PM Quiz Questions

Question 1

Which type hypersensitivity is asthma associated with?

Answer 1

Asthma is associated with type 1 hypersensitivity.

Question 2

Legionella pneumophilia should be suspected where multiple people contract pneumonia in an air conditioned space.

Answer 2

Legionella pneumophilia should be suspected where multiple people contract pneumonia in an air conditioned space.

Question 3

What pathogen is responsible for the majority of cases of bronchiolitis?

Answer 3

Respiratory syncytial virus

Question 4

Emphysema summary:

Answer 4

The residual volume is the volume of air left in the lungs after full expiration (in other words, what is left in the lungs at the end of testing the vital capacity). Emphysema is a form of chronic obstructive airways disease in which damage to the alveolar walls causes many alveoli to fuse forming large air sacks called bullae.

In emphysema there is loss of compliance in the lungs so on breathing out they do not fully spring back to normal and air becomes trapped in the bullae causing an increase in the residual volume. This loss of elasticity means that the total volume that can be blown out becomes reduced and there is a corresponding reduction in vital capacity.

Question 5

Respiratory centres of the brain:

Medulla

Apneustic

Pneumotaxic

Answer 5

Question 6

What appears on chest x-ray in someone with COPD?

Answer 6

Patients with COPD typically have a flattened diaphragm on CXR.

Question 7

Presentation of bronchiolitis:

Answer 7

This is a classic presentation of bronchiolitis: coryzal symptoms and increased work of breathing causing feeding difficulty in a child <1 year. Respiratory syncytial virus is the most common cause of bronchiolitis.

Question 8

What is the most common cause of croup?

Answer 8

Parainfluenza virus is the most common cause of croup.

Question 9

Trismus (difficulty opening the mouth) is a feature of peritonsillar abscess (quinsy).

Answer 9

Trismus (difficulty opening the mouth) is a feature of peritonsillar abscess (quinsy).

Question 10

Sarcoidosis is associated with increased concentrations of what enzyme?

Answer 10

Elevated angiotensin-converting enzyme levels are associated with sarcoidosis.

Question 11

‘Red-currant jelly’ sputum is a feature of what pathogenic pneumonia?

Answer 11

‘Red-currant jelly’ sputum is a feature of Klebsiella pneumoniae

Question 12

A 70-year-old man is admitted to the respiratory ward following an infective exacerbation of his chronic obstructive pulmonary disease (COPD). He is being treated with amoxicillin and prednisolone. This is his fourth exacerbation and second hospital admission in the last 12 months. He has previously given up smoking 10 years ago after receiving his diagnosis and has attended pulmonary rehabilitation courses which have offered minimal improvement to his symptoms.

Which antibiotic can be started as prophylaxis for this patient?

Answer 12

Azithromycin prophylaxis is recommended in COPD patients who meet certain criteria and who continue to have exacerbations.

Question 13

A 45-year-old woman presents to the GP with a new rash on her face. On examination, there is a raised purple lesion covering the nose, cheeks and lips. At first, this was diagnosed as rosacea however it has rapidly progressed. The GP also notes axillary and inguinal lymphadenopathy. On further questioning, she notes some fatigue as well as some dyspnoea over the last 6 months. She has smoked 10 cigarettes a day for the last 8 months and drinks 10 units of alcohol a week.

What is the likely diagnosis?

Answer 13

Sarcoidosis - Facial rash plus lymphadenopathy think sarcoidosis.

Question 14

Mesothelioma

Answer 14

Mesothelioma is a malignant tumor that is caused by inhaled asbestos fibers and forms in the lining of the lungs, abdomen or heart. Symptoms can include shortness of breath and chest pain. The life expectancy for most mesothelioma patients is approximately 12 months after diagnosis.

Question 15

Transudate vs Exudate pleural effusions

Answer 15

Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.

