Respiratory Medicine Pastest

1. A 49-year-old woman has been admitted with haemoptysis and epistaxis, the chest X-ray shows multiple rounded lesions with alveolar shadowing. Laboratory parameters show a leucocytosis without eosinophilia but with microhaematuria, proteinuria as well as antineutrophil cytoplasmic antibodies (c-ANCA). Which drug treatment is the most appropriate? Erythromycin Ampicillin Cyclophosphamide in combination with corticosteroids Ciclosporin Aciclovir

Your answer

The combination of prednisolone and cyclophosphamide is now established as the standard induction therapy for patients with generalised Wegeners granulomatosis or microscopic polyangiitis. There is consensus on how corticosteroids should be used, but less so for cyclophosphamide. Prednisolone is given in doses of around 1 mg/kg per day initially, after which the dose is reduced rapidly, typically at weekly intervals. Controlled trials show that the addition of pulses of methylprednisolone is unlikely to confer additional benefit. Traditionally, patients received daily oral cyclophosphamide (2 mg/kg per day), but latterly intravenous boluses have proved increasingly popular, given in doses of 0.50.75 g/m2 body surface area at intervals of 2 weeks (at least for short periods) to 2 months.

2. A 30-year-old man from Somalia attends your clinic with a productive cough. Sputum is smear-positive for tuberculosis. What does this mean? He needs treatment for tuberculosis and his close contacts need screening, but he is not infectious to casual contacts He needs treatment for tuberculosis, his close contacts need screening and he needs to be isolated from casual contacts He needs treatment for tuberculosis, but he is not infectious to close or casual contacts

Your answer

He has multidrug-resistant tuberculosis He has HIV-associated tuberculosis Smear-positive tuberculosis means the patient is highly infectious to both close contacts (more than 8 hours together per day) and casual contacts, such as other patients on the ward and healthcare workers. He therefore needs isolating in a negative-pressure room and contacts should wear particulate masks until he has received antituberculous therapy for 2 weeks. The sputum may remain positive after this time, but the organisms will be dead. Culture-positive tuberculosis means the immediate smear is negative, but prolonged culture has shown tuberculosis. Smear-positive TB does not necessarily indicate drug resistance or associated HIV infection.

3. A 69-year-old former coal-miner is referred to you by the on-call team. There is a smoking history and he has been managed by his GP for COPD. He has been admitted with dyspnoea that is now so bad that he is unable to manage at home and cannot walk from the chair to the bathroom. There is a cough productive of black sputum. Lung function tests show a mixed restrictive and obstructive picture. A chest X-ray shows marked changes with massive fibrotic masses predominantly in the upper lobes. There are also changes consistent with lung destruction and emphysema. His rheumatoid factor is positive. Which diagnosis fits best with this clinical picture? Progressive Massive Fibrosis (PMF) Chronic obstructive pulmonary disease Tuberculosis Asthma Category 1 pneumoconiosis Your answer

PMF is associated with fibrotic masses in the apices, sometimes up to 10 cm in diameter. There are also emphysematous changes. Usually there is a history of dust inhalation such as coal dust, and rheumatoid factor and antinuclear antibody are often positive. There is a mixed obstructive and restrictive lung defect with reduced transfer factor. PMF may rapidly progress, even in the absence of further dust exposure, leading to respiratory failure and eventually death. Category 2 pneumoconiosis progresses to PMF in around 7% of cases, the rate of progression of category 3 pneumoconiosis is much higher, at around 30%.

4. A 56-year-old woman, who is known to suffer from rheumatoid arthritis, complains she has had recurrent haemoptysis for over 5 years. She has never smoked and only takes a non-steroidal anti-inflammatory agent. According to her, she coughs up phlegm every day and at times this contains streaks of fresh blood. She has no known respiratory disease, but tends to get frequent chest infections that are relieved by a course of antibiotics. What is the most likely diagnosis? Lung cancer Bronchiectasis Your answer Tuberculosis Pulmonary embolism Atypical pneumonia

Some 34% of patients with rheumatoid arthritis develop bronchiectasis. This is characterised by recurrent haemoptysis. The history of expectorating phlegm on most days and frequent chest infections are suggestive of the diagnosis. A highresolution computed tomography (CT) scan of her lungs will establish the diagnosis.

