RESPIRATORY

Question 1

ILD

Answer 1

ILD:
Clubbing
SOB,cough
HRCT: honeycombing, sub pleural basal predominance
Unfortunately responsiveness to corticosteroids in idiopathic pulmonary fibrosis is poor, although up to 20% may show some objective response with respect to stabilisation of lung function.
Whilst only 20% of patients may be steroid responsive, other treatments for alveolitis include azathioprine and cyclophosphamide.
Other options under clinical trials include interferon-gamma 1 beta and bosentan.

Question 2

Sleep apnoea

Answer 2

The multiple sleep latency test on the other hand only measures how quickly a person falls asleep in a quiet environment, and whilst it is a standard test for narcolepsy and idiopathic hypersomnia, it doesn’t provide the information required to make a diagnosis of OSA.

Polysomnography will provide you with information regarding oxygen saturations and respiratory rate in addition to sleep quality, and can confirm or exclude the diagnosis of OSA

Question 3

cystic fibrosis

Answer 3

Pancreatic insufficiency is very common, with 85% of patients affected.

Sweat test is most imp test for cystic fibrosis
Normally sweat sodium is more than sweat chloride- reversed ratio is another pointer for CF
Older children with CF and pancreatic insufficiency have low immunoreactive trypsin

Question 4

heerfordt syndrome

Answer 4

Heerfordt’s syndrome is an acute syndromal presentation of sarcoidosis, presenting with the following features:
Fever.
Uveitis.
Swelling of parotid ± other salivary/lacrimal glands.
Facial nerve palsy may be a feature but is not thought necessary to confirm the syndrome by all authors.

Question 5

felty’s syndrome

Answer 5

Felty’s syndrome is the association triad of rheumatoid arthritis, neutropenia and splenomegaly

Question 6

loegren syndrome

Answer 6

Lofgren’s syndrome is a subtype of sarcoidosis which presents with hilar lymphadenopathy, erythema nodosum, arthralgia and fever

Question 7

meig’s syndrome

Answer 7

Meig’s syndrome is the association of a benign ovarian tumour, ascites and pleural effusion

Question 8

turner’s syndrome

Answer 8

Turner’s is the syndrome associated with the XO sex chromosome type. Affected girls have a classical appearance, including neck webbing, short stature and ovarian failure. There is also an increased risk of congenital heart defects, lymphoedema, renal malformations, deafness and osteoporosis.

Question 9

mesothelioma

Answer 9

mesothelioma. Tissue can be obtained from thoracoscopy with biopsy from abnormal looking areas, as such this is the most appropriate investigation to deliver the diagnosis

Question 10

mycoplasma

Answer 10

Epidemic pneumonia due to Mycoplasma infection is seen occasionally, and the fact that a number of his class mates have recently been ill points to this as a possible cause.
Classically, mycoplasma presents with a slow-onset of symptoms (sometimes over weeks) with prominent constitutional upset, including headache, chest pain, myalgia and malaise. There is classically a persistent dry cough.
Extra-respiratory features include:
erythema multiforme
erythema nodosum
urticaria
Guillain-Barré syndrome
transverse myelitis
aseptic meningitis
cold agglutinins
haemolytic anaemia (as seen here)
arthritis
pericarditis
myocarditis, and
pancreatitis (rarely).
It is spread by direct contact, and most cases resolve spontaneously within a few weeks.Often signs on examination are less severe than would be expected once the x ray findings are reviewed, as is the case here.
Macrolides such as clarithromycin are first choice antibiotics if required.

Question 11

drug causes of pulm fibrosis

Answer 11

Amiodarone
Bleomycin
Methotrexate
Busulphan
Gold, and
Nitrofurantoin.

rarely-dosulepin

Question 12

pertussis vaccine

Answer 12

The pertussis vaccine is rarely associated with a hemiseizure-hemiplegia syndrome, probably related to hyperpyrexia rather than direct neurological toxicity.

Question 13

squamous cell carcinoma

Answer 13

Squamous cell carcinomas usually arise from a central airway, and cavitate. Small cell carcinomas arise in the central airways and grow rapidly. Adenocarcinomas may be peripheral and slow-growing; they are the commonest lung carcinomas in non-smokers. Smoking is associated with all forms but is most strongly linked with small-cell and squamous cell carcinoma.

Question 14

cavitating lung lesions

Answer 14

Infection (Staphylococcus aureus, tuberculosis, Klebsiella, Pneumocystis jiroveci)
Pulmonary infarcts
Wegener’s granulomatosis, and
Rheumatoid nodules.

Question 15

histoplasmosis

Answer 15

Histoplasmosis normally evolves slowly over as long as 20 years but may follow a more rapid course in the immunocompromised (seamen may be more prone to sexually transmitted diseases such as HIV).

Question 16

pancoast’s syndrome

Answer 16

Ipsilateral invasion of the cervical sympathetic plexus, leading to Horner’s syndrome (miosis, enophthalmos, ptosis) in 14-50% of patients[2].
Ipsilateral reflex sympathetic dystrophy in the arm, with enhanced sensitivity to touch, and skin changes.
Shoulder and arm pain (from the brachial plexus invasion C8-T1) with wasting of the intrinsic hand muscles and paraesthesiae in the medial side of the arm.
Less commonly, unilateral recurrent laryngeal nerve palsy producing unilateral vocal cord paralysis (hoarse voice ± bovine cough), and/or phrenic nerve involvement.
Arm oedema secondary to the compression of blood vessels.
Superior vena cava obstruction, with facial swelling, difficulty breathing and a flushed appearance.

