-cm, large, left upper lobe cavity. Active tuberculosis is suspected. What is the next appropriate step to confirm the diagnosis? Computed tomographic (CT) scanning Mantoux test Blood cultures Sputum sample Serum inflammatory markers

Your answer

The laboratory diagnosis of pulmonary tuberculosis relies on examination and culture of sputum or other respiratory tract specimens. The definitive diagnosis requires the growth of Mycobacterium tuberculosis from respiratory secretions, while a probable diagnosis can be based on typical clinical and chest X-ray findings with either sputum positive for acid-fast

bacilli or other specimens, or typical histopathological findings on biopsy material. The specificity of these latter approaches depends on the prevalence of disease due to nontuberculosis mycobacteria in the population.

166. A 60-year-old woman attends the clinic complaining of shortness of breath over the preceding 2 months. She has also had problems with nasal irritation, discharge and sinus pain. She is known to have asthma, which has recently been poorly controlled, despite inhaled steroids. Her full blood count has shown an eosinophilia of 13% and her chest X-ray shows peripheral pulmonary shadows. What is the most likely diagnosis? Severe asthma Allergic bronchopulmonary aspergillosis (ABPA) ChurgStrauss syndrome Your answer Wegeners granulomatosis Cryptogenic organising pneumonia (COP) This womans eosinophil count is high, higher than it would be with asthma alone. Eosinophil levels in the blood are tightly regulated. Eosinophils accumulate in allergic or hypersensitivity disease, including asthma with associated eczema, as well as allergic bronchopulmonary aspergillosis, Churg Strauss syndrome, Loefflers syndrome, tropical pulmonary eosinophilia, chronic pulmonary eosinophilia, hypereosinophilic syndrome and acute eosinophilic pneumonia. ChurgStrauss syndrome is an eosinophilic granulomatous inflammation of the respiratory tract with small- and medium-vessel necrotising vasculitis. It is diagnosed on finding four out of the following: asthma, blood eosinophilia > 10%, vasculitic neuropathy, pulmonary infiltrates, sinus disease or extravascular eosinophils on biopsy findings. It is diagnosed clinically, although a biopsy should be sought for pathological confirmation. Wegeners granulomatosis is not typically associated with an eosinophilia, neither is COP. ABPA is a condition where people with asthma have a vigorous IgE response to aspergillus, with associated eosinophilia, a positive skin-prick test to

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

167. A 72-year-old woman is admitted with a sudden-onset, left-sided pleuritic chest pain with shortness of breath. She is being treated for asthma, which has been well controlled on a low dose of inhaled corticosteroids and long-acting -agonist. She underwent left hemiarthroplasty 12 days ago, and was discharged as she was doing well. Her chest is clear on auscultation. She is tachycardic (132 beats/min) and an ECG shows sinus tachycardia. Her peak expiratory flow (PEF) rate is 300 l/min (best 400 l/min). Arterial blood gases are as follows: pH 7.34, pa(O2) 7.6 kPa, pa(CO2) 3.5 kPa. She is started on oxygen. A chest radiograph is normal. What would be the most appropriate immediate action taken by you as a medical SHO? Start nebulised bronchodilators and monitor PEF rate Request D-dimers urgently Start low molecular weight heparin suspecting PE, and request a V/Q scan Start low molecular weight heparin suspecting PE, and request CT pulmonary angiography Request a chest radiograph in expiration

Your answer

Her PEF rate is only mildly reduced (75% best). It is unlikely that this patients symptoms are due to an exacerbation of her asthma. A small pneumothorax, not apparent on the inspiratory chest radiograph, is also unlikely since it would not cause marked hypoxia. The symptoms and findings point towards a pulmonary embolism (PE), for which the clinical probability is high. D-Dimers should not be measured, since the result would not alter the need for definitive investigation: because she has had a recent operation it would be high anyway. D-Dimers should only be measured when the probability of PE is low and further investigations would not be pursued. A V/Q scan is unlikely to be helpful in view of her asthma. Therefore a CT pulmonary angiogram would be the imaging procedure of choice in this case, after starting low molecular weight heparin.

168. Regarding the value of lung function tests The peak expiratory flow rate is not dependent on age In a restrictive disease, the flow-volume loop is different in shape to normal A mid-expiratory flow rate between 25% and 75% of expired vital capacity is not indicative of airway obstruction Your answer

They are not needed as a routine in the management of asthma They cannot differentiate between different causes of wheeze The most accurate correlation of the PEFR is with height. In a restrictive pattern, the fv loop is reduced in size but looks similar in shape to normal. A mid-expiratory flow rate (between 25% and 75% of the expired vital capacity) is a good measure of airways obstruction. PEFR readings are an objective measure of airway obstruction and in any child able to do PEFR, it is advisable to do them regularly to assess lung function.

