Respiratory Medicine Flashcards

Question

Describe Pulmonary Aspiration, its features, investigations, and management.

Answer 1

Aspiration of solid or liquid material into the upper and lower airways is likely when: - decreased GCS - decreased cough/gag reflexes - tendency to regurgitate/vomit (Last meal?) Features: large food particles may cause complete airway obstruction (choking, stridor, cyanosis, loss of concisouness) vomit leads to sudden onset of severe SOB, wheeze and cyanosis, the acidity causes severe damage to the alveolar-capillary membrane, with desaturation of pulmonary surfactant and increased pulmonary permeability with oedema and atelectasis. Investigations: - ABG shows hypoxemia initially with decreased CO2 due to hyperventilation until Pulmonary compliance and increased work of breathing lead to hypoventilation. - CXR abnormalities may take hours to develop, Right lower lobe most commonly affected, diffuse bilateral infiltrates and pulmonary oedema similar to ARDS appearance. Management: - Prevention is key, in at risk patients pass an NG tube to empty the stomach - correct hypoxia and give nebulised salbutamol. Although secondary infection is common use of antibiotics or steroids in initial management is not routinely indicated.

Answer 2

Caused by high energy transfer during blunt injury e.g. RTA or high falls. Suspect in all patients with flail segments, or multiple rib fractures. Features: Causes ventilation-perfusion mismatch and so hypoxia and respiratory distress. CXR may show patchy opacification which tend to become more prominent over time. Management: -Mostly supportive, high flow oxygen and monitor ABG to help assess need for GA, tracheal intubation and IPPV.

Answer 3

Lights criteria determines presence of exudates with protein and LDH levels, there are 3 main criterion: 1) Pleural fluid protein to serum protein ratio is greater than 0.5 2) Pleural fluid LDH to serum LDH ratio is greater than 0.6 3) Pleural fluid LDH is over 2/3 of upper value 4) Serum Albumin - Pleural Fluid albumin is less than 1.2g/dL

Answer 4

An increase in mean pulmonary arterial pressure of greater than 25mmHg at rest or 30 mmHg after exercise. (Normally 8-20mmHg). Causes: Pulmonary Arterial Hypertension Group 1: Idiopathic, inherited (autosomal dominant mutation in BMPR2 gene), drug-induced (cocaine, SSRIs, Interferon), congenital heart disease, HIV, connective tissue disease, portal hypertension (Normal PCWP) Group 2: Left heart disease e.g. Left ventricular systolic dysfunction, left ventricular diastolic dysfunction, valvular heart disease, cardiomyopathy (Raised PCWP) Group 3 secondary to lung disease: COPD, ILD, Sleep apnoea, Chronic high altitude Group 4 thromboembolic: Blood clots in pulmonary arterial system Group 5 unclear or multifactorial: e.g. Myeloproliferative disorders, systemic disorders e.g. Vasculitis, metabolic disorders e.g. Thyroid disease Features: Progressive SOB, Odema, Ascites, left parasternal heave, Loud P2, pulmonary regurgitation, triscupid regurgitation, raised JVP, Investigations: LFTs, TFTs, Autoimmune screen, CXR, echo, Management: - Treat underlying condition. - acute vasodilator testing aims to decide which patients show a significant fall in pulmonary arterial pressure following the administration of vasodilator such as IV epoprostenol or inhaled nitric oxide - For those with a positive response to acute vasodilator testing oral Ca-Channel blockers, - For those with a negative response to acute vasodilator testing, Prostacyclin analogues e.g. treprostinil, iloprost, Or Endothelin receptor antagonists e.g. bosentan. Or phosphodiesterase inhibitors e.g. sildenafil.