Transudate (< 30g/L protein)

• heart failure (most common transudate cause)
• hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
• hypothyroidism
• Meigs’ syndrome

Exudate (> 30g/L protein)

• infection: pneumonia (most common exudate cause), TB, subphrenic abscess
• connective tissue disease: RA, SLE
• neoplasia: lung cancer, mesothelioma, metastases
• pancreatitis
• pulmonary embolism
• Dressler’s syndrome
• yellow nail syndrome

Question 16

A 64-year-old woman presents to ED with productive cough, haemoptysis, and vague abdominal pain for the past 2 weeks. She has no past medical history of note. Chest X-ray shows multiple large, round, well-circumscribed masses in both lungs.

What is the most likely underlying diagnosis?

Answer 16

Renal cell carcinoma can metastasise to the lungs, causing ‘cannonball metastases’.

The multiple large, round, well-circumscribed masses in both lungs seen on Chest X-ray here are a characteristic description for ‘cannonball metastases’. Metastases with this appearance are often due to renal cell carcinoma, although they can also be seen with other malignancies such as choriocarcinoma or endometrial cancer.

Question 17

What is Kartagener’s syndrome?

Answer 17

Kartagener’s syndrome is a rare, autosomal recessive genetic ciliary disorder comprising the triad of situs inversus, chronic sinusitis, and bronchiectasis. The basic problem lies in the defective movement of cilia, leading to recurrent chest infections, ear/nose/throat symptoms, and infertility.

Question 18

What is the cardinal triad of Meig’s syndrome?

Answer 18

Meig’s syndrome: Benign ovarian tumour, ascites, and pleural effusion.

Question 19

What is the most common cause of an exudative pleural effusion?

Answer 19

Pneumonia is the most common cause of an exudative pleural effusion.

Question 20

What is meant by an exudative pleural effusion?

Answer 20

>30g of protein in the pleural effusion

Note: Transudate = <30g of protein

Question 21

Causes of a transudate pleural effusion:

Answer 21

Transudate (< 30g/L protein)

• heart failure (most common transudate cause)
• hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
• hypothyroidism
• Meigs’ syndrome

Question 22

Causes of an exudate pleural effusion:

Answer 22

Exudate (> 30g/L protein)

• infection: pneumonia (most common exudate cause), TB, subphrenic abscess
• connective tissue disease: RA, SLE
• neoplasia: lung cancer, mesothelioma, metastases
• pancreatitis
• pulmonary embolism
• Dressler’s syndrome
• yellow nail syndrome

Question 23

Oscar is a 59-year-old man who presents to his general practitioner with a 4-month history of a persistent cough, dyspnoea, unintentional weight loss of 4kg and anorexia. Oscar has no significant past medical history and has never been admitted to hospital. He is a lifelong non-smoker and works as a receptionist.

On examination, his observations are blood pressure 125/90mmHg, respiratory rate 14/minute, heart rate 85/minute, afebrile and oxygen saturation 94% on room air. There is notable bilateral gynaecomastia with watery nipple discharge, hypertrophic pulmonary osteoarthropathy and supraclavicular lymphadenopathy.

Given the likely diagnosis of lung carcinoma, which is the most likely type given the history and examination findings?

Answer 23

Gynaecomastia - associated with adenocarcinoma of the lung.

Question 24

In patients suffering with severe asthma what is the order in which you escalate treatment?

Answer 24

The SIGN guidelines give clear instructions on how to escalate care.

1. Oxygen
2. Salbutamol nebulisers
3. Ipratropium bromide nebulisers
4. Hydrocortisone IV OR Oral Prednisolone
5. Magnesium Sulfate IV
6. Aminophylline/ IV salbutamol

Question 25

In sarcoidosis what are the indications for corticosteroid treatment?

Answer 25

Indications are PUNCH - Parenchymal Lung Disease - Uveitis - Neurological involvement or - Cardiac involvement - HyperCa

Question 26

A 76-year-old man presented with dyspnoea, mild haemoptysis, decreased appetite and his clothing looks loose. His past medical history includes atrial fibrillation, ischaemic heart disease, hypertension. He used to work as a heating engineer fixing boilers and is a smoker. What is the likely diagnosis?

Answer 26

The history of dyspnoea with haemoptysis and weight loss suggests the most likely diagnosis is malignancy. Given the history of fixing boilers and the unilateral pleural effusion, a very likely diagnosis is mesothelioma.