5. You review a 56-year-old man with chronic obstructive pulmonary disease, who is suffering an acute exacerbation. Which of the following features would suggest suitability for non-invasive ventilation? Profound hypoxia Hypercapnia without profound hypoxia Confusion Cryptogenic fibrosing alveolitis

Your answer

Decreased conscious level The answer is (b). Non-invasive ventilation (NIV) is suitable for patients who are conscious, cooperative and able to protect their airway. Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) is applied via a tight-fitting nose- or face-mask. NIV may be particularly useful in a patient suffering acute hypercapnic respiratory failure associated with chronic obstructive pulmonary disease, if the patient is not profoundly hypoxic. NIV may also be an option in a patient who has mild hypoxia associated with community-acquired pneumonia. There is a reduced risk of ventilatorassociated pneumonia, and improved patient comfort and preservation of airway protection mechanisms.

6. A 30-year-old asylum seeker has been complaining of cough, fever and weight loss. The chest X-ray shows a large, upper lobe lesion, the sputum shows acid-fast bacilli that are confirmed as Mycobacterium tuberculosis by polymerase chain reaction (PCR). Drug therapy with isoniazid, rifampicin, ethambutol and pyrazinamide has been started under directly observed therapy (DOT). During the next 4 weeks the disease is still progressing. What is the most likely reason? Infection with multi-resistant tuberculosis Infection with atypical mycobacteriae Underlying bacterial pneumonia Carcinoma of the lung Aspiration pneumonia Your answer

Multidrug-resistant tuberculosis is defined as resistance to rifampicin and isoniazid with or without resistance to other anti-TB drugs. The treatment of patients with drug-resistant tuberculosis should only be carried out by specialist physicians with appropriate experience in the management of such cases. Initial drug resistance is uncommon (< 2%) in previously untreated White patients born in the UK. Higher levels of resistance occur in ethnic minority groups, particularly those of the Indian subcontinent and Black-African ethnic origin, with isoniazid resistance occurring in 46% of such patients. HIV-positivity, independent of ethnic group, is also a marker for increased drug resistance: a positive HIV result increases at least fourfold the chances of single- or multiple-drug resistance compared with an HIV-negative individual. Treatment is complex, time-consuming and demanding for both the patient and the physician. Such treatment should only be carried out by physicians with substantial experience in managing complex resistant cases, and only in hospitals with appropriate isolation facilities. This may require transfer of the patient to an appropriate unit. Treatment of such patients has to be planned on an individual basis and needs to include reserve drugs. Such treatment must be closely monitored because of increased toxicity, but,

more importantly, full compliance is essential to prevent the emergence of further drug resistance. Therefore all such treatment must be directly observed throughout, both on an in-patient and an out-patient basis. Treatment should start with five or more drugs to which the organism is, or is likely to be, susceptible and continue until sputum cultures become negative. Drug treatment then has to be continued with at least three drugs to which the organism is susceptible on in vitro testing for a minimum of a further 9 months and perhaps up to or beyond 24 months, depending on the in vitro drug-resistance profile, the available drugs and the patients HIV status. Consideration may also have to be given to resection of pulmonary lesions under drug cover.

7. Which of the following is the best agent for treating chlamydia pneumonia? Clarithromycin Piperacillin Clindamycin Ampicillin Imipenem Your answer

Macrolide antibiotics (eg clarithromycin or erythromycin) are the treatment of choice for chlamydia and other atypical pneumonias. The most frequent side-effects are nausea, vomiting and diarrhoea. It should be kept in mind that treatment is likely to be most effective when given over a long rather than a short time, suboptimal doses are avoided and compliance is strict.

8. You are asked to see a 32-year-old immigrant who complains of chronic cough and weight loss over the past few months. Examination of sputum reveals acid and alcohol fast bacilli (AAFBs) and tuberculosis is confirmed. You elect to begin treatment with isoniazid, rifampicin, ethambutol and pyrazinamide as he is from an area where high levels of drug resistance are present. Which of the following blood tests is most desirable before starting therapy? Liver function testing Serum calcium Renal function testing Clotting Full blood count Your answer

Both isoniazid and rifampicin may be associated with significant hepatic dysfunction. In particular, severe and sometimes fatal hepatitis has been seen with use of isoniazid. Particular problems occur in slow acetylators who have markedly elevated serum isoniazid levels. In patients with existing liver dysfunction, rifampicin and isoniazid should only be used in cases of absolute clinical necessity. Even then, dose reduction of rifampicin is recommended and initial weekly monitoring of liver function tests should be carried out.

