Radiological findings

Question 1

HIV positive man with SOB, cough, raised LDH and diffuse ground glass opacities

Answer 1

PCP

Question 2

70 year old with prgressive SOB and dry cough. Bilateral lower zone reticulonodular shadows on CXR

Answer 2

IPF

Question 3

65 year old ex-coal miner presents with worsening SOB. Previous CXRs showed multiple irregular linear opacities. Recent CXR showed large densities in the upper lobes

Mnemonic for conditions with upper lobe predominance (CHARTS)

Answer 3

Progressive massive fibrosis (progressed from pneumoconiosis)
- Distinguished from sarcoid which is usually perihilar

Coal workers’ pneumoconiosis
Histiocytosis X
Ankylosing Spondylitis
Radiation
TB
Sarcoidosis/Silicosis

Question 4

45 year old alcoholic presents with 3 day history of productive cough and fever. CXR shows cavitating lesion in the right upper lobe

Answer 4

Klebsiella pneumonia
- DDx: TB (more chronic history)

Question 5

30 year old non-smoker with wheeze, haemoptysis and a well-demarcated lesion in proximal right lower lobe

a) Diagnosis
b) Apperarance of bronchoscopy
c) Cell line
d) Management
e) Prevalence of carcinoid syndrome

Answer 5

a) Carcinoid tumour

b) Cherry red (very vascular)

c) Kulitchky cell (NET) - benign

d) Cardiothoracic surgery - resection curative (not biopsy as will bleed +++)

e) 1-2%

Question 6

Upper lobe predominant conditions
(A TEA SHOP)

Answer 6

A: allergic bronchopulmonary aspergillosis
T: tuberculosis
E: extrinsic allergic alveolitis
A: ankylosing spondylitis
S: sarcoidosis
H: histiocytosis (Langerhan’s)
O: occupational (silicosis, berylliosis)
P: pneumoconiosis (coal workers)

Question 7

85 year old with recurrent cough
HRCT demonstrates basal fibrosis associated with dilated bronchi, but no honeycombing or ground-glass change

Answer 7

Chronic aspiration pneumonia - causing bronchiectasis-like changes

Question 8

65 year old male presents 8 weeks post pneumonia with an area of non resolving consolidation. He is coughing up a lot of clear sputum

Answer 8

Bronchoalveolar carcinoma
- goblet cell origin

Question 9

47 year old lifelong non smoker presents with cough, haemoptysis and weight loss. Gottrons papules and HPOA seen in the hands. CXR shows RUL tumour with hilar extension.

A) diagnosis

Answer 9

Adénocarcinoma
- more commonly peripheral
- more likely in non smokers
- dermatomyositis and HPOA more common in adeno
(Note - bronchial carcinoid more likely to be central and visible on bronchoscopy)

Question 10

70 year old smoker presents with rapid progression of cough, SOB and low sodium. CXR shows mediastinal mass and lymphadenopathy.

a) most likely diagnosis
b) other possible paraneoplastic phenomema

Answer 10

A) Small cell lung cancer
- SIADH évident with the low Na

B) Cushings
LEMS
Cerebellar ataxia, sensory neuropathy, limbic encephalitis

Question 11

65 year old smoker presents with cough, high calcium and central cavitating mass.

a) Diagnosis

Answer 11

Squamous cell carcinoma

Question 12

22 year old tall thin man presenting with pleuritic chest pain following gym session. Clicking sound heard synchronous with heart sounds. Otherwise exam unremarkable with normal CXR
a) Likely diagnosis
b) Management

Answer 12

a) Apical PTX

b) - Consider lateral decubitus CXR
- Discharge and follow up in clinic

Question 13

HRCT
a) Uses
b) Why it’s not used for lung cancer, nodule assessment or PE

Answer 13

a) Looking at the lung parenchyma. Used for assessing ILD, fibrosis, chronic infection, bronchiectasis and emphysema

b) - Thick slices around 5mm so would miss smaller nodules
- no contrast used so not good for PE

Question 14

70 year old woman presents with acute pleuritic chest pain and SOB. ABG shows T1RF and respiratory alkalosis. Her HR is 120, BP is 80/50, apyrexial. CTPA shows filling defects in the right and left main pulmonary arteries.
a) Type of PE and other grades
b) Management

Answer 14

a) - Massive = PE with shock
- Submassive = PE with myocardial dysfunction (e.g. RV strain, troponin rise) but no shock
- Non-massive = none of the above features

b) Alteplase

Question 15

Suspected PE in pregnancy
a) Investigation
b) Treatment

https://www.rcog.org.uk/media/wj2lpco5/gtg-37b-1.pdf

Answer 15

a) - D-dimer has undetermined role in pregnancy
- All patients should have a CXR and ECG
- If signs or symptoms of DVT, proceed to bilateral lower limb doppler USS
- If no signs or symptoms of DVT, proceed to CTPA or V/Q
- Advise women that…
–> V/Q scanning may carry a slightly increased risk of childhood cancer
–> CTPA is associated with a higher risk of maternal breast
cancer
–> in both situations, the absolute risk is very small

b) - LMWH based on booking weight
- Continue LMWH for duration of pregnancy, for at least 3 months in total, and for at least 6 weeks post-natal
- Note: warfarin is teratogenic / DOACs not licensed
- In massive PE, consider thrombolysis

Question 16

Investigation and management of DVT

Answer 16

Wells score:
- 1 or less - DVT unlikely. D-dimer –> if +ve, proceed to Dopplers. If doppler negative –> repeat in 6-8 weeks
- 2 or more - DVT likely –> proceed to Dopplers (no D-dimer)

Start anticoagulation - LMWH
Continue for 3 months. If unprovoked, consider continuing further depending on bleeding vs clotting risk
Do routine bloods + physical examination for unprovoked

Consider catheter-directed thrombolytic therapy for people with symptomatic iliofemoral DVT who have:
- symptoms lasting less than 14 days, and
- good functional status, and
- a life expectancy of 1 year or more, and
- a low risk of bleeding.