169. A 23-year-old woman who is 34 weeks pregnant is admitted to the emergency department with shortness of breath, cough and wheeze. She is known to have moderate asthma and normally takes fluticasone 750 g salmeterol twice a day and salbutamol as needed. Her peak flow is usually 450. She has been deteriorating over the past 3 days despite increasing her fluticasone and starting 40 mg oral prednisolone daily. She is now unable to speak in sentences, her peak flow is less than 150 l/min and her pulse rate is 130/minute. Saturations are 96% and you hear a widespread wheeze on examination. Her p(O2) is 15 kPa and p(CO2) 4.5 kPa. She has been given highflow oxygen, repeated nebulised salbutamol and Atrovent. Which of the following would you consider to be appropriate next? Liase with the obstetricians regarding emergency section Intravenous aminophylline Your answer Intravenous hydrocortisone Non-invasive ventilation Intubation and ventilation Drug therapy for the pregnant woman should be delivered as for the nonpregnant patient. Saturations should be maintained above 95% with oxygen and close monitoring essential. Intravenous aminophylline is safe, although levels need monitoring, and this would be the next step in the management of this woman. She has had adequate doses of oral steroids, so does not need iv hydrocortisone. It is of paramount importance to stabilise her and an emergency

section would not be in her best interests. She has features of acute severe asthma, but may respond to iv aminophylline and the nebulisers and not require intubation. However, if her blood gases deteriorate, with hypoxia and hypercapnia, or she tires or becomes drowsy, she would need to be transferred to intensive care for intubation and ventilation. There is minimal evidence at present to support the use of non-invasive ventilation in acute asthma (see British Guideline on the Management of Asthma 2003. Thorax,58,Suppl. 1).

170. A 47-year-old man presents to hospital with acute breathlessness. His arterial blood gases show a pa(O2) of 8.5 kPa (65 mmHg) and a pa(CO2) of 5.6 kPa (42.5 mmHg) whilst breathing room air. Which of the following is the least likely explanation for this abnormality? Ventilation/perfusion (VQ) mismatch Right-to-left shunting Hypoventilation Diffusion abnormality Anaemia

Your answer

The Alveolararterial (Aa) oxygen gradient is one way to find the answer to this question, although the clinical history of breathlessness does make hypoventilation seem an unlikely answer. pA(O2) = FiO2 (pa(CO2)/0.8) = 21 (5.6/0.8) = 14 kPa Therefore, Aa gradient = 14 8.5 = 5.5 kPa (42 mmHg), the normal being approximately 0.52.0 kPa (< 15 mmHg). VQ mismatch, diffusion abnormalities and right-to-left shunting all cause widening of the Aa gradient. Hypoventilation causes hypoxaemia with a normal Aa gradient and is therefore the most unlikely explanation in this case.

171. A 62-year-old man presents with flushing and wheezing. A mass is seen on his chest radiograph. You suspect he may have a carcinoid tumour, but which one of the following would be unusual with this diagnosis? Histological appearance similar to that of a small-cell carcinoma Highly vascular appearance Unlikely to be seen at bronchoscopy A low percentage develop carcinoid syndrome

Your answer

90% 5year survival post-surgery Carcinoid tumours make up 1% of all lung tumours and 60% are visible in the bronchial tree. They originate from the APUD cell line. Typically, they are very vascular structures that on bronchoscopy appear as cherry-red balls that tend to bleed easily. Only a small percentage develops carcinoid syndrome (flushing, cramp, diarrhoea and wheezing). Histologically, they may resemble small-cell carcinoma. With surgery the 5-year survival is 90% and 10-year survival is 75%.

172. A 25-year-old male patient with cystic fibrosis is to undergo lung transplantation. Which of the following is NOT true about the lung transplant in this patient? Donor-selection parameters include age under 40 years Donors chest measurements should be slightly smaller than those of the recipient It is essential to match for the ABO blood group Matching for the rhesus blood group compatibility is not essential A single lung transplant is preferred to double lung transplant Your answer

Indications for the treatment are patient under 60 years with life expectancy of less than 18 months. No underlying cancer or serious systemic disease should be present. Donor is matched for the ABO grouping and the rhesus blood group compatibility is not essential. Donor should have good cardiac and lung function and should be under the age of 40. The chest of the donor should be slightly less than the recipient. Double lung transplant is usually performed because of the risk of chronic infection in the remaining lung.