9. A 67-year-old woman has been diagnosed as suffering from bronchiectasis on a highresolution computed tomography (HRCT) scan of the lung. Which one of the following statements is NOT true? She is at risk of developing a pneumothorax She is at risk of developing a brain abscess Massive haemoptysis is the commonest cause of death in her age group Your answer Recurrent chest infections are likely at her age Her immunoglobulin levels should be checked Congenital and acquired immunodeficiencies are well-known causes of bronchiectasis. To exclude them, the serum immunoglobulins should be checked. In particular, the IgG subclass (IgG1, -2, -3 and -4). Patients with an immunoglobulin deficiency should be treated with regular immunoglobulin infusions. Pneumothorax, recurrent chest infections and brain abscesses are well-known complications of bronchiectasis. Haemoptysis is a common symptom but is rarely a cause of death. 10.Which one of the following conditions is MOST likely to be associated with low FEV1 and normal TLCO? Asthma Your answer Emphysema Sarcoidosis Pulmonary hypertension Fibrosing alveolitis

The diffusion of CO from the alveoli to the pulmonary blood is governed by the integrity of the alveolar membrane, the capillary blood volume, or both (airblood barrier). A reduction in the diffusion capacity of CO is encountered in conditions affecting the capillary bed size such as pulmonary emboli and pulmonary vasculitis, or conditions that cause changes in the characteristics of the alveolar membrane which include diseases in which some form of intraalveolar filling process has occurred and the air to blood diffusion pathway is actually lengthened (pneumonia, pulmonary oedema, alveolar proteinosis). Similarly, TLCO is reduced in patients with infiltrative disorders of the lung that affects both the capillary bed size and the alveolar membrane integrity such as sarcoidosis, interstitial lung diseases, or collagen vascular diseases. Removal or destruction of lung tissue, such as surgery or emphysema decreases both membrane and blood volume components and produces low TLCO. An increase in TLCO results occasionally from an increase in capillary blood volume secondary to haemodynamic changes in pulmonary circulation; an increase in pulmonary arterial or left atrial pressures, as in congestive heart failure, or an increase in pulmonary blood flow, as in arterial septal defect. The TLCO is sometimes increased in patients with bronchial asthma during an attack, but the cause of this change is not known. Alveolar haemorrhage from any cause can result in a false increase of TLCO despite the presence of an underlying diffusion defect.

11. Which of the following does not increase the risk of death in patients with severe pneumonia? Diastolic blood pressure < 60 mmHg Age 49 years Urea > 7 mmol/l WBC count < 4 109/l Atrial fibrillation

Your answer

Patients over 60 years of age with severe pneumonia have an increased of risk of dying. The other factors that increase the risk of death are tachypnoea (respiratory rate > 30/min), underlying disease, confusion, multi-lobular involvement, albumin < 35 g/l, hypoxia pa(O2) < 8 kPa, leucocytosis > 20 109/l and bacteraemia. Leukopaenia is also associated with a higher rate of mortality in pneumonia.

12. Which one of the following statements with regard to sarcoidosis is true?

Parenchymal lung disease is often accompanied with pleural effusion Clubbing of the fingers is an early feature Jaundice and portal hypertension are the predominant features of hepatic sarcoidosis A positive tuberculin test in a patient with chronic sarcoidosis is Your suggestive of concomitant tuberculosis answer Hypercalcaemia when it manifests is usually resistant to steroid therapy Sarcoidosis is a systemic disorder of unknown cause that is characterised by its pathological hallmark, the noncaseating granuloma primarily affecting the respiratory tract, skin, eye, heart, kidneys and liver. Pleural disease is relatively infrequent, with effusions occurring in fewer than 5% of patients. Clubbing of the fingers is not a recognised feature of sarcoidosis. Although liver biopsy reveals granulomatous involvement in 4070% of patients, clinically significant hepatic disease is rare. A tuberculin test is usually negative in chronic sarcoidosis, however, most sarcoidosis patients who develop tuberculosis become tuberculin-positive. Hypercalcaemia, a potentially important complication of sarcoidosis, occurs in fewer than 10% of patients and is thought to be due to elevated levels of 1,25dihydroxyvitamin D (calcitriol), which is produced by macrophages within the granulomas. High-dose glucocorticoids are very helpful in vitamin D intoxication, granulomatous diseases such as sarcoidosis, and haematologic malignancies known or likely to be glucocorticoid-responsive. 13. A 37-year-old man presents with increasing breathlessness and is diagnosed after investigation with emphysema. Which of the following conditions is most likely to predispose to the development of emphysema? Allergic bronchopulmonary aspergillosis Hypogammaglobulinaemia Childhood bronchiolitis Bronchial adenoma Crohns disease

Your answer

McLeods syndrome is unilateral emphysema following childhood bronchiolitis. Emphysema is most commonly related to smoking, although it may also be associated to 1-antitrypsin deficiency. The other stems are associated with bronchiectasis. Bronchiectasis may occur as a consequence of bronchial obstruction either by intrinsic or extrinsic pathology. Infections such as tuberculosis and previous pneumonia may lead to bronchiectasis. Congenital syndrome such as cystic fibrosis, immotile cilia syndrome and Kartageners syndrome may also be implicated in the development of bronchiectasis. Inflammatory bowel disease has also been associated with development of bronchiectasis.