Answer 5

An acute condition characterised by bilateral pulmonary infiltrates and severe hypoxaemia (PaO2/FiO2 ratio under 200) in the absence of evidence for cardiogenic pulmonary oedema (clinically or pulmonary capillary wedge pressure (CVP) less than 18mmHg Causes: Sepsis, aspiration, trauma, acute pancreatitis, fat embolism, head injury (sympathetic stimulation leads to acute pulmonary HTN) Features: Acute dyspnoea and hypoxaemia, hours/days after event. Multi-organ failure, rising ventilatory pressures. Management: - treat underlying cause - antibiotics if signs of sepsis/aspiration - negative fluid balance (diuretics) - recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure - mechanical ventilation with LOW tidal pressures (conventional tidal pressures may cause lung injury)

Answer 6

Aka C1 esterase inhibitor deficiency. C1 esterase inhibitor is a member of the serum protease inhibitors and acts to inhibit the classical pathway of complement cascade. In the absence of C1 esterase inhibitor activation of complement leads to increased levels of vasoactive peptides that increase capillary permeability, most notably, bradykinin. This patients taking ACE-i leads to further increase of bradykinin. This is mast-cell independent so there is no itching or erythema. Features: Facial oedema, laryngeal oedema, with subsequent airway obstruction. No Urticaria. Episodes may be provoked by traum to mucosal membranes e.g. sexual intercourse or dental work. Management: - patients may not respond to adrenaline and ultimately need C1 esterase inhibitor concentrate. - intubate and involve ITU for supportive treatment

Answer 7

An autosomal recessive disease, reflecting mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR) on chromosome 7, which codes for a cAMP-regulated sodium/chloride channel. Neonates are screened for immuno reactive trypsin on the Guthrie card, then DNA analysis if raised. 85% coverage. Presentation: 10% present with meconium ileus as neonates, most present later with recurrent pneumonia (+/- clubbing), steattorrhoea, or slow growth. Meconium ileus present with failure to pass stol or committing in the 1st 2 days of life. Distended loops of bowel are see through abdominal wall. Initially patients become infected with Staph Aureus, before subsequent colonisation with gram -ve bacteria most commonly Burkholderia cepacia and pseudomonas aeruginosa Investigations: - sweat test - CXR may show shadowing suggestive of bronchiectasis especially in upper lobes. Management: - (meconium ileus may require nasogastric drainage, washout enemas and excision of the gut containing meconium). - genetic counselling - antibiotics and good nutrition key to long-term survival. - May need enzymes due to pancreatic malabsorption. - Omeprazole helps absorption by increasing duodenal pH. Low fat diet may be needed if these measures fail to control steattorrhoea. - monitor glucose tolerance and insulin may be need later in life. Optimise diet.

Answer 8

Increased kCO: Alveolar haemorrhage e.g. Goodpastures, GPA, Chung-Strauss, SLE Decreased kCO: Destroyed alveoli e.g. Emphysema, pulmonary fibrosis.

Answer 9

Uveoparotid fever, there is parotid enlargement, fever and uveitis secondary to sarcoidosis

Answer 10

Results from an allergy to aspergillosis spores. Features: Bronchoconstriction (wheeze, cough, dyspnoea), bronchiectasis (proximal) Investigations: - Eosinophilia - Flitting CXR changes - Positive Skin prick to Asperigillus most specific - Positive RAST test to aspergillus - Positive IgG precipitins - Raised IgE Management: - Steroids - Itraconazole is sometimes used as second-line agent

Answer 11

Silicosis is a fibrosing lung disease caused by the inhalation of crystalline silicon dioxide. It is a risk factor for developing TB. Risk Factors: Mining, Slate works, Foundries, Potteries Features: Fibrosing lung disease typically affecting upper lobes 'Egg-shell' calcification of hilar lymph nodes