173. A 45-year-old woman known to suffer from systemic lupus erythematosus (SLE) is referred to the chest clinic with a history of worsening dyspnoea. She is on a maintenance dose of 15 mg of prednisolone. She has never smoked, and according to her she developed an unproductive cough and dyspnoea three months ago. There is no history of fever, night sweats or weight loss. Her doctor has tried various types of inhalers with no benefit. A PEFR diary shows no nocturnal dips. A chest X-ray shows a reticulonodular pattern. Examination is unremarkable apart from the skin changes of SLE. What is the most likely diagnosis? Asthma

Bronchiectasis Bronchiolitis obliterans Your answer Tuberculosis Fungal infection

Bronchiolitis obliterans is the term used to describe fibrous scarring of the small airways. It is seen following: toxic-fume inhalation; mineral-dust exposure; viral infection; mycoplasma and legionella infection; bone marrow, heartlung and lung transplantation; rheumatoid arthritis; SLE; and as a side-effect of penicillamine. It presents as a dry cough and dyspnoea. Physical examination is unremarkable. Expiratory wheeze may be audible. The chest X-ray findings can vary from normal to a reticular or reticulonodular pattern. The diagnosis can be confirmed by lung biopsy. Patients rarely respond to steroids. The prognosis is poor.

174. Which one of the following features is MOST accurate regarding Pneumocystis jiroveci pneumonia (PCP)? Occurs exclusively in AIDS Pleural effusion is frequently bilateral Auscultation of the lungs usually reveals no abnormality Your answer Blood culture is positive in one-third of cases Metronidazole is the treatment of choice

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

immunoglobulin G and M, and patients deficient in cellular mediated immunity. The vast majority of adult patients have AIDS, however, it can also occur in those who received chemotherapy for haematological malignant disease or organ transplant. It can also occur in malnourished or premature infants. On examination patients usually show signs of respiratory distress (tachypnoea, dyspnoea). Auscultation of the lung usually reveals no abnormalities. The trophozoite does not enter the blood, the organism is identified in pulmonary secretions obtained by bronchopulmonary lavage or lung biopsy and stained by methenamine silver or Giemsa stain. Pentamidine isethionate or cotrimoxazole is the recommended treatment (metronidazole is not effective in the treatment of PCP).

175. A 20-year-old woman complains of a sudden onset of dyspnoea associated with pleuritic chest pain. Which assessment is the most accurate to confirm your diagnosis of pulmonary embolism? D-Dimer Echocardiography Ventilation/perfusion scan Contrast-enhanced spiral computed tomography Pulmonary angiography

Your answer

Although pulmonary angiography is associated with serious complications in about 1% of patients, it remains the diagnostic reference test for pulmonary embolism. A negative D-dimer test is useful for excluding pulmonary embolism in patients who are clinically thought to be at low risk, but a positive result does not establish the diagnosis. Echocardiography may show right ventricular dilatation and evidence of pulmonary hypertension, which, in the proper clinical setting, may strengthen the clinical impression that a pulmonary embolism has occurred. The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study emphasised the poor predictive value of scans reported as intermediate probability, a common occurrence in routine clinical practice.

176. A 64-year-old mechanic and lifelong smoker noticed haemoptysis a few days after he had a cold. Clinical examination is unremarkable. His chest X-ray shows bilateral hilar enlargement and mediastinal widening. What is the most likely diagnosis? Tuberculosis

Bronchial carcinoma Your answer Lymphoma Hilar metastases Lung abscess The value of the chest X-ray in the diagnosis and management of pulmonary neoplasm needs no emphasis. No initial examination is complete without a lateral film. Coned views of the ribs may help where rib invasion is suspected clinically. However, the finding of a normal X-ray of the chest does not exclude bronchial carcinoma as patients presenting with haemoptysis and a normal chest X-ray are sometimes found to have a central tumour on bronchoscopy. The common appearance of a tumour arising from the main central airways (70% of all cases) is enlargement of one or other hilum. Even experienced observers sometimes have difficulty in deciding whether or not a hilar shadow is enlarged, and if there is any suspicion, investigation by bronchoscopy and/or CT should be pursued. Consolidation and collapse distal to the tumour may have occurred by the time the patient presents, with the tumour itself often being obscured in the process. Collapse of the left lower lobe is often hard to identify, as is a tumour situated behind the heart. Apically located masses or superior sulcus tumours (Pancoast tumours) may be misdiagnosed as pleural caps, and patients often have a long history of pain in the distribution of the brachial nerve roots. Loss of the head of the first, second or third rib is not unusual. The mediastinum may be widened by enlarged nodes. Involvement of the phrenic nerve may lead to paralysis and elevation of the hemidiaphragm, which then moves paradoxically on sniffing. Tumour spreading to the pleura causes effusion, but such an abnormality may be secondary to infection beyond obstruction caused by a central tumour. The ribs and spine should be carefully examined for the presence of metastases. Spread of tumour from mediastinal nodes peripherally along the lymphatics gives the characteristic appearance of lymphangitis carcinomatosa bilateral hilar enlargement with streaky shadows fanning out into the lung fields on either side. Rarely, localised obstructive emphysema may be observed.