14. The nurses on the ward ask you to look at a chest drain that has been inserted in a patient for a pneumothorax. They are concerned about whether it is still working. When the patient coughs, nothing happens. When he breathes in and out, the fluid in the tube moves up and down. What does this mean? Air and fluid are draining from the pleural space Fluid alone is draining from the pleural space Air is no longer draining from the pleural space as the drain is blocked Air is no longer draining from the pleural space, but the drain is still working He needs to commence suction to the drain The fluid level rising and falling in the drain swinging shows it is still in contact with the pleural space and the fluid level is moving with respiration. Air is not bubbling out of the drain when the patient coughs, as the air has stopped draining from the pleural space and the lung has re-inflated. If a drain does not bubble or swing, then it is blocked or kinked and is not working. With a simple pneumothorax, there would be minimal fluid drainage from the chest. Suction is necessary if the drain is still bubbling, but the lung has not fully re-inflated on the chest X-ray.

Your answer

15. A patient presents with symptoms suggesting bronchiectasis and abdominal distension, bloating and foul-smelling faeces. What is the most likely diagnosis? Carcinoma of the lung Wegeners granulomatosis Pneumococcus pneumonia Goodpastures syndrome Cystic fibrosis

Your answer

The United States Cystic Fibrosis Foundation Registry data show that as many as 10% of cystic fibrosis patients are not diagnosed until adult life. The main presentation is with respiratory problems, usually recurrent lower respiratory infections with chronic sputum production. Some patients are given a prior diagnosis of bronchiectasis, atypical asthma, nasal polyposis or allergic bronchopulmonary aspergillosis. A new diagnosis of cystic fibrosis has been described even in adults in their seventh decade. Depletion of sodium, chloride and potassium due to excessive sweating, and secondary renal chloride retention, may result in presentation with dehydration and heat exhaustion in an otherwise apparently completely fit adult. Pancreatic insufficiency can lead to steatorrhoea. The vast majority of patients with cystic fibrosis can be diagnosed by a sweat test.

16. A 38-year-old man presents with emphysema. He is a non-smoker. He also has abnormal liver function tests, and his liver biopsy reveals evidence of cirrhosis. You suspect alpha-1 antitrypsin deficiency. What is the genotype that fits best with this clinical picture? PiMM PiMZ PiSZ PiZZ PiSS

Your answer

This man has severe disease, which is most commonly associated with the PiZZ genotype. Such a patient may even present with liver disease in childhood and require eventual transplantation. Around 1015% of patients with PiZZ genotype develop cirrhosis by the age of 50 years, and 75% develop respiratory problems. Heterozygotes are less likely to develop liver disease, and tend to develop less severe lung disease, although the PiMZ or PiSZ genotypes (heterozygotic state) may accelerate emphysema associated with smoking. Levels of 1-antitrypsin correlate with genotype; in homozygotes they run at around 10% of the normal level, while heterozygotes have levels at around 60% of normal. Best prognosis from 1-antitrypsin deficiency is seen in non-smoking patients; for this reason, advise patients to refrain from smoking at all costs.

17. A 72-year-old man is admitted via the on-call team with an acute respiratory tract infection. He has a 40 pack-year smoking history and continues to smoke 15 cigarettes per day. After recovery from his initial infection, lung function testing indicates that his FEV1 (forced expiratory volume in 1 second) is less than 50% of predicted, and chronic obstructive pulmonary disease (COPD) is diagnosed. This is his third exacerbation this

year so far, which have necessitated hospital admission. What is the best pharmacological intervention for him? Salbutamol prn for symptom relief Low-dose beclometasone inhaled-steroid therapy as prophylaxis High-dose inhaled steroid therapy as prophylaxis Inhaled anticholinergics for symptom relief Combination therapy with a high-dose inhaled steroid and a long-acting Your answer 2-agonist Recent evidence has shown that, for patients who suffer recurrent severe exacerbations of COPD and who have an FEV1 less than 50% predicted, combination therapy with highdose inhaled steroids and a long-acting b2-agonist may reduce severe exacerbations. A long-term study (TORCH) is continuing to ascertain if this combination may be diseasemodifying. Of course, this combination should be used in conjunction with smoking cessation where possible, and long-term home oxygen therapy if the criteria for its prescription are met. COPD carries a worse long-term survival than some cancers. Once respiratory failure criteria have been met, the 5-year survival rate is only around 25%. There is now value in using low-dose inhaled steroid therapy in the management of COPD.