Question 27

What are the features of small cell lung cancer?

Answer 27

Small Cell Lung Cancer * usually central * arise from APUD\* cells * associated with ectopic ADH, ACTH secretion * ADH → hyponatraemia * ACTH → Cushing's syndrome * ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis * Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome

Question 28

Upper zone pulmonary fibrosis is typically caused by what?

Answer 28

Tuberculosis typically causes upper zone pulmonary fibrosis.

Question 29

Sudden deterioration upon ventilation is suggestive of what?

Answer 29

Tension pneumothorax.

Question 30

Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome (Kartagener's syndrome)

Answer 30

Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome (Kartagener's syndrome)

Question 31

A 40-year-old female presents with painful, red bumps over her shins. Her GP suspects erythema nodosum. On further questioning she admits to having a non-productive cough and some recent joint pains. The GP requests a chest x-ray, which shows bilateral hilar lymphadenopathy. What's the diagnosis?

Answer 31

Sarcoidosis The likely diagnosis here is sarcoidosis, given by the presence of erythema nodosum, a non-productive cough, arthralgia and bilateral hilar lymphadenopathy on chest x-ray. Sarcoidosis is known to cause hypercalcaemia due to macrophages inside the granulomas causing an increased conversion of vitamin D to its active form.

Question 32

Obstructive vs Restrictive Lung Conditions ## Footnote **HIGH YIELD**

Answer 32

Ø Obstructive → Causes • Asthma, COPD, bronchiectasis, cystic fibrosis → Results • ↓↓↓↓↓ FEV1, ↓ FVC, ↓ FEV1/FVC ratio of\<70% • Reversibility after bronchodilators is seen in asthma Ø Restrictive → Causes • Idiopathic pulmonary fibrosis, pneumoconiosis • Extrinsic restrictive (restrictive due to out of lung) - anka sp, scoliosis → Results • ↓ FEV1, ↓↓↓↓↓ FVC, ↑ FEV1/FVC ratio of\>70%

Question 33

Small cell lung carcinoma secreting ACTH can cause Cushing's syndrome

Answer 33

Small cell lung carcinoma secreting ACTH can cause Cushing's syndrome

Question 34

Adult with asthma not controlled by a SABA - add a low-dose ICS (then you add LABA)

Answer 34

Adult with asthma not controlled by a SABA - add a low-dose ICS (then you add LABA)

Question 35

Connective tissue disorders e.g. systemic lupus erythematosus can cause exudative pleural effusion

Answer 35

Connective tissue disorders e.g. systemic lupus erythematosus can cause exudative pleural effusion

Question 36

What is the treatment for patients having a severe asthma attack?

Answer 36

Nebulised salbutamol, nebulised ipatropium bromide, oral prednisolone. According to the British Thoracic Society (BTS), as a baseline all patients presenting with severe or life-threatening asthma should be given a nebulised short acting β2 agonist (e.g. salbutamol), a corticosteroid - either oral or IV, and nebulised ipratropium bromide. For milder exacerbations ipratropium bromide is not required as a first line agent but may be considered if the patient does not respond to initial therapy.

Question 37

ABG interpretation ROME

Answer 37

Respiratory = Opposite ## Footnote low pH + high PaCO2 i.e. acidosis, or high pH + low PaCO2 i.e. alkalosis Metabolic = Equal low pH + low bicarbonate i.e. acidosis, or high pH + high bicarbonate i.e. akalosis

Question 38

What is the CURB65 score and what is it used for?

Answer 38

The CURB-65 calculator can be used in the emergency department setting to risk stratify a patient's community acquired pneumonia.

Question 39

A 55-year-old man is seen in the respiratory clinic. He describes progressively worse shortness of breath, that is worse when walking, and a dry cough. On examination he has bibasal crackles and there is evidence of finger clubbing. Spirometry is done, which shows a clearly restrictive pattern. He is previously fit and well, and has worked as a gardener all his life. What is the diagnosis and what is best investigation for your most likely diagnosis?