177. A 49-year-old man with unexplained cough undergoes bronchoscopy and transbronchial biopsy. Histology shows evidence of neutrophil infiltrate, granulomas are absent. Which is the most likely diagnosis? Histiocytosis X Histoplasmosis ChurgStrauss syndrome Berylliosis Polyarteritis nodosa (PAN)

Your answer

Histiocytosis X (eosinophilic granuloma) is a disease of young adults with widespread nodules in the lungs. Fibrosis appears early and may progress to respiratory failure and death. Histoplasmosis is the commonest fungal infection in North America and has both acute (usually self-limiting) and chronic (those with previous lung disease) forms. Churg Strauss syndrome is characterised by a prodromal phase of asthma, a second phase of tissue and peripheral eosinophilia and a final phase of systemic vasculitis. PAN affects mediumsized arteries (cf small arteries in ChurgStrauss syndrome) and the infiltrate is composed of neutrophils but granulomas are absent. Berylliosis has features similar to sarcoid.

178. A 33-year-old man is found to have strongly positive aspergillus precipitins in his blood and complains of a cough with intermittent bloody sputum. He has a business working as a builder, particularly involved in renovating farm houses and barns. What is the most likely diagnosis? Allergic bronchopulmonary aspergillosis (ABPA) Colonising aspergillosis Invasive aspergillosis Aspergers syndrome Type I hypersensitivity to Aspergillus fumigatus

Your answer

Aspergillus precipitins are IgG antibodies typically found in colonising aspergillosis (aspergilloma), which occurs in areas of damaged lungs, eg cavities. Type I hypersensitivity to Aspergillus fumigatus occurs in ABPA. Invasive aspergillosis occurs in immunocompromised patients. Aspergers syndrome has nothing to do with aspergillus infection. 179. A 36-year-old woman with systemic sclerosis develops breathlessness on exertion. Her pulmonary function tests show normal spirometry but a decreased gas transfer factor (TLCO, transfer factor for carbon monoxide) and transfer coefficient (KCO). Which of the following is the most likely explanation for this abnormality?

Fibrosing alveolitis Pulmonary vascular disease Severe thoracic skin thickening Pleural involvement Respiratory muscle weakness

Your answer

Isolated decreases in gas transfer are typical of pulmonary vascular disease, eg vasculitis, recurrent pulmonary embolism (PE). In fibrosing alveolitis you would also expect to see decreased lung volumes with a restrictive ratio (> 80%) on spirometry. The other three answers would all give a picture of extrapulmonary restriction with a restrictive ratio, low TLCO but normal/high KCO (same cardiac output going through smaller alveolar volume).

180. A 49-year-old homosexual accountant came to the clinic with increased breathlessness. He had began to become wheezy after a tooth extraction procedure 5 months ago and also had an associated troublesome cough. He used to smoke 15 cigarettes per day but gave up smoking about 2 months ago. Salbutamol and beclometasone inhalers poorly controlled his symptoms. Recently he had been unwell: he had had a fever and had lost about 3.2 kg (7 lb.) in weight. There was no history of recent foreign travel and no significant past illness. On examination, he had a temperature of 37.2 C and occasional rhonchi on both sides. Tests showed: Hb 14.6 g/dl, WBC 10.2 109/l (neutrophils 53%, lymphocytes 30%, raised eosinophils noted) , ESR 110 mm in first hour; normal U&E; normal urine dipstick. Chest X-ray showed extensive symmetrical homogenous shadowing affecting all the peripheral lung field. A skin test for inhaled antigens, including Aspergillus fumigatus , was negative. His serum IgE was normal. A serological screen for parasitic infection was negative. Pulmonary function was within normal limits. Oxygen saturations are 97% and there is no desaturation on exerciese. What is the probable diagnosis? Pneumocystis pneumonia Lofflers syndrome Asthma Cryptogenic pulmonary eosinophilia Churg-Strauss Syndrome

Your answer

This patient has eosinophilia and associated definite pulmonary signs. There is no indication of drug involvement or malignancy. Nothing was mentioned about atopy or extrapulmonary involvement in the scenario. ChurgStrauss syndrome is unlikely. The IgE level is normal unlike fungal and parasitic hypersensitivity. Patients may have systemic features of malaise, weight loss, fever and a raised ESR, and about half of them have features of asthma. When the disease is self-limiting and lasts less than a month it is Loefflers syndrome. The disease responds to steroid treatment, which needs to be

continued for about one year. There is no relation to the patients sexual orientation and Pneumocystis jiroveci secondary to HIV is unlikely.