18. Which lung disease is associated with the clinical observations pink puffer and blue bloater? Cystic fibrosis Pulmonary fibrosis COPD Small-cell lung cancer Tuberculosis Pink puffers have a good respiratory drive. Features include: purse-lip breathing with intense dyspnoea, patient is often thin and elderly, little sputum produced, oedema and overt heart failure are rare complications. Investigations: blood gases are near normal until pre-terminally there is very severe airways obstruction, total lung capacity is increased, there is a reduction in transfer factor. Blue bloaters have a poor respiratory drive. Features include: quite mild dyspnoea, patient often obese, large volumes of sputum produced, infective exacerbations, patient often oedematous, may develop cor pulmonale.

Your answer

Investigations: blood gases hypercapnia, hypoxaemia, elevated plasma bicarbonate, severe nocturnal hypoxaemia, airways obstruction may only be moderate, transfer factor approximately normal.

19. An 18-year-old student presents to A&E suffering from severe pharyngitis and earache, there is also lethargy and muscle ache. He also complains of wheezing, but there is no previous history of asthma. On examination he has a non-exudative pharyngitis and bullous myringitis, wheeze on auscultation but no evidence of consolidation. There is erythema nodosum. The white blood cell count is 14 109/l , but there is no specific indication of bacterial infection. Cold agglutinins are detected. A chest X-ray reveals dramatic upperlobe consolidation quite out of character with the clinical examination. What diagnosis best fits this clinical picture? Streptococcus pneumoniae pneumonia Haemophilus influenzae pneumonia Tuberculosis Mycoplasma pneumonia Chlamydia pneumonia

Your answer

Mycoplasma occurs in epidemics occurring every 4 to 5 years, more commonly amongst close-knit populations like those in schools and colleges. Peak age of presentation is 5-20 years, and mycoplasma is said to account for 7% of community-acquired pneumonia. Cold agglutinins are associated with up to 50% of cases, muscle tenderness is said to occur in up to 50% of cases and, often, X-ray appearances are much worse than is suggested by the clinical examination of the respiratory system. Treatment is a 2-week course of erythromycin or clarithromycin. X-ray resolution is complete by week 8 in around 90% of patients.

20. The anatomical dead space may be used to calculate alveolar ventilation by subtracting it from the tidal volume and multiplying the result by the respiratory rate. What would you expect the normal anatomical dead space to be in a healthy adult male? 50 ml 150 ml 250 ml 350 ml 450 ml

Your answer

The normal anatomical dead space is approximately 150 ml. If we take tidal volume to be about 500 ml and respiratory rate to be about 15/minute, this gives a normal alveolar ventilation of (500 150) 15 = 5250 ml/min. Diseases that cause an additional physiological dead space where parts of lung do not take part in gas exchange, eg pneumonia, may increase this dead space.

21. A 74-year-old man, who is a retired builder of railway carriages, presents to his GP. Over the past year or so he has noticed gradually increasing shortness of breath on exertion. He has a frequent dry and non-productive cough. On examination the GP notices that he has digital clubbing, peripheral oedema and a raised JVP, with fine end-inspiratory crackles heard at the bases on auscultation. Chest X-ray reveals irregular shadows in the lower lung zones and thickened pleural plaques affecting the lower zones. What diagnosis would fit best with this clinical history and these findings on examination and investigation? Asthma Bronchial carcinoma Cryptogenic fibrosing alveolitis Asbestosis Silicosis

Your answer

The clue lies in this mans occupation since asbestos fibres were often used in the building of railway carriages. There is a long gap between exposure to the fibres and asbestosis of some 2030 years, therefore many cases are still coming to light, and quite some time after the exposure to asbestos was curtailed. Currently, around 510 new cases per 100,000 of the population occur per year. Without the exposure to asbestos option C would have been a reasonable alternative answer. Diagnosis is confirmed on exposure history, typical imaging studies and isolation of fibres. Arterial blood gas measurement in these patients usually demonstrates hypoxia, while pulmonary function tests demonstrate decreased vital capacity, decreased total lung capacity and decreased gas transfer. Death may occur due to cor pulmonale or asbestos exposure-related cancer. such as mesothelioma or bronchial carcinoma. Therapy is with oxygen by prescription and effective management of acute infections, but decline is usually inexorable.

