Respiratory medicine

Question 1

What is the most common type of primary lung cancer?

Answer 1

Adenocarcinoma
- Associated with asbestos;
- More common in non-smokers.

Question 2

How to confirm diagnosis of lung cancer?

Answer 2

Biopsy: through either
- Bronchoscopy (if central tumour);
- Thoracoscopy (if pleural effusion).

Question 3

Describe the features and treatment of legionella infection.

Answer 3

Clinchers
- Traveling;
- Hotel stays;
- Whirlpool spas;
- Hot tubs

Symptoms
- Dry cough
- Shortness of breath
- Hyponatraemia
- Lymphocytopenia

Rx
- Macrolides (clarithromycin or azithromycin);
- Fluoroquinolones;
- Tetracyclines.

Question 4

How to diagnose and treat bronchiectasis?

Answer 4

Diagnosis
- Most appropriate: CT chest
- Initial: Chest X-ray may be normal, or show opacities

Treatment:
- Bronchodilators
- Physiotherapy
- Postural drainage of bronchial secretions
- Stop smoking
- Immunisation against influenza and pneumococcus
- Long-term oral antibiotics for patients having 3 or more exacerbations per year

Question 5

What clinchers related to mesothelioma? How should it be treated?

Answer 5

• associated with occupational exposure to asbestos
• report deaths to the coroner as it’s an industrial disease
• latent period may be up to 45 years
• compensation is often available for patients and families
• often the diagnosis is made post-mortem

Management is usually symptomatic since the cure is only possible for localised stage I mesothelioma

Question 6

How to recognise obstructive lung disease in the pulmonary function test? What are examples of obstructive diseases?

Answer 6

Observe forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC)

Obstructive lung disease
- FEV1 less than 80% predicted (low)
- FVC more than 80% predicted (normal)
- FEV1/FVC less than 0.7 (low)

Examples: asthma, COPD, cystic fibrosis, bronchiectasis

They cause airway resistance to expiratory flow and so result in obstructed airways. When expiratory flow is obstructed, the patient will struggle to breathe air out and thus FEV1 will decrease. Because FEV1 is the numerator of the ratio, any obstructive disease will also cause a decrease in the ratio.

Question 7

How to recognise restrictive lung disease in the pulmonary function test? What are examples of restrictive diseases?

Answer 7

Observe forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC)

Restrictive lung disease
- FEV1 less than 80% predicted (low)
- FVC less than 80% predicted (low)
- FEV1/FVC 0.7 or more (normal or high)

Examples: pulmonary fibrosis, interstitial lung disease (obesity, chest or spine deformities, neuromuscular disorders)

Restrictive lung diseases restrict lung expansion and cause a decrease in the amount of air that the lung can hold, leading to decrease in the vital capacity, which results in a decreased FVC. Because there’s also lung elasticity, it also becomes harder for the lungs to force out air, and this causes decrease in the FEV1. Because both FEV1 and FVC decrease, the ratio remains the same.

Question 8

What are the clinchers related to staphylococcal pneumonia?

Answer 8

• caused by staphylococcus aureus
• multiple-lobe involvement and cavitation
• co-infection with influenza

Question 9

What is the CURB-65 score?

Answer 9

C - confusion
U - urea > 7 mmol/L
R - respiratory rate above 30 ipm
B - systolic blood pressure below 90 or diastolic equal or below 60
65 - above 65 yo

Question 10

Is pneumococcus a gram positive or gram negative bacteria?

Answer 10

Pneumococcus is a gram positive cocci, and it’s the most common cause of community acquired pneumonia

Question 11

When should atypical pneumonia be suspected?

Answer 11

• prolonged and gradual onset
• flu-like symptoms classically precede a dry cough
• bilateral consolidation on X-ray
• erythema multiforme (infection with mycoplasma pneumoniae)

Question 12

What are the clinchers for sarcoidosis?

Answer 12

• Bilateral hilar lymphadenopathy
• skin rash

Lofgren syndrome - a distinct sarcoid syndrome
- erythema nodosum
- arthritis
- hilar adenopathy

Question 13

Which organism most commonly causes pneumonia in a HIV patient that presents with desaturation on exercise?

Answer 13

Pneumocystis carinii infection (pneumocystis jiroveci pneumonia)

Question 14

How to investigate and diagnose a Pancoast tumour?

Answer 14

• MRI scan only assess structures at the thoracic inlet since it provides a higher soft tissue resolution
• histology is achieved by percutaneous methods rather than bronchoscopy since there tumours are peripherally located

Question 15

Which antibiotic should be prescribed in a case of pneumonia for a patient that is allergic to amoxicillin and is currently using statin?