The tumour causes pain in the C8 and T1 distribution and Horner’s syndrome.
It may cause small muscle wasting of the hands and erosion of the first rib.
The nerve root for abduction of shoulder is C5.

Question 17

phrenic nerve palsy

Answer 17

The diaphragm is innervated by the phrenic nerve (C3,4,5).
Palsy is a recognised complication of thoracic surgery, infection, Guillain-Barré or invasion by an adjacent tumour.
It may also be stretched by an aortic aneurysm.

Question 18

extrinsic allergic alveolitis

Answer 18

Farmer’s lung is the commonest occupational hypersensitivity pneumonitis, due to thermophillic actinomycetes

Crackles are typically heard at the bases. Other signs depend on the stage of disease.
In the acute form, the symptoms usually start four hours after exposure to the sensitising antigen. There is malaise, fever, chest tightness, dry cough, and dyspnoea. Signs include tachypnoea and bibisal fine inspiratory crackles; wheeze is rare. Life-threatening respiratory failure can develop.
In the subacute form, symptoms are less severe and include a productive cough, dyspnoea, fatigue, anorexia, and weight loss. There are often recurrent attacks, which may present as pneumonia. After the exposure is removed it can take weeks or months for the symptoms to resolve.
In the chronic form there are minimal systemic symptoms, but marked limitation of exercise tolerance due to dyspnoea. If the source of the antigen is removed there is usually only partial improvement of symptoms. Cyanosis, clubbing, and apical inspiratory crackles may be present (due to an apical fibrosis). Eventually chronic hypoxia and pulmonary hypertension with right heart failure develop. There may be acute exacerbations.
Eosinophilia can be seen but is not typical.
Immunoglobulin levels are frequently elevated but not a paraprotein.
PO2 may be decreased particularly with exercise.
A restrictive pattern on LF studies is seen.

Question 19

smoking and birth weight

Answer 19

Smoking reduces birth weight which may be of critical importance if the baby is born pre-term.
On average, the babies of smokers weigh 170 g less than non-smokers, but the reduction in birth weight is related to the number of cigarettes smoked per day.
Smoking is also associated with an increased risk of miscarriage and still birth. The infant has a greater risk of sudden infant death syndrome.
There is some evidence that maternal smoking may adversely affect ovarian function in female children.
No dysmorphic syndrome has yet been described.
Maternal smoking has been shown to increase lung maturity, possibily by enhancing the production or secretion of cortisol. This makes neonates less likely to develop respiratory distress syndrome, but as lung maturation is often abnormal babies may have reduced lung function and increased rates of other respiratory illnesses.

Question 20

physio

Answer 20

Because of surfactant, the pressure difference across the pleura required to inflate the lungs, is usually no more than about 4 cmH2O.
Resting pulmonary blood flow in an adult is around 5 L/min.
The V:Q ratio is higher in the apical than the basal segments.
While a single small airway provides more resistance than a single large airway, resistance to air flow depends on the number of parallel pathways present. For this reason, the large and particularly the medium-sized airways actually provide greater resistance to flow than do the more numerous small airways.
Cartilage disappears in the terminal bronchioles.

Question 21

Tuberculosis

Answer 21

Pyrazinamide-intracellular org
Streptomycin-extracellular org
Only smear positive untreated pulm tb is infectious

Primary TB is usually asymptomatic with miliary TB most likely to occur in children

The ghon focus is the area of consolidation from cellular infiltration and response to uptake of organisms by macrophages which transform into epitheloid cells and group into granulomata. Bacilli are transported via lymphatics early in the disease process to regional lymph nodes to cause marked lymphadenopathy.

Pleural and pericardial infections (can result in effusions) occur at or shortly after primary infection.

Positive tuberculin test occurs between 3 weeks and 3 months after primary

Question 22

Pulmonary embolism Vs panic attack

Answer 22

Panic attack causes hypocapnia and increase in oxygen levels- it can also cause loss of consciousness

PE- cyanosis

Question 23

Amiodarone induced lung disease

Answer 23

Desaturation
Patchy infiltration on CXR
Insidious presentation
Associated with cumulative dose
Rx:withdraw amiodarone and initiate steroid therapy
DD: lymphangitis/pneumonitis
HRCT can help.

Question 24

Sarcoidosis

Answer 24

Grading (radiographic)
Normal-0
BHL-1
BHL + pulm infiltrates-2
Pulm infiltrates - BHL-3
Pulm fibrosis -/+ bullae-4

Question 25

Small cell ca

Answer 25

Non metastatic- paramalignant manifestations:

1. inappropriate ADH/ ectopic ACTH
2. Polymyositis
3. Dementia
4. Cerebellar syndrome
5. Peripheral neuropathy

Eaton-Lambert syndrome:
Non metastatic paramalignant manifestation.70% in association with small cell lung ca. Autoimmune effecting release of acetyl choline at NMJ causing proximal muscle weakness, fatiguability, muscle wasting. Power initially increasrd by exercise. Weakness fatigue improved with guanidine hydrochloride.

Hypertrophic pulm osteo arthropathu and ectopic pth related peptide secretion relates to squamous cell ca.

Question 26

Salmeterol

Answer 26

Salmeterol reported to produce acute exac of asthma, possibly through an acute hypersensitivity reaction