22. A 50-year-old woman patient presents with increasing dyspnoea. She is obese, smokes and takes oestrogens for menopausal symptoms. On examination

you find clinical, electrocardial and radiological findings of a right-sided heart failure without signs of left ventricular failure. What is the most likely cause for the cor pulmonale? Asthma Recurrent pneumonias Recurrent small pulmonary embolisms Your answer Bronchiectasis Carcinoma of the lung Pulmonary hypertension develops as the result of a critical reduction of crosssectional area for blood flow. The relatively high flow through non-occluded vessels may cause secondary hypertensive changes in the resistive or precapillary vessels. Patients with mean pulmonary artery pressures over 30 mmHg have a 5year survival rate of 30%, but this rate falls to 10% if the mean pulmonary artery pressure is over 50 mmHg. Most patients do not have an obvious history of venous thrombosis or pulmonary embolism. Dyspnoea is present in virtually all, but in the early stages may occur only on exertion. Compensatory right ventricular hypertrophy develops, and there may be a period of months to years when symptoms remain stable, but ultimately right ventricular function deteriorates. Symptoms then include worsening dyspnoea, fatigue, presyncope, syncope (rarely), pleuritic pain, angina-like pain, abdominal swelling and peripheral oedema. Signs of respiratory and right ventricular failure develop, with cyanosis, grossly elevated jugular venous pulse, palpable right ventricular heave, right ventricular gallop, loud P2, hepatomegaly, ascites and peripheral oedema. Bruits may be heard over the pulmonary arteries. Ventilationperfusion lung scans typically show one or more mismatched segmental or larger perfusion defects, with most patients having several bilateral mismatched perfusion defects. Pulmonary angiography is the most definitive diagnostic test. It shows narrowed segmental pulmonary arteries, sometimes accompanied by post-stenotic dilatation, irregularity of the intima, luminal narrowing of the central arteries and oddly shaped vessels. Pulmonary fibre-optic angioscopy is useful to define surgical accessibility.

23. A 61-year-old man with a 40 pack-year smoking history presents with chronic cough, haemoptysis and weight loss. Unfortunately his chest X-ray reveals a large mass at the left hilum, suggestive of a bronchial carcinoma. A raised calcium is noted on routine blood work-up. What type of carcinoma would best fit this clinical picture? Adenocarcinoma of the bronchus Squamous cell-carcinoma of the bronchus Small-cell bronchial carcinoma Large-cell bronchial carcinoma Bronchioalveolar-cell carcinoma Correct answer Your answer

Squamous-cell and small-cell bronchial carcinomas tend to occupy a central location. Squanmous-cell carcinomas are more frequently associated with hypercalcaemia, so the correct answer in this case is option B. The other options tend to occur more frequently in the periphery. In terms of frequency, adenocarcinomas are the commonest, making up around 35% of the total, squamous-cell carcinomas make up around 20-30%, small-cell carcinomas around 20%, large cell carcinomas 15-20% and bronchioalveolar-cell carcinomas around 5% of the total. Bronchioalveolar-cell carcinoma has no correlation with cigarette smoking.

24. A 26-year-old man presents with fever, headache and a non-productive cough. The chest X-ray shows increased interstitial markings. The laboratory examination shows an elevated LDH and anaemia with the presence of cold agglutinins. What is the most appropriate treatment? Erythromycin Your answer Piperacillin Clindamycin Ampicillin

Imipenem This patient presents with mycoplasma pneumonia. With regard to treatment, the pathogen lacks a cell wall and hence is not susceptible to penicillin, cephalosporins or other cell-wall active antibiotics. Macrolide antibiotics (eg erythromycin or clarithromycin) are the treatment of choice for mycoplasma and other atypical pneumonias. The most frequent side-effects are nausea, vomiting and diarrhoea. It should be kept in mind that treatment is likely to be most effective when given over a long rather than short time, suboptimal doses are avoided and compliance is strict. Acute cold autoimmune haemolytic anaemia is commonly seen in adolescents and young adults following infection with mycoplasma. Haemolysis occurs approximately 12 weeks following infection and is most commonly associated with a rise in polyclonal anti-IgM antibodies with mycoplasma pneumonia. The typical patient is usually a young adult who experiences a respiratory tract infection accompanied by headache, myalgia, cough and fever, and with a chest X-ray that shows bronchopneumonia. The cough is often non-productive, but when sputum is obtained it is mucoid, shows predominantly mononuclear cells and no dominant organism. A characteristic feature is the relatively high frequency of extrapulmonary complications such as rash, neurological syndromes (aseptic meningitis, encephalitis, neuropathies), myocarditis, pericarditis and haemolytic anaemia. The diagnosis should be suspected in those patients with a relatively mild form of pneumonia, particularly in previously healthy young adults.