Answer 39

Idiopathic pulmonary fibrosis - high resolution CT is the investigation of choice. This is a typical history of idiopathic pulmonary fibrosis- a man 50-70, progressive exertional dyspnoea, dry cough, finger clubbing, bilateral basal crackles, and a restrictive lung pattern. A chest x-ray will show interstitial shadowing, and a high resolution CT will show 'honeycomb' lungs.

Question 40

What are the landmarks for a chest drain insertion?

Answer 40

The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi.

Question 41

What are the features of COPD on chest x-ray?

Answer 41

* hyperinflation * flattened hemidiaphragms * hyperlucent lung fields Chronic obstructive pulmonary disease requires spirometry to confirm the diagnosis but a chest x-ray can be highly suggestive.

Question 42

A 55-year-old man is admitted to the wards with acute pancreatitis for which he is receiving supportive care and prophylactic dalteparin injections. He becomes breathless on day 3 of his stay. A chest X-ray is performed which shows bilateral alveolar shadowing with a normal cardiothoracic index. His observations are taken, and while his temperature is found to be 36.5ºC his respiratory rate is 24/min. Given this man's presentation what is the most likely diagnosis?

Answer 42

Acute respiratory distress syndrome Acute respiratory distress syndrome is a complication of acute pancreatitis.

Question 43

How do you identify type 1 vs type 2 respiratory failure from an ABG?

Answer 43

Type 1 respiratory failure: Low pO2, no CO2 retention Type 2 respiratory failure: Low pO2, high pCO2

Question 44

COPD symptoms in a young person - think what?

Answer 44

COPD symptoms in a young person - think alpha-1 antitrypsin (A1AT) deficiency

Question 45

What should patients who have pneumonia and are diagnosed with COPD be given in addition to antibiotics?

Answer 45

Patients diagnosed with pneumonia who have COPD should be given corticosteroids even if no evidence of the COPD being exacerbated.

Question 46

What are the indications for corticosteroid treatment for sarcoidosis?

Answer 46

Indications for corticosteroid treatment for sarcoidosis are: parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement.

Question 47

How can you differentiate a tension pneumothorax from a simple pneumothorax?

Answer 47

You can help to differentiate a tension pneumothorax from a simple pneumothorax due to the deviated trachea and the systemic features such as low blood pressure and worsening shortness of breath.

Question 48

PUNCH

Answer 48

Indications for sarcoidosis treatment with corticosteroids: **P**arenchymal lung disease **U**veitis **N**eurological involvement **C**ardiac involvement **H**ypercalcemia

Question 49

RISK FACTORS: SOME OCCUPATIONAL CAUSES OF LUNG DISEASE

Answer 49

Question 50

Prophylaxis for COPD?

Answer 50

Azithromycin is the standard antibiotic prophylaxis in patients with COPD. According to the most recent NICE guidelines, you should consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they do not smoke, have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and experience frequent (typically 4 or more per year) exacerbations with sputum production.

Question 51

On aspiration of a pleural effusion what features would suggest an empyema. pH of... Glucose high/low LDH high/low

Answer 51

Empyema: Turbid effusion with pH\<7.2, Low glucose, High LDH

Question 52

Important drug side effects:

Answer 52

Infliximab - reactivation of TB, HBV, and demyelinating disease. Hydroxychloroquine - Corneal deposits and retinopathy. Sulphasalazine - oligospermia, rash, folate deficiency and megaloblastic/ Heinz body anaemia. Azothiaprine - Skin cancer (SCC), lymphoma, gout. Methotrexate - Myelosuppression, ILD/ pneumonitis and liver toxicity.

Question 53

WHatis the next important investigation following this chest x-ray?

Answer 53

CT Abdomen The chest x-ray shows cannonball metastases which are most commonly caused by renal cell cancer. A CT abdomen is the most appropriate test to investigate this possibility. Other tests should of course be considered including a prostate specific antigen.

Question 54

Interpreting FEV1/FVC ratio

Answer 54

FEV1/FVC: The FEV1/FVC of a normal healthy lung is 70-80%. A result of 65% indicates that this condition is an obstructive lung condition, which narrows the options down to asthma or emphysema. You would expect a raised FEV1/FVC with pulmonary fibrosis and pulmonary oedema. A left to right cardiac shunt does not affect lung compliance and hence you would expect a normal FEV1/FVC with this.