Answer 12

Common autosomal recessive / co-dominant condition caused by a lack of protease inhibitor normally produced by the liver. A1AT protects cells from enzymes such as neutrophil elastae. A1AT located on chromosome 14. Alleles classified by their electrophoretic mobility M for normal S for slow and Z for very slow e.g. PiMM is normal, Homozygous PiZZ 10% normal A1AT levels. Features: - Lungs: Panacinar emphysema, most marked in lower lobes - Liver: cirrhosis and hepatocellular carcinoa in adults, cholestatis in children. Management: - A1AT concentration - No smoking - Supportive: bronchodilators, physiotherapy - IV A1AT concentrate - Surgery for volume reduction/ lung transplantation

Answer 13

Results from an Allergy to Aspergillus spores. Exam questions often give a history of bronchiectasis and eosinophilia. Features: - Bronchoconstriction: wheeze, cough, dyspnoea - Bronchiectasis Investigations: - Eosinophilia - Flitting CXR changes - Positive RAST test to Aspergillus - Positive IgG precipitins - Raised IgE Management: - Steroids - Itranconazole is sometimes introduced second line

Answer 14

Aka Optiflow, able to deliver high FiO2 humidified oxygen. Also has. A CPAP effect due to mechanical splinting of the nasopharynx and low levels of PEEP which contribute to alveolar recruitment and improved compliance and decreased work of breathing. Observational data suggest it outperforms face masks for relieving respiratory distress preventing the need for NIV or intubation. Indications: Hypoxic respiratory failure e.g. CAP, Acute asthma, Cardiogenic pulmonary oedema, pulmonary embolism, interstitial pneumonia, carbon monoxide poisoning. Contraindications: epistaxis (also a complication), base of skull fracture, surgery to nose, Nasal obstruction.

Answer 15

A type of pleural effusion that results from lymphatic fluid accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct. Can be identified by its turbid, milky white appearance, and high levels of triglycerides. Important to distinguish chlyothroax from psuedochylothroax which is an effusion high in cholesterol. Causes: - Traumatic e.g. Direct laceration from surgery e.g. Open heart surgery. - nontraumatic most common is malignancy e.g. Lymphoma, left-heart failure, infections and developmental abnormalities e.g. Down syndrome and noonan syndrome. Treatment: - Drainage - pleuroperitoneal shunting - Pleurodesis - omitting fat from the diet.

Answer 16

In sensitised individuals inhalations of allergens provokes a hypersensitivity reaction. In the acute phase the alveoli are infiltrated with acute inflammatory cells. With chronic exposure granuloma formation and obliterative bronchiolitis occurs. Causes: - Bird-fancier's lung (Proteins in bird droppings) - Farmer's Lung (Micropolyspora Faeni, Thermoactinomyces vulgaris) - Malt Worker's Lung (Aspergillus clavatus) - Bagassosis or Sugar Worker's lung (thermactinomyces sacchari) - Nitrofuratoin Features: - Acute: Fever, rigors, myalgia, dry cough, dyspnoea, crackles - Chronic: Increasing dyspnoea, weight loss, type 1 respiratory failure, cor pulmonale - Bloods: neutrophilia, raised ESR, - CXR: Upper zone fibrosis Hilary lymphadenopathy Management: -remove allergen and give O2 -prednisolone 40mg OD followed by reducing dose :

Answer 17

Predicts 30-day outcome of patients with pulmonary emobilism using 11 clinical criteria. If the patient is considered very low (Less than 65) or low risk (66-85) by the PESI score, patient has an overall low risk of mortality or severe morbidity and outpatient management should be considered If the patient is considered intermediate (86-105), high risk (106-15) or very high risk (over 125) by the PESI the patient has an overal high risk of mortality and severe morbidity and higher levels of care e.g. ICU should be considered.

Answer 18

Oxygen dissociated curve shift to the left means lower oxygen delivery. ``` The L rule: Low H+ (Alkali) Low pCO2 Low 2,3-DPG Low temperature ``` And HbF, Methaemoglobin, Carboxyhaemoglobin.