181. After a tennis match, a 20-year-old thin woman complains of left-sided chest pain that radiates into her abdomen. The physical examination reveals reduced air entry at the right base of the lung with hyper-resonant percussion. The abdominal examination shows generalised tenderness. A few minutes later she develops cyanosis. What is the diagnosis? Myocardial infarction Tension pneumothorax Ectopic pregnancy Pulmonary embolism Acute pancreatitis

Your answer

If a tension pneumothorax is present, a cannula of adequate length should be promptly inserted into the second intercostal space in the mid-clavicular line and left in place until a functioning intercostal tube can be positioned. Tension pneumothorax occurs when the intrapleural pressure exceeds the atmospheric pressure throughout inspiration as well as expiration. It is thought to result from the operation of a one-way valve system, drawing air into the pleural space during inspiration and not allowing it out during expiration. The development of tension pneumothorax is often, but not always, heralded by a sudden deterioration in the cardiopulmonary status of the patient related to impaired venous return, reduced cardiac output and hypoxaemia. The development of tension in a pneumothorax is not dependent on the size of the pneumothorax, and the clinical scenario of tension pneumothorax may correlate poorly with chest X-ray findings. The clinical status is striking. The patient rapidly becomes distressed with rapid laboured respiration, cyanosis, sweating and tachycardia. It should be particularly suspected in those on mechanical ventilators or nasal non-invasive ventilation who suddenly deteriorate or develop EMD arrest, and is frequently missed in the ICU setting. If a tension pneumothorax occurs, the patient should be given high-concentration oxygen and a cannula should be introduced into the pleural space, usually in the second anterior intercostal space mid-clavicular line. Air should be removed until the patient is no longer compromised and then an intercostal tube should be inserted into the pleural space as previously described. Advanced Trauma Life Support guidelines recommend the use of a 36 cm long cannula to perform needle thoracocentesis for life-threatening tension pneumothorax. However, in 57% of patients with tension pneumothorax the thickness of the chest wall has been found to be greater than 3 cm. It is therefore recommended that a cannula length of at least 4.5 cm should be used in needle thoracocentesis of tension pneumothoraces. The cannula should be left in place until bubbling is confirmed in the underwater-seal system to confirm proper function of the intercostal tube.

182. A 74-year-old man with previously stable emphysema presents to A&E with rightsided pleuritic chest pain and sudden increase in shortness of breath. There are no other associated symptoms and no signs to suggest acute infection. There appears to be increased resonance over the upper right side of the chest. Which is the most likely diagnosis in this case? An exacerbation of COPD A spontaneous pneumothorax Acute-onset pneumonia Empyema Pulmonary embolism

Your answer

Underlying chronic obstructive pulmonary disease (COPD) is the usual cause of pneumothorax in patients of this age group. The sudden onset of shortness of breath associated with pleuritic chest pain in this case makes pneumothorax more likely than COPD exacerbation. Other, rarer causes of pneumothorax include asthma, underlying carcinoma, lung abscess and severe pulmonary fibrosis with cyst formation. If possible, pneumothoraces occurring in relation to COPD should be managed conservatively or with needle air-aspiration depending on their size. Formal chest drain may be required where the size is > 50% or there is significant respiratory compromise. Unfortunately, they tend to be recurrent when linked to emphysema.

183. A 26-year-old woman arrives in the UK from Australia. A few days later she presents to hospital with pleuritic chest pain and breathlessness. She is not on the oral contraceptive pill and has no family or personal history of DVT/PE. A pulmonary embolus is confirmed radiologically and she is commenced on warfarin. How long would you continue warfarin therapy in these circumstances? 46 weeks 3 months 6 months 1 year Lifelong Your answer

This young womans only risk factor given is the long-haul flight, which is only a temporary risk factor. The standard duration of anticoagulation is: 46 weeks for temporary risk factors; 3 months for first idiopathic; at least 6 months for other. The risk of bleeding needs to be balanced against the risk of further emboli.

184. A 36-year-old lorry driver who smokes heavily presents with a 2-day history of cough associated with fever. He also complains of right-sided chest pain on inspiration. On examination he is slightly cyanosed. His temperature is 38 C, respiratory rate 38/min, BP 100/70 mmHg and pulse 130/min. He has basal crepitations and dullness to percussion at the right lung base. What is the most important next step in confirming the diagnosis? ESR (Erythrocyte sedimentation rate)
D-Dimer

Chest X-ray Your answer Sputum sample Blood cultures

The classic presentation of pneumonia is of a cough and fever with the variable presence of sputum production, dyspnoea and pleurisy. Most patients have constitutional symptoms such as malaise, fatigue and asthenia, and many also have gastrointestinal symptoms. Examination of the lung might reveal decreased vesicular breath sounds, localised foci of crepitations, dullness to percussion and sometimes a bronchial wheeze. The chest X-ray is a pivotal test for the confirmation of pneumonia.

