Week 4

Question 1

Early morning headache, no photophobia, distended external jugular vein, anastamoses visible on abdomen.

Answer 1

Superior vena cava obstruction

Question 2

A paraneoplastic change affecting the ends of long bones, causing pain and altered shape.

Answer 2

hypertrophic pulmonary osteoarthropathy

Question 3

A non-specific sign of respiratory disease, with loss of nail bed angle and increased fluctuation on examination.

Answer 3

Finger clubbing

Question 4

The immunoglobulin that binds to allergen in a Type I hypersensitivity reaction.

Answer 4

IgE

Question 5

A mast cell degradation product that can be measured during an acute episode of anaphylaxis.

Answer 5

Serum tryptase

Question 6

Seen in high quantities with chronic Type I hypersensitivity reactions, particularly as an infiltrate. Within the lungs, may contribute to chronic yellow sputum production.

Answer 6

Type I hypersensitivity reaction

Question 7

Causes pneumonia, or a pyrexia of unknown origin (Q fever). This infection is a zoonosis. Complicated cases can include a culture-negative endocarditis.

Answer 7

Coxiella burnetti

Question 8

This organism causes an atypical community acquired pneumonia. It is mostly seen in older children and young adults, and spreads from person to person.

Answer 8

Respiratory syncytial virus

Question 9

An organism that causes pneumonia, acute epliglottitis and exacerbations of COPD. It is gram negative and is cultured on chocolate agar.

Answer 9

Haemophilus influenzae

Question 10

A 19 year old is admitted to A+E short of breath. He is very breathless, appears distressed, and you are unable to take a full history. Following examination, a chest x-ray is requested (see above). What urgent management would you initiate?

Answer 10

Insert a large bore cannula into the 2nd intercostal space, mid clavicular line on the right side

Question 11

The treatment you choose is successful (confirming your diagnosis), but he is moved from A+E to a ward in the hospital. What management would you suggest when handing over his care to the new team?

Answer 11

Insert a chest drain into the 4th or 5th intercostal space in the mid axillary line

Question 12

The same patient is readmitted twice more during the following few months, each time with the same problem. What definitive management would possibly prevent further recurrence?

Answer 12

Refer for pleurodesis

Question 13

Have a major role in innate immunity. Kill pathogens by oxidative free radicals. Can test function using the NBT (nitroblue tetrazdium) test. Important in the defence against bacterial and fungal infection.

Answer 13

neutrophil

Question 14

Respond to pathogen peptides bound to HLA class 1 molecules. Directly kill infected cells via the production of perforin, inducing apoptosis. Protect against viral infections and tumours.

Answer 14

CD8 T cell

Question 15

Antibody producing cells. Fully differentiated.

Answer 15

plasma cell

Question 16

A 22 year old nursery nurse visits her GP for the fourth time this year. She has had multiple chest infections and is worrying about how much time she needs to spend away from work. She says she is coughing up yellow-green phlegm most of the time and experiences chest pain. She is referred to the chest clinic. Investigations include a HRCT, which does not show widened airways. Her sputum does return abnormal growth.

Answer 16

Chronic bronchial sepsis

Question 17

A 43 year old man who is normally fit and well fails to recover from what he thought was a winter cold. He is admitted to hospital and diagnosed with community acquired pneumonia. A repeat CXR shows a D sign, and his pleural tap is frank pus.

Answer 17

Empyema

Question 18

A 5 year old girl is referred to hospital by her GP, primarily for failure to thrive. When taking a history with her parents, you discover she struggles to gain weight. She is small for her age. Her parents say she is intolerant to many foods, and often complains of an upset tummy and what sounds like steatorrhoea. She has had multiple chest infections that don’t respond well for antibiotics, and a HRCT shows widened airways. Genetic testing revels a recessive defect.

Answer 18

Cystic fibrosis

Question 19

Respond to pathogen peptides bound to HLA class II molecules. Activate other lymphocytes. Produce cytokines and influence phagocyte function. Immunoregulatory cells.