Answer 19

Oxygen dissociation curve shift to the right means raised oxygen delivery. ‘CADET, Face Right’ ``` CO2 raised Acid - Raised H+ DPG - Raised 2,3-DPG Exercise Temperature - Raised ```

Answer 20

Features: Patients present with sympathetic hyperactivity such as tachycardia, Hypertension, dilated pupils and chest pain, productive cough, dyspnoea and hypoexamia along with fever, haemoptysis and respiratory failure. There may be pneumothorax, pneumomediastinum, Pulmonary haemorrhage usually due to the vaslava manoeuvre performed whilst smoking. Management: -Most cases are conservative may require ventilatory supports or corticosteroids may have a role.

Answer 21

Hypoventilation e.g. CNS depression, Obesity hypoventilation, muscular weakness, poor chest wall elasticity. V/Q mismatch i.e. increased A-a gradient e.g. COPD, Asthma, pulmonary vascular disease, ILD Right-to-left shunt (Shunt equation Qs/Qt = (CcO2 - CaO2) / (CcO2 - CvO2). Causes may be anatomical e.g. AVM, Intracardiac shunt, Hepatopulmonary syndrome, or physiological e.g. pneumonia, ARDS Diffusion Limitation e.g. ILD or exercise, lack of time for oxygenation to occur. Reduced inspired oxygen tension e.g.s altitude

Answer 22

The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or than corrected for lung volume (Transfer coefficient KCO). Causes of a raised TLCO: - Asthma - Pulmonary Haemorrhage (Wegener's, Goodpasture's) - Left-to-right cardiac shunts - Polycythaemia - Hyperkinetic states - Male gender, exercise Causes of a lower TLCO: - Pulmonary Fibrosis - Pnemonia - Pulmonary Embolism - Pulmonary Oedema - Emphysema - Anaemia - Low cardiac output KCO also tends to increase with age. Some conditions may cause an increased KCO with a normal or reduced TLCO: - Pneumonectomy/lobectomy - Scoliosis/Kyphosis - Neuromuscular weakness - Ankylosis of costovertebral joints e.g. ankylosing spondylitis.

Answer 23

A tracheostomy is a surgical procedure which consist of making an incision on the anterior aspect of the neck and opening a direct away through the incision into the trachea. Indications: - After a period of time following intubation with an endotracheal tube - reduced sedation - improved patient communication - possible reduction in laryngeal damage - nursing care potentially easier - Facilitation of weaning. Complications: - Displacement or obstruction - Evidenced by failing gas exchange, unexpected ventilator pressures, patient may be able to talk despite cuff inflated. If available use capnography to detect oscillating FiCO2 and determine if obstructed or not. Remove inner tube, and check for secretion build up. try passing suction catheter. - Infection early or late good stoma care should prevent this - Bleeding, local erosion at entry site, damage from vigorous suctioning, more seriously erosion by tracheostomy tip or high pressure balloon cuff rarely into the innominate artery which lies anteriorly.

Answer 24

Indications: - pH less than 7.35, pCO2 over 6 - COPD - Neuromuscular disease - Obesity hypoventilation syndrome Contra-indications: - Vomiting - Facial burns/trauma/recent surgery - Fixed upper airways obstruction - Undrained pneumothorax - Relative contraindications: life-threatening hypoxaemia, severe co-morbidity, confusion/agitation, inability to protect airway, Haemodynamically unstable, copious secretion. Implentation: - In COPD start at 15/4 then increase to 20/4 in first 30mins. Repeat ABG if no significant improvement increase to 22/4, and if still no improvement continue to increase up to 30/4. - In Neuromuscular disease start at 10/4, increase to 12/4 in first 30mins. Repeat ABG if no significant improvement increase to 14/4 and if still no improvement continue to increase up to 16/4. - In obesity hypoventilation syndrome start at 15/6 and increase to 20/6 in first 30 mins. Repeat ABG if no significant improvement increase to 24/8 and if still no improvement continue to increase to 30/8. Weaning: -Once pH has normalised begin weaning, starting with meal breaks for 24 hours with overnight continuous NIV, then 2hrly breaks, then 4hrly breaks then just overnight NIV. Assess weaning each day with repeat ABG.