185. Which one of the following features is MOST characteristic of cystic fibrosis? Inherited as autosomal dominant Pancreatic insufficiency is almost always identified in adult patients In patients with recurrent chest infections Pseudomonas cepacia is the most frequent organism isolated from sputum Family members who carry the gene are at risk of developing mild recurrent bronchitis Patients typically have reduced levels of sodium and chloride in the sweat Your answer

Cystic fibrosis (CF) is an autosomal recessive disease affecting both eccrine and exocrine gland function, characterised by elevated levels of sodium and chloride in the sweat. It is caused by abnormal viscid secretions from mucous glands leading to chronic pulmonary disease and pancreatic insufficiency, which will be evident in more than 95% of adult cases. Recurrent chest infections are usually caused by Pseudomonas aeruginosa and Staphylococcus aureus. Pseudomonas cepacia occurs in 510% of cases. The carrier rate is 5% in the Caucasian population, heterozygotes are clinically normal.

186. A 26-year-old, previously healthy, naval officer is admitted to the hospital with a sudden-onset, left-sided chest pain. A chest X-ray confirms a small leftsided pneumothorax. The patient is not breathless and his oxygen saturation on air is 95%. He smokes 1015 cigarettes a day. Which of the following statements is true? Simple aspiration is the first-line treatment if the patient is symptomatic If admitted for observation, he does not need oxygen Once the pneumothorax has resolved he can go back to work, including resuming his diving duties Smoking cessation has no role in management, apart from in the prevention of COPD in later life He should be treated with a small (1014 F)-sized chest drain Your answer

A small pneumothorax in a person with no previous chest disease should be aspirated if the patient is breathless. A pneumothorax can be classed as small or large depending on the presence of a visible rim of < 2 cm or 2 cm between the lung margin and the chest wall. Ideally, an asymptomatic patient with a small, primary spontaneous pneumothorax can be discharged with the advice to return if he becomes symptomatic. If a patient is admitted for observation, high-flow oxygen increases the absorption of air from the pleural cavity. Smoking increases the chances of a

recurrence. Diving is contraindicated unless the patient has undergone pleurectomy.

187. A young adult was referred because of cough and shortness of breath. An extrinsic allergic alveolitis was diagnosed. Beside reduction of exposure to the allergen, which other therapy is most likely to be successful? Antibiotics Non-steroidal anti-inflammatory drugs Immunoglobulins Corticosteroids Desensitisation

Your answer

Management of the patient centres on reducing any further exposure to a minimum, but first the diagnosis must be secure. Desensitisation has no beneficial effect. Ideally, affected individuals change their relevant working, domestic and recreational environment completely, but this may mean a profound loss of income or great expense, and is often unrealistic. Nor is it fully justified on purely medical grounds since continued exposure does not inevitably lead to progressive disease. Affected individuals who continue to work in the occupation responsible for their disease can often reduce their exposure substantially by changing the pattern of their particular duties. An alternative is to use industrial respirators, which filter out 9899% of respirable dust from the ambient air. These are especially valuable when exposures are intermittent and short, but they may be uncomfortably hot when worn for long periods or when there is heavy work, and so compliance with their use may be poor. Whatever course is followed, continuing exposure should be accompanied by regular medical surveillance. If there is no progression, it is reasonable for some exposure to continue. When there is progressive disease, exposure should cease. This may involve a loss of earnings, and may entitle the affected worker to compensation. Occasionally, individuals with progressive disease may refuse to change their occupation or hobby, and their physician must weigh the possible advantages of longterm corticosteroid therapy against the risks.

188. Which of the following conditions is most likely to be associated with a decreased DLCO? Polycythaemia Anaemia Pulmonary embolism Exercise

Your answer

Acute poliomyelitis DLCO, the diffusion capacity in the lung for carbon monoxide, is decreased in any condition that reduces the effective alveolar surface area or affects the alveolar membrane. Examples include pulmonary embolism and emphysema in which the alveolar surface area is reduced.