Question 55

What is meant by TLCO (total gas transfer)

Answer 55

The total gas transfer (TLCO) is an overall measure of gas transfer for the lungs from the alveoli into the capillaries and reflects how much oxygen is taken up into the red cells. You would only expect to find a raised TLCO in asthma or a left-to-right cardiac shunt. This is because in these conditions, the problem is not affecting the alveoli directly or gas exchange and so the lungs try to compensate for the problem by improving gas exchange.

Question 56

What are causes of a raised TLCO?

Answer 56

Causes of a raised TLCO ## Footnote asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise

Question 57

What are causes of a low TLCO?

Answer 57

Causes of a lower TLCO ## Footnote pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output

Question 58

Interpretting ABG's

Answer 58

**ROME** Respiratory = Opposite low pH + high PaCO2 i.e. acidosis, or high pH + low PaCO2 i.e. alkalosis Metabolic = Equal low pH + low bicarbonate i.e. acidosis, or high pH + high bicarbonate i.e. akalosis

Question 59

A 71-year-old man is seen in the respiratory clinic with suspected chronic obstructive pulmonary disease (COPD). He is a smoker for 50 years, 20 cigarettes per day, and has a chronic cough and shortness of breath for the last 3 years. On post-bronchodilator spirometry testing, he has an FEV1 of 81% of predicted value, and his FEV1/FVC is 0.5. How would grade this patients COPD?

Answer 59

This man is a smoker, over 35, symptomatic, with FEV1/FVC \<0.7- all of these things mean that he has COPD. His FEV1 is normal (\>80%), therefore his disease is mild. The severity of COPD is based upon FEV1 readings. Moderate is FEV1 50-79%, severe is 30-49%, and very severe is \<30%. Stage 1 COPD has normal FEV1 readings, but is symptomatic.

Question 60

A 25-year-old female presents to her general practitioner with a four-week history of a dry cough. She is otherwise well and takes no regular medication. Examination of her chest is unremarkable, but there are tender red nodules on her shins bilaterally. What is the most likely diagnosis?

Answer 60

Painful shin rash + cough → ?sarcoidosis

Question 61

A 79-year-old man with a past medical history of chronic obstructive pulmonary disease (COPD) presents to their GP with worsening shortness of breath, cough, and wheeze for the past week. The cough is productive of white sputum. The only finding on examination is a widespread expiratory wheeze. His observations are heart rate 82/min, respiratory rate 22/min, blood pressure 134/79 mmHg, oxygen saturations 96% on air, and temperature 37.4ºC. What is the most appropriate management for this patient?

Answer 61

This patient is presenting with an acute exacerbation of their COPD. As such, they should be prescribed a 5-day course of prednisolone (typically 30mg daily) to manage this. He does not require antibiotics as he does not have purulent sputum or any clinical signs of pneumonia.

Question 62

In a patients suffering with exacerbations of bronchiectasis what is the most likely organism causing this?

Answer 62

Given the diagnosis here of an acute exacerbation of bronchiectasis, the correct answer is Haemophilus influenzae, as this is the most commonly isolated organism in patients with this condition.

Question 63

A 24-year-old female presents with facial weakness, fever and painful red eyes. On examination you note a left sided facial palsy and tender swelling of the parotid glands. Laboratory results reveal a calcium level of 2.82 mmol/L. What is the most likely diagnosis?

Answer 63

Sarcoidosis is a multi-system disease involving abnormal collections of inflammatory cells known as granulomas. Sarcoidosis can cause facial palsies, parotid enlargement, hypercalcaemia and ocular problems, as seen in this case.

