Disorders of the pleura and mediastinum, including pneumothorax Flashcards
Which nerve innervates the mediastinal parietal pleura?
A) Phrenic nerve
B) Intercostal nerve
C) Vagus nerve
D) Hypoglossal nerve
E) Pulmonary plexus
Phrenic nerve
Phrenic nerve provides mediastinal parietal sensory innervation
Intercostal nerve provides costal parietal pleura sensory innervation
You review a 86 year old male with a CFS of 7 with a right sided pleural infection after being admitted for an Ischaemic stroke. His stroke was treated with high dose aspirin only. He had a chest drain inserted the day before which initially drained 800mls. Repeat CXR and Subsequent Pleural US shows a heavily loculated effusion.
What is the next appropriate management?
A) refer for VATS
B) tPa and DNAase Via chest drain
C) Saline Irrigation (250mls TDS)
D) Streptokinase Via chest drain
E) Remove chest drain and insert another one
Saline Irrigation (250mls TDS)
Patient too frail for surgery
Fibrinolytics contraindicated in recent stroke
Streptokinase should not be considered for treatment of pleural infection.
Saline irrigation can be considered for the treatment of pleural infection when intrapleural TPA and DNase therapy or surgery is not suitable.
You see a 67 female with a left sided pleural effusion in the context of infective symptoms. The initial pleural aspiration shows a pH of 7.29. You are awaiting for the rest of the biochemistry.
Which biochemical results will make you strongly consider putting a chest drain in?
A) Protein >45
B) LDH >900
C) Glucose <4
D) Albumin >15
E) ADA > 35
LDH >900
If pleural fluid pH is >7.2 and <7.4, this implies an intermediate risk of CPPE or pleural infection. Pleural
fluid LDH should be measured and if >900 IU/L ICD should be considered, especially if other clinical parameters support CPPE (specifically ongoing
temperature, high pleural fluid volume, low pleural fluid glucose (72 mg/dL ≤4.0 mmol/L), pleural contrast enhancement on CT or septation on ultrasound.
Which of these anti-epileptic medications is associated with a eosinophilic effusion?
A) Levetiracetam
B) Lamotrigine
C) Phenytoin
D) Sodium Valproate
E) Carbamazepine
Sodium Valproate
Sodium valproate can cause an eosinophilic pleural effusion as a side effect. It may also cause peripheral blood eosinophilia
What is a positive triglyceride level in pleural fluid to confirm chylothorax?
A) >50mg/dL
B) >80mg/dL
C) >90mg/dL
D) >100mg/dL
E) >110mg/dL
> 110mg/dL
Chylothorax:
* Triglycerides – high>1.24mmol/L (110mg/dL)
* Cholesterol – low
* Cholesterol crystals – absent
* Chylomicrons – usually present
You review a patient in pleural clinic after a recent pneumothorax. She has complete resolution of her pneumothorax on todays CXR.
When is she safe to fly on a plane
A) Today
B) 24hours
C) 7 days
D) 14 days
E) 28 days
7 days
In those with resolved pneumothorax confirmed radiologically (ie, at least CXR), patients can fly 7 days after the X-ray demonstrates full resolution (the rationale for waiting 7 days is to exclude early recurrence).
Which of these is a posterior mediastinal lesion?
A) Thymoma
B) Schwannoma
C) Lymphoma
D) Teratoma
E) Thyroid Goitre
Schwannoma
Most masses in the posterior mediastinum are neurogenic in nature. These can arise from the sympathetic ganglia (eg neuroblastoma) or from the nerve roots (eg schwannoma or neurofibroma).
Histology showing Antoni A and B regions are typically associated with schwannomas
In Pleural effusion related to peritoneal dialysis, which of these characteristics is most common?
A) Low pH, High protein
B) High pH, Low Protein
C) High glucose, Low protein
D) Low glucose, High Protein
E) High Creatinine, Low Protein
High glucose, Low protein
The typical characteristic of this type of effusion is high glucose and it is transudative in nature.
Which of these is most correct regarding pseudochlothorax effusion?
A) Turbid, Cholesterol high (>200mg/dl), Triglyceride low, separates after centrifugation
B) Turbid, Cholesterol low, Triglyceride high (>110mg/dl), separates after centrifugation
C) Turbid, Cholesterol low, Triglyceride high (>110mg/dl), does not separate after centrifugation
D) Turbid, Cholesterol high (>200mg/dl), Triglyceride low, does not separate after centrifugation
E) Non - Turbid, Cholesterol low, Triglyceride low, does not separate after centrifugation
Turbid, Cholesterol high (>200mg/dl), Triglyceride low, does not separate after centrifugation
Pseudochylothorax:
* Triglycerides – low
* Cholesterol – high>5.18mmol/L (200mg/dL)
* Cholesterol crystals – often present
* Chylomicrons – absent
Causes of Pseudochylothorax:
* Tuberculosis
* Rheumatoid arthritis
What is the drainage capacity of the pleural space?
A) 10 -20mls
B) 50 - 100mls
C) 100 - 250mls
D) 250 - 1000mls
E) 1000 - 2000mls
E) 1000mls - 2000mls
Which of the RAPID score has the highest score for mortality?
A) Serum Urea
B) Age
C) Presence of Pus
D) Infection source
E) Serum Albumin
A) Serum Urea
&
B) Age
Serum Urea and Age both have a max score of 2 whereas the others have a max score of 1