189. A 73-year-old woman presents with weight loss and a chronic cough. Her husband has noticed that her pupil is constricted and her right eyelid is drooping. She has had pain in her right shoulder for some months, which her GP has described as 'probable rheumatism'. Unfortunately her chest x-ray reveals a mass in the right lung apex with possible lymphadenopathy at the right hilum. What is the most likely diagnosis in this case? Eaton-Lambert Syndrome Horners syndrome caused by Pancoasts tumour Small-cell carcinoma Tuberculosis Aspergilloma

Your answer

Eaton-Lambert syndrome is a paraneoplastic syndrome associated with proximal myopathy, related to a deficient action of cholinergic neurones. Horners syndrome is caused by an apical lung tumour, which leads to spinal cord damage between spinal levels C8 and T1. Symptoms are pupil constriction, ptosis and facial anhydrosis. Pancoasts tumours are mostly squamous or adenocarcinomas, only 3-5% are said to be due to small cell tumours, this is because small-cell carcinoma of the bronchus is more likely to occur centrally and so wouldnt be expected to present like this. It is associated with SIADH in 510% of cases.

190. A 60-year-old hairdresser complains that, after an attack of flu last year, she has been more breathless than usual when taking her evening walk, and has also felt short of breath when climbing the stairs. She has become concerned that she has a cardiac problem. She has lost about 6.4 kg (14 lbs) during the last year. She has smoked 20 cigarettes per day for 45 years but does not drink alcohol. Other than an occasional paracetamol for her headache, she is on no regular medication. On examination she was apyrexic and had bilateral clubbing. No lymphadenopathy was seen. Her JVP was not raised and heart sounds were normal. Bibasal inspiratory crepts were audible. No pedal oedema was seen. Bilateral reticular shadowing, mostly on the bases, was seen on chest X-ray. Routine bloods were normal, except for an ESR of 35 mm in the first hour. Her HRCT showed peripheral reticular ground-glass opacification, best seen in the basal region. Respiratory

function test showed restrictive ventilatory defect. Bronchoalveolar lavage showed an increased number of cells neutrophils and macrophages but no malignant cells. An open-lung biopsy showed an exudate of intra-alveolar macrophages with patchy interstitial fibrosis. What is the likely diagnosis? Cryptogenic fibrosing alveolitis Extrinsic alveolitis Lymphangitis carcinomatosis Chronic left heart failure Sarcoidosis Your answer

Cryptogenic fibrosing alveolitis is the group of disease consisting of interstitial pneumonia with differing amounts of cellularity and fibrosis. Patients with desquamative histology have a favourable response to treatment with prednisolone. All other causes should be excluded before diagnosing cryptogenic fibrosing alveolitis. Median survival time is approximately 5 years. Azathioprine or cyclophosphamide may be added to the treatment and a single lung transplant may be offered.

191. In which of the following emergency medical presentations is non-invasive ventilation an established treatment? Tension pneumothorax Acute asthma Acute exacerbation of COPD ARDS Pulmonary oedema

Your answer

Non-invasive ventilation (NIV) is currently being evaluated in an number of emergency situations. The best evidence relates to exacerbations of chronic obstructive pulmonary disease (COPD). In particular, this type of therapy is effective in patients with decompensated type-2 respiratory failure. Physiological responses (heart and respiratory rate, and arterial blood gases) improve more quickly with NIV in these patients compared to standard treatment. Intubation is also less frequently required.

192. An arterial blood sample from a 48-year-old male patient with progressive dyspnoea has an oxygen tension of 8.5 kPa (11.3-12.6), and a carbon dioxide tension of 8.5kPa (4.76.0). Given these blood gas results, what is the most likely diagnosis? Pulmonary embolus Aspirin overdose

Ankylosing spondylitis Viral pneumonitis Lobar pneumonia

Your answer

This is type II respiratory failure. pa(CO2) rises due to hypoventilation and this can occur acutely due to drug overdose or more chronically with gross obesity, kyphoscoliosis (and similar musculoskeletal disorders) and end-stage muscle, neurological and airways disorders. Lobar pneumonia causes hypoxia but a normal/low pa(CO2) (type I respiratory failure) unless exhaustion supervenes when the patient may start to retain carbon dioxide.

193.A 58-year-old memorial stonemason presents to the chest clinic. Over the past few years he has noted a gradual increase in shortness of breath, with cough and occasional wheeze. He is a non-smoker and has no other past history of note. His chest X-ray is abnormal with small rounded opacities and irregular upper zone fibrosis. There is hilar lymphadenopathy with eggshell calcification. Pulmonary function testing reveals a restrictive picture and there is mild hypoxia. Which diagnosis best fits with this clinical picture? Silicosis Asthma Idiopathic pulmonary fibrosis Tuberculosis Byssinosis Your answer

This mans job is likely to have exposed him to silica dust, and unfortunately he is suffering from silicosis. Silicosis is characterised by shortness of breath, wheeze and cough with lung function tests and chest X-ray suggestive of irregular fibrosis. Pathogenesis is related to activation of alveolar macrophages via ingestion of silica dust, releasing a number of proteolytic enzymes and inflammatory cytokines. Chronic silicosis may not progress, but accelerated forms and continued exposure are associated with respiratory failure over a few years. Management involves removal of exposure, screening for and treatment of tuberculosis if found in association and supportive measures such as bronchodilators and oxygen therapy.