Answer 19

CD4 T cell

Question 20

Found within the bloodstream as monocytes. Phagocytic.

Answer 20

macrophage

Question 21

A component of this pathway is vital in opsonisation of pathogens. When bound to antigen can indirectly activate phagocytes.

Answer 21

complement

Question 22

A 57 year old woman has been in hospital in the intensive care unit following GI surgery. She has been fed via a nasogastric tube, but the aspirate is inconclusive. On CXR the NG placement is found to be incorrect, but there is a further abnormality within her right lung field which you believe is secondary to this.

Answer 22

Intrapulmonary abscess

Question 23

A patient with slowly resolving pneumonia is found to have a new abnormality on CXR. It is unclear whether this requires drainage, surgical management or is likely to resolve. Investigations show pH 8.1, LDH 800, Glucose 3.5. Clear fluid on tap.

Answer 23

Simple effusion

Question 24

A 35 year old man is admitted to the acute medical unit short of breath. He seems generally unwell. On examination he has a low BMI (17), and you notice multiple bruises and infected puncture wounds on his extremities. He tells you he regularly injects various street drugs. He has a cardiac murmur and his CXR shows multiple small opacities throughout both lung fields.

Answer 24

Right sided bacterial endocarditis

Question 25

Occurs when the airway is narrowed. May be distressing, can be associated with shortness of breath. Can be relieved with stents.

Answer 25

Stridor

Question 26

An interruption in the sympathetic chain affecting the innervation of the face. Includes ptosis, anhydrosis and miosis.

Answer 26

Horner’s syndrome
Ptosis - Drooping eyelids
Anhydrosis - Failure of sweat glands; decreased sweating
Miosis - Decrease pupil size; excessive contraction

Question 27

A lung cancer in the apex of the lung which can invade into the brachial plexus, causing wasting of the small muscles of the hand and interrupts sympathetic innervation to the head.

Answer 27

Pancoast tumour

Question 28

A boy is referred to genetics following investigation for repeated infections. He has had multiple viral and bacterial infections, and has had recurrent oral candidiasis. Clinically he has multiple facial features suggestive of a genetic cause to his condition. His investigations to date have revealed a low T cell count and hypocalcaemia. His cardiovascular system is abnormal.

Answer 28

Di George syndrome

Question 29

A patient with psoriatic arthritis is started on an immunological therapy for their joint disease. They had no clinical features of chest disease prior to treatment, but now they are short of breath and feel generally unwell. A new chest x ray shows a suspicious cavitating lesion in their left lung apex.

Answer 29

Reactivation of latent tuberculosis

Question 30

A 3 month old baby boy is referred to dermatology with recurrent skin rashes and infections, and the GP was unsure if this was eczema or another underlying diagnosis. His skin is noted to be abnormal across his whole body, and the underlying diagnosis is found to be a form of SCID, though his skin condition has a specific cause.

Answer 30

Graft versus host disease

Question 31

Infects children, with peak incidence in winter. May be secondary to another infection, and can cause mild to severe illness, which may be flu-like. Diagnosis is confirmed by PCR.

Answer 31

Metapneumovirus

Question 32

The commonest cause of bronchiolitis. Diagnosis is by PCR on throat or pernasal swabs. Treatment is supportive.

Answer 32

Respiratory syncytial virus

Question 33

A sexually-transmitted infection that can cause infantile pneumonia by vertical transmission.

Answer 33

Chlamydia trachomatis

Question 34

A paraneoplastic change, also known as myasthenic syndrome, involving hyporeflexia, proximal limb weakness and reduced autonomic activity.

Answer 34

Eaton Lambert syndrome
The attack occurs at the connection between nerve and muscle (the neuromuscular junction) and interferes with the ability of nerve cells to send signals to muscle cells.

Question 35

Local tumour spread that can cause effusion of the related anatomical cavity and atrial fibrillation.

Answer 35

Pericardial invasion

Question 36

A feature of metastatic disease, found on examination and often affecting the neck. Cells from the primary tumour can be seen on aspiration or biopsy.

Answer 36

lymphadenopathy