25. A patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l. Which of the following is the most likely cause? Sodium-restricted diet Sodium-reduced water drinking SIADH Liver metastases Bone metastases

Your answer

The continued secretion of vasopressin (antidiuretic hormone, ADH) in an amount in excess of the bodys needs, leads to overhydration in both the intracellular and extracellular compartments the so-called syndrome of inappropriate antidiuretic hormone secretion

(SIADH). The cerebral oedema resulting from water intoxication causes drowsiness, lethargy, irritability, mental confusion and disorientation, with seizures and coma being the most profound features. Peripheral oedema is remarkably rare. The patient is usually asymptomatic until the sodium concentration falls below 120 mmol/l and the hyponatraemia is dilutional in type with a low serum osmolality. Urine osmolality usually exceeds 300 mOsmol/kg. The commonest cancer causing this syndrome is small-cell cancer, where it is clinically obvious in 10% of cases, with subclinical involvement detectable by a water-loading test in more than 50%. Restriction of fluid to a daily intake of 7001000 ml may redress the hyponatraemia, but demethylchlortetracycline (demeclocycline) 6001200 mg daily is often highly effective, making water restriction unnecessary.Infusion of hypertonic saline is hazardous, often precipitating cardiac failure or cerebral oedema.

26. A 29-year-old office secretary has been suffering from intermittent pain and tenderness affecting her elbows, wrist and ankles for last 2 years. Symptomatic relief had being obtained from NSAIDs. For last 3 months she has been increasingly unwell, and with night sweats, fever and a weight loss of about 6.4 kg (14 lbs). She also developed a nonproductive cough and left-sided pleuritic chest pain. She smoked 30 cigarettes per day. On examination she had temperature of 37.8 C. The syno vium was palpable over her wrist joints. On respiratory examination her left lower zone was dull to percussion with decreased breath sounds. A chest X-ray confirmed a left-sided pleural effusion in addition to some fibrotic patches on both the upper zones. Aspiration showed a straw-coloured fluid with a protein concentration of 46 g/l and a glucose concentration of 1.6 mmol/l. The fluid contained many lymphocytes but no malignant cells. A culture was sterile on the fifth day. What is the probable cause of the pleural effusion? Sarcoidosis Rheumatoid pleural effusion Tuberculosis Pleural effusion secondary to lung malignancy Lymphoma

Your answer

Two main points for the diagnosis are the unilateral pleural effusion and upper zone shadowing. Rheumatoid effusions are unusual in the young and are small and asymptomatic. This woman may have rheumatoid disease but this is not the cause of her effusion. It is now well recognised that tuberculosis may be associated with an inflammatory polyarthritis which may follow a similar pattern to rheumatoid arthritis seen here. Lymphocyte predominance suggests lymphoma, carcinoma or tuberculosis. A low glucose concentration favours an infection, malignancy or a rheumatoid condition. But the fibrotic shadow of the upper zone clinches the diagnosis in this case and is typical of post-

primary tuberculosis. Sarcoidosis shows upper zone fibrosis with pleural effusion at endstage only, and it is rare. No other feature favours the diagnosis.

27. A 24-year-old medical student (height 165 cm, weight 78 kg) has been complaining of a few months history of shortness of breath on exertion and of coughing up blood once. She is a few days away from her final examination and smokes 20 cigarettes per day. She takes no medication except for the oral contraceptive pill. What is the most likely diagnosis? Hyperventilation syndrome due to stress Tuberculosis Recurrent pulmonary embolism Your answer Sarcoidosis Goodpastures syndrome

Pulmonary embolism can present in diverse ways. The syndrome of pleuritic pain or haemoptysis, in the absence of circulatory collapse, is the most frequent mode of presentation of acute pulmonary embolism. It occurred in 60% of patients recruited in a collaborative investigation, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). A syndrome of dyspnoea in the absence of haemoptysis or pleuritic pain or circulatory collapse occurred in 25%. Circulatory collapse (systolic blood pressure less than 80 mmHg or loss of consciousness) was an uncommon mode of presentation, occurring in 15%. Obesity and a high oestrogen content in oral contraceptives have been linked to thromboembolic events. Most patients with pulmonary embolism had smoked at one time or continued to smoke at the time of their pulmonary embolism.