194. Which of the following is not a common symptom of lung cancer on presentation? Cough Chest pain Cough and chest pain Coughing blood

Shortness of breath

Your answer

Cough is the commonest symptom (about 41% of patients) at presentation, followed by chest pain in 22% of patients who have later been diagnosed to have lung carcinoma. About 15% of patients present with both cough and chest pain. Only 7% of patients present with the symptom of coughing up blood. In less than 5% of cases they present with other symptoms: shortness of breath, hoarseness, weight loss, malaise and distant spread. 195. A 36-year-old woman is under follow up for recurrent pulmonary thrombo-embolic disease. Which of the following features is she most likely to have? Quiet P2 Matched ventilation perfusion defect Paroxysmal dyspnoea Increased transfer factor Widening of the alveolararterial (Aa) gradient on exercise

Your answer

Recurrent pulmonary emboli (PE) should always be considered in cases of progressive SOB with no obvious cause. Possible clues include pulmonary hypertension, right ventricular enlargement, hypoxia with a low pa(CO2) and a low transfer factor. Widening of the lveolararterial (Aa) gradient on exercise is likely to be found. Mismatched defects are classical of PE.

196. Which of the following is a poor prognostic factor in patients suffering from pneumonia? White cell count (WCC) 17 109/l Blood pressure 110/70mmHg Respiratory rate 35/min Rigors Temperature 39C

Your answer

The following are poor prognostic factors in patient with pneumonia:

confusion: abbreviated mental test score of 8 or less urea greater than 7 mmol/l respiratory rate greater than 30/min blood pressure: systolic less than 90 mmHg and/or diastolic less than 60mmHg.

197. A 65-year-old man known to have COPD presented with progressive respiratory failure. He was treated in ITU with mechanical ventilation and improved. After extubation he was transferred to the ward. On the second day on the ward, his temperature spiked and he developed a productive cough with a yellow-greenish sputum. Blood results showed leucocytosis. A chest X-ray revealed a right-sided middle and lower lobe pneumonia. What is the most probable cause of his pneumonia? Pneumococcal pneumonia Aspiration pneumonia Pseudomonas pneumonia Staphylococcal pneumonia Haemophilus pneumonia

Your answer

Pseudomonas is a common pathogen in patients with bronchiectasis and cystic fibrosis. It also causes hospital-acquired infections, particularly on the ITU or after surgery. Nosocomial or hospital-acquired infections should be suspected in patients with an onset of symptoms at least 48 hours after admission to the hospital. The sputum colour also gives a clue to the most likely diagnosis. Treatment is with anti-pseudomonal penicillin, ceftazidime, meropenem or ciprofloxacin.

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

Refer to the palliative care team This is a man with potentially operable non-small-cell lung cancer. He has enlarged hilar nodes, but these could be removed with pneumonectomy, but he also has enlarged mediastinal nodes, which if they were cancerous, would make the cancer resection non-curative. However CT is not great at assessing whether enlarged nodes are inflammatory or malignant. He therefore needs further assessment of his mediastinal nodes prior to surgery, and this can be done with mediastinoscopy or a positron-emission tomography (PET) scan. In a PET scan, radiolabelled glucose is injected peripherally and is taken up by metabolically active tissues, such as the brain and any cancer. It would show metastases from the primary cancer. If his cancer is inoperable, palliative radiotherapy can be given to the mass, to try and control the haemoptysis. Chemotherapy could also be considered. Palliative care team referral would be appropriate if he does not want interventions or has troublesome symptoms.

199. Which of the following is the best predictor for obstructive sleep apnoea? Neck size Your answer Chest size Abdominal girth Waist to hip ratio Uvulopalatal distance

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

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

200. What are the indications for home oxygen? Low forced expiratory colume in 1 s (FEV1) Low p(CO2) Cor pulmonale Low p(O2) Ischaemic heart disease

Your answer

The National Institute for Clinical Excellence (NICE) states that the following are indications for considering long-term oxygen therapy (LTOT): patients with a pa(O2) of less than 7.3 kPa when stable, or pa(O2) of 7.38.0 kPa when stable and also an additional risk feature like secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema or pulmonary hypertension. Oxygen should be used for at least 15 h a day.