Answer 25

A reflex triggered to prevent over-inflation of the lung. Pulmonary stretch receptors present in the smooth muscle of the airways respond to excessive stretching by sending action potentials via the vagus nerve to the inspiratory area in the medulla and apneustic area of the pons. In response the insularity area is inhibited directly and the apneustic area is inhibited from activating the inspiratory area this inhibits inspiration, allowing expiration to occur.

Answer 26

Right lung is divided into three lobes and ten segments: - Right upper lobe - Apical, Posterior, Anterior - Right Middle lobe - Lateral, medial - Right Lower lobe - superior, medial, anterior, lateral, posterior. The left lung is divided into two lobes and eight segments: - Left Upper lobe - Apicoposterior, Anterior, Superior lingular, Inferior lingular - Left Lower lobe - Superiorm anteriomedial, lateral, posterior.

Answer 27

Acute sarcoidosis characterised by bilateral hilarity lymphadenopathy, erythema nodosum, fever and polyarthralgia. It typically occurs in young females and carries an excellent prognosis.

Answer 28

1-alpha-hydroxylase is activated by macrophages in sarcoid granulomas and Converts 25-hydroycitamin D3 to 1,25 dihydroxyvitamin D3, the active form of the vitamin leading to absorption of calcium from the gut and increased renal calcium absorption from the distal tubule.

Answer 29

Rules out PE if no criteria are present and pre-test probability is less than 15%. The PERC rules can be applied to patients where the diagnosis of PE is being considered but the patient is deemed low-risk. PERC 1 point for: - Age over 50 - HR over 100 - SpO2 less than 95% - Unilateral leg swelling - Haemoptysis - Recent surgery or trauma (1 month) - Prior PE/DVT - Hormone use A single point means the patients will likely require well's criteria and D-dimer to further evaluate. If this criteria scores 0 can be safely discharged without FU or D-Dimer.

Answer 30

Only potential curable form of pulmonary hypertension. Pulmonary hypertension secondary to chronic PE. Features: Progressive Dyspnoea, exercise intolerance. Investiations: - V/Q scan imaging of choice the. Right Heart Catheterisation / Pulmonary angiography. - Diagnosis depends on pulmonary hypertension present i.e. PAP over 25mmHg in absence of elevated PCWP (i.e. less than 15mmHg). - Evidence of thromboembolic occlusion in the proximal or distal vasculature. Management: -pulmonary endarectomy

Answer 31

A form of non-infectious pneumonia, more specifically an inflammation of the bronchioles and surrounding lung tissue. Cause: It is often a complications of existing chronic inflammatory disease such as RA, Dermatomyositis, or a side effect of medications such as Amiodarone. Features: Radiological features of pneumonia, That tends to affect different areas on serial imaging. SOB, fevers, fatigue, cough.

Answer 32

Aka popcorn lung. Causes include toxic fumes, Connective tissue disorder, or complications following bone marrow or heart-lung transplant. Features: Dry cough, SOB, wheezing, Lethargy. Investigations: HRCT, Lung function tests, Biopsy. Chest X-ray is often normal.

Answer 33

Aka Brown lung disease, an occupational lung disease caused by exposure to cotton. Occurs in workers of yarn and fabric manufactures thought to be due to endotoxins from walls of gram-negative bacteria that grow on cotton. Features: Breathing Difficulties, chest tightness, wheezing, cough.

Answer 34

The fluoroscopic sniff test, also known as diaphragm fluoroscopy, is used most often to confirm absence of muscular contraction of the diaphragm during inspiration in patient with phrenic nerve palsy or breathing difficulties following a stroke. During a sniff the diaphragm contract during inspiration (moves downwards) and relapses during expiration and both hemidiaphrams move together. If there is a diaphragmatic palsy the affected diaphragm does not move downwards during inspiration and even paradoxical motion can occur.