Question 64

Obstructive sleep apnoea can cause hypertension

Answer 64

Obstructive sleep apnoea can cause hypertension

Question 65

Summary of BIPAP:

Answer 65

BIPAP (Bilevel Positive Airway Pressure) is a form of non-invasive ventilation that has been shown to be very effective in acute type two respiratory failure. It works by stenting alveoli open to increase the surface area available for ventilation and gas exchange. A BIPAP machine alternates between the IPAP (Inspiratory Positive Airway pressure) applied when a patient breathes in and the EPAP (Expiratory Positive Airway Pressure) which is applied between patient triggered breaths. A minimum respiratory rate can be set on the machine and the pressures up-titrated as tolerated. Regular arterial blood gas analysis in needed to asses the patient's response to NIV

Question 66

The most common bacterial organisms that cause infective exacerbations of COPD are:

Answer 66

Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis

Question 67

NICE only recommend giving oral antibiotics in an acute exacerbation of COPD in the presence of purulent sputum or clinical signs of pneumonia otherwise give...

Answer 67

Oral prednisolone

Question 68

How does idiopathic pulmonary fibrosis present?

Answer 68

Key characteristics of this condition include; **exertional dyspnoea** and a **dry cough**. **Weight loss** can also be a feature. It is twice as common in men and typically presents between 50-70 years of age. Examination findings include ; **bibasal inspiratory crackles** on auscultation and **finger clubbing**.

Question 69

How do you treat someone still breathless with COPD on a SABA/SAMA if they have atopic/asthmatic features.

Answer 69

COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add a LABA + ICS

Question 70

How do you treat someone still breathless with COPD on a SABA/SAMA if they don't have atopic/asthmatic features.

Answer 70

SABA/SAMA + add a long-acting muscarinic antagonist (LAMA) and LABA.

Question 71

First line antibiotics in infective exacerbation of COPD?

Answer 71

Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline

Question 72

Painful shin rash + cough →

Answer 72

Sarcoidosis

Question 73

Which rash is commonly associated on the shins of someone with sarcoidosis?

Answer 73

Lymphoma can cause erythema nodosum, however it typically causes a pruritic rash, that sometimes ulcerates. It is a common differential of sarcoidosis as there are many overlapping symptoms such as unexplained weight loss, fatigue and sweating.

Question 74

Treatment of acute bronchitis

Answer 74

Management ## Footnote analgesia good fluid intake consider antibiotic therapy if patients: are systemically very unwell have pre-existing co-morbidities have a CRP of 20-100mg/L (offer delayed prescription) or a CRP \>100mg/L (offer antibiotics immediately)

Question 75

Fibrosis predominately affecting the upper zones

Answer 75

Fibrosis predominately affecting the upper zones ## Footnote hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) coal worker's pneumoconiosis/progressive massive fibrosis silicosis sarcoidosis ankylosing spondylitis (rare) histiocytosis tuberculosis

Question 76

Fibrosis predominately affecting the lower zones

Answer 76

Fibrosis predominately affecting the lower zones ## Footnote idiopathic pulmonary fibrosis most connective tissue disorders (except ankylosing spondylitis) e.g. SLE drug-induced: amiodarone, bleomycin, methotrexate asbestosis

Question 77

CHARTS - acronym for upper zone fibrosis

Answer 77

Acronym for causes of upper zone fibrosis: CHARTS ## Footnote C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis

Question 78

Alpha-1 antitrypsin deficiency is a risk factor for what cancer?

Answer 78

Alpha-1 antitrypsin deficiency is a risk factor for **hepatocellular carcinoma**. Due to the deficiency, there is accumulation of the abnormal, mutant Z protein within hepatocytes. The accumulation of this mutant Z protein triggers apoptosis in some hepatocytes, while other hepatocytes can proliferate to preserve hepatic mass. The chronic, ongoing process of cell death and proliferation leads to liver cirrhosis and significantly increases the risk of developing hepatocellular carcinoma (HCC). Therefore, once alpha-1 antitrypsin deficiency is diagnosed, ongoing surveillance to monitor for HCC development should be undertaken.

Question 79

79yr old with a history of recent weight loss what does this xray show?

Answer 79

**Lung cancer** - The x-ray shows a large right sided hilar mass with resultant collapse of the right upper lobe. As a consequence the hyperexpanded right middle and lower lobes are hyperlucent ('blacker').

Question 80

What are the general signs of lobar collapse on x-ray?

Answer 80

The general signs of lobar collapse on a chest x-ray are as follows: ## Footnote Tracheal deviation towards the side of the collapse Mediastinal shift towards the side of the collapse Elevation of the hemidiaphragm

Question 81

Common causes of lobar collapse

Answer 81

Common causes of lobar collapse include: ## Footnote lung cancer (the most common cause in older adults) asthma (due to mucous plugging) foreign body

Question 82

Gold standard investigation for a patient with suspected lung cancer:

Answer 82

NICE recommends that patients with known or suspected lung cancer are offered a **contrast-enhanced CT scan** of the chest, liver and adrenals.

Question 83

Pneumonia investigations

Answer 83

Investigations chest x-ray in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests CRP monitoring is recommend for admitted patients to help determine response to treatment

Question 84

CURB-65 - what is it used for and what's it's criteria.

Answer 84

CURB-65, also known as the CURB criteria, is a clinical prediction rule that has been validated for predicting mortality in community-acquired pneumonia and infection of any site. NICE recommend, in conjunction with clinical judgement: Consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk) Consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk) Consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)

Question 85

Managment of low severity CAP

Answer 85

Management of low-severity community acquired pneumonia ## Footnote amoxicillin is first-line if penicillin allergic then use a macrolide or tetracycline NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia

Question 86

Management of moderate and high-severity community acquired pneumonia

Answer 86

Management of moderate and high-severity community acquired pneumonia ## Footnote dual antibiotic therapy is recommended with amoxicillin and a macrolide a 7-10 day course is recommended NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia

Question 87

What treatment is first-line for acute bronchitis?

Answer 87

Oral doxycycline is first-line for acute bronchitis (unless pregnant/child)

Question 88

What are the key indications for NIV?

Answer 88

Non-invasive ventilation - key indications ## Footnote COPD with respiratory acidosis pH 7.25-7.35\* Type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea Cardiogenic pulmonary oedema unresponsive to CPAP Weaning from tracheal intubation

Question 89

What are the features of heart failure on x-ray? ABCDE

Answer 89

Alveolar oedema (bat’s wings), Kerley B lines (interstitial oedema), Cardiomegaly, Dilated prominent upper lobe vessels, Effusion (pleural) are features of heart failure on a chest x-ray.

Question 90

What is the treatment of pneumothorax \>2cm in someone with COPD?

Answer 90

If a **secondary pneumothorax** \> 2cm and/or the patient is short of breath then patient should be treated with chest drain (not aspiration) as first-line.

Question 91

Adenocarcinoma of the lung causes what distinct feature?

Answer 91

Gynecomastia

Question 92

Which type of lung cancer can cause hyponatraemia?

Answer 92

Small cell lung cancer is associated with syndrome of inappropriate ADH production (SiADH) which can cause euvolaemic hyponatraemia.

Question 93

**Red jelly like sputum** in a diabetic who drinks alcohol = what bacteria?

Answer 93

Klebsiella pneumonia-\> commonly due to aspiration

Question 94

COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features add what?

Answer 94

COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add a LABA + ICS

Question 95

Sarcoidosis treatment =

Answer 95

Prednisolone

Question 96

Target sats in COPD?

Answer 96

Target saturations in COPD are 94-98% if CO2 is normal on ABG. 88-92% is CO2 high as this indicates they are a retainer and rely on low oxygen to breathe.

Question 97

COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features → add what?

Answer 97

COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features → add a LABA + LAMA

Question 98

How do thiazide diuretics effect electrolyte?

Answer 98

Thiazide diuretics can cause hyponatraemia, hypokalemia, hypercalcaemia and hypocalciuria.

Question 99

Complete heart block following an MI, the lesion is most likely to be in what artery?

Answer 99

Complete heart block following a MI? - right coronary artery lesion

Question 101

SLE what antibodies are positive?

Answer 101

Anti-nuclear antibodies Anti-ds DNA

Question 102

Lung cancer and low sodium = what type?

Answer 102

Small cell cancer Small cell = small sodium