Answer 35

In 70kg man: ``` Peak Expiratory flow 520-700l/min Total Lung capacity 5-6.5L Functional Residual Capacity 2-3L Tidal Volume 500 - 700mL Inspiratory reserve volume 3300mL ```

Answer 36

Omazilzumab is used in severe asthma with raised IgE Mepolizumab is used in severe asthma with eosinophilia

Answer 37

Characterised by alveolar capillary bleeding and accumulation of haemosiderin in the lungs. May be associated with circulating anti-GBM antibodies and cow’s milk hypersensitivity Features: Haemoptysis, Diffuse parenchyma infiltrates on chest radiographs and IDA. Usually found in children. 2-8 Management: - Corticosteroids - steroid sparing immunotherapies.

Answer 38

Features: Fevers, cough, Haemoptysis CXR shows consolidation in cavity with halo sign ring of air around fungus ball. Management: -Surgical resection is first line unless poor lung function in which case oral itraconazole is used.

Answer 39

Eosinophilic pneumonia is a rare respiratory pathology characterised by pulmonary infiltrates and pulmonary eosinophilia. It can be idiopathic or secondary to parasites, drugs or systemic diseases such as vasculitis. The peripheral Eosinophil count is not always raised. The serum IgG is raised in two-thirds of patients and the ESR is elevated. Sputum and Bronchoalveolar Lavage often show and eosinophilia. Features: This presents over months to years, usually occurs in those aged in their 50s with a. Female to male ration 2:1. It can be irreversible. About 60% of patients with CEP have asthma and 90% are non-smokers. Patients present with constitutional symptoms, cough, wheeze, and fever. Chest X-RAY often shows the opposite of pulmonary oedema with bilateral pulmonary infiltrates in the out two thirds of the lung. Management: Steroids.

Answer 40

A histopathologic and radiologic pattern of interstitial lung disease which is the hallmark pattern of idiopathic Pulmonary Fibrosis. Features: On imaging, UIP usually presents with a lung volume loss and a craniocaudal gradient of peripheral septal thickening, bronchiectasis and honeycombing. Causes: - Idiopathic Pulmonary fibrosis - rheumatoid Arthritis (UIP is the most dominant pattern) - Systemic Sclerosis (NSIP more common than UIP) - Polymysitis (A UIP, NSIP or COP pattern) - mixed connective tissues disease (Either UIP or NSIP) - Asbestosis - Chronic Hypersensitivity Pneumoniitis - Radiation pneumonitis - Amiodarone lung - Hermansky-Pudlak Syndrome

Answer 41

The second most common morphological and pathological pattern of interstitial lung diseases. Types: - Fibrotic Type: Most Common, worse outcome - Cellular type: Less common, better prognosis due to good treatment response. Features: Symmetric Bilateral ground-glass opacities with associated fine reticulations and volume loss resulting in traction Bronchiectasis. Immediate Subpleural sparing is considered very specific for NSIP. Causes: Connective Tissue disorders, RA, PBC, Hashimoto’s Thyroiditis, Chemotherapy induced lung disease, Hypersenitivity lung disease. HIV, IgG4 disease. MDS.

Answer 42

NSIP: Bilateral Ground-glass Opacities with fine reticulations and sparing of the immediate subpleural space. UIP: Macroscopic Honeycombing

Answer 43

Improved gas exchange ( Particularly oxygenation) Reduced work of breathing Offloads the left ventricle as the positive pressure applied counteracts the normal negative pressure which normally cause LVEDV to increase impairing cardiac function. The positive pressure leads to Lower LVEDV and increased stroke volume

Answer 44

The difference between IPAP and EPAP

Answer 45

If hypoxaemic increase CPAP up to 10cmh20 and increase FiO2 If tachypneoic and acidotic increase IPAP in 2cmh20 increments as tolerated If asynchronous check mask fit, assess intrinsic PEEP or trigger sensitivity

Answer 46

- Broad-spectrum IV Antibiotics - Urgent Intrapleural chest drainage - If not resolving within 48hrs consider discussing with Thoracic surgeons: - VATS /Open Thoracotomy. - TPA/DNAase may be used in loculated lesions, MIST 2 Protocol showed reduction in need for Surgery and reduced length of stay when used.

Answer 47

An extremely rare autosomal recessive condition which results in oculocutaenous albinism, bleeding problems, and storage of an abnormal fat protein compound. Affects 1 in 500000 and more common in Puerto Rican’s ( 1 in 1800). Features: - albinism and eye problems, individuals will have varying amounts of melanin. This leads to photophobia, impaired vision, strabismus and nystagmus - bleeding disorders, platelet dysfunction leads to abnormal clotting. - cellular storage disorders, wa lax substance to accumulate in the lungs and kidneys leading to fibrosis.

Answer 48

For use in patients over 35yrs old hospitalised with IECOPD. 1) (On a good day, within the last 3 months) Extended MRC Dyspnoea scale - score 1-4 = 0 Points, - score 5a (Too dysgenic to leave the house but independent with washing/dressing) +1 - Too dyspneic to leave the house and wash/dress 5b = +2 2) Eosinopenia Eos less than 0.05 = +1 3) Consolidation on CXR = +1 4) Acidaemia pH less than 7.3 = +1 5) AF on ECG or Hx of AF = +1 A score of 0-1 is associated with a mortality risk of 0-1.5% and these patients can be considered for early discharge. A score of 2 is associated with 5.4% in-hospital mortality these patients require clinical judgement regarding early discharge. A score of 3-6 is associated with 15.3%-50% mortality these patients should not only be kept in hospital but might benefit from early ITU involvement or Palliative care.

Answer 49

A combination of Rheumatoid Arthritis and Pneumoconiosis that manifests as intrapulmonary nodules which appear homogenous and well defined on CXR. Occurs in dust-exposed persons with RA or subsequently develop RA within 5-10years. Usually related to mining dust (Coal, Asbestos, Silica) Features: Cough, SOB, Joint Pain/ Swelling Management: -Exclude TB and manage with steroids.

Answer 50

If CT shows Solid non-calcified nodules and there are clear features of benign disease (e.g. Hamartoma, typical peri-fissures nodule), or nodule less than 5mm diameter (or 80mm3) or patient unfit for any surgery they can be discharged. If the nodule is less than 8mm diameter or 300mm3 they can under go CT Surveillance. Otherwise they need to be risk assessed using Brock Model. If less than 10% risk of malignancy with brock model they can undergo CT Surveillance, if over 10% they require PET-CT with risk assessment using Herder Model. If the risk of malignancy is less than 10% with Herder model they can undergo CT Surveillance, 10-70% risk should be considered for CT-Guided biopsy or excision biopsy, or CT Surveliannce guided by individual risk and patient preference. If the risk is over 70% excision or non-surgical treatment (+/- image guided biopsy) should be considered. CT Surveillance depends on the initial size. If 5-6mm CT 1 year after baseline and calculate the Volume Doubling Time (VDT). If Volume over 80mm3 or 6mm diameter repeat CT in 3 months. If VDT less than 400days or clear evidence of growth further work up is needed. If stable in diameter repeat CT at 2 years, if stable in volume discharge. If VDT over 600 days consider discharge. If VDT 400-600 consider biopsy or further surveillance.

Answer 51

A scoring calculator that outputs a Malignacy probability based on nodule size and number, type (Solid, pure ground glass, part solid), Location, speculation, and patient demographics such as age, sex, FHx and presence of emphysema.

Answer 52

A scoring system which outputs a probability of malignancy in patients who have under gone PET-CT. It takes into account, age, smoking status, history of malignancy, nodule size and location, spiculation. And PET Activity (No, Faint, Moderate or Intense FDG)