28. A 23-year-old army cadet is admitted to hospital with cough, headaches and malaise. He has a temperature of 38 C. His blood count, renal and liver functions are normal. Cold agglutinins are positive. A chest X-ray shows bi-basal shadowing. What is the most likely diagnosis? Legionella pneumonia Viral pneumonia Q fever Klebsiella pneumonia Mycoplasma pneumonia Your answer Mycoplasma pneumonia is a common cause of pneumonia often occurring in young people. It is characterised by headaches, malaise and cough. Chest X-ray findings may not correlate with the patients condition. The white blood count may be normal and cold agglutinins occur in half of the patients. Extrapulmonary complications are pericarditis, myocarditis, erythema multiforme, vomiting, diarrhoea and meningoencephalitis.

29. You have a Caucasian patient with cystic fibrosis on the ward. His 20-year-old sister does not have cystic fibrosis, but comes to ask you about the chances of her having children with cystic fibrosis. They have the same parents. Which of the following statements is correct? She has a 1 in 4 chance of being a carrier of the cystic fibrosis gene She is not a carrier of the cystic fibrosis gene

If she does not have the F508 deletion she is not a cystic fibrosis carrier Genetic testing is not necessary to assign carrier status Her Caucasian partner has a 1 in 25 chance of being a cystic fibrosis carrier

Your answer

The carrier frequency for cystic fibrosis (CF) in Caucasians is 1 in 25. The CF gene is inherited autosomal recessively. Therefore a sibling of an affected person has a 1 in 2 chance of being a CF carrier. In the case of this patient's sister, she knows she doesn't have CF, so her chance of being a carrier for the CF gene is 2/3. CF accounts for 1 in 2500 live births. CF is much rarer in patients of Afro Caribbean and Asian origin. There are more than 1000 different mutations recognised in the gene for the cystic fibrosis transmembrane conductance regulator. The most common is F508, which accounts for around 67% of CF alleles in the UK and northern Europe: 85% of CF alleles can be screened for genetically. Genetic testing would be necessary to assign carrier status, although the diagnosis of cystic fibrosis could be made clinically with sweat testing on someone who is homozygous.

30. A 58-year-old man with a heavy previous asbestos-exposure history smokes 20 cigarettes per day and has done since he was 17 years old. What is his increased risk of developing bronchial carcinoma compared to a lifelong nonsmoker, never exposed to asbestos? 100 times 50 times 20 times 10 times 2 times

Your answer

Asbestos exposure increases the risk of developing bronchial carcinoma 5 times, whereas smoking increases the risk approximately 1011 times. However, if a patient has both risk factors then the risk is multiplicative and is approximately 50 times greater than a lifelong non-smoker never exposed to asbestos.

31. A 42-year-old has had Raynauds phenomenon for many years, but now presents to her GP with non-specific symptoms of shortness of breath and a dry non-productive cough, as well as heartburn and a flitting arthralgia affecting a number of small joints. On examination the GP notices that her face appears a little waxy and expressionless and that her hands are cold with nodular thickening of the skin over the fingers. There is telangiectasia. The most striking abnormality on respiratory examination are fine endexpiratory crackles on chest auscultation. Chest X-ray reveals a fibrotic lung picture. Antinuclear antibodies are positive. What diagnosis fits best with this clinical picture? Amyloidosis Cryptogenic fibrosing alveolitis Systemic lupus erythematosus Progressive systemic sclerosis Primary pulmonary hypertension

Your answer

The picture of Raynauds disease, peripheral calcinosis, oesophageal symptoms, sclerodactyly, telangiectasia and evidence of pulmonary fibrosis is highly suggestive of progressive systemic sclerosis, indeed of the CREST syndrome. Positive antinuclear antibodies support the diagnosis. Some 30% of patients are also rheumatoid factor-positive. At present, there are no proven disease-modifying agents and patients suffer from progressive symptoms including worsening pulmonary hypertension: however, penicillamine does show at least some promise in this area. Calcium antagonists may prove useful in the treatment of Raynauds, and there are a number of therapies that can be employed for symptomatic reflux disease.

32. A 72-year-old man with ischaemic heart disease is on a variety of medication following a myocardial infarction 12 months ago, including aspirin, atenolol, lisinopril, amiodarone and furosemide (frusemide). He is becoming progressively breathless and his cardiologist sends him for pulmonary function tests, which show a restrictive ventilatory defect with decreased gas transfer. Which one of his medications is most likely to be the cause of these abnormalities? Aspirin

Atenolol Lisinopril Amiodarone Your answer Furosemide Aspirin is associated with nasal polyps and asthma, atenolol with bronchoconstriction, lisinopril with cough and furosemide very rarely with bronchoconstriction. Amiodarone is associated with pulmonary fibrosis.

33. A 35-year-old woman visits her GP complaining of a dry non-productive cough and lethargy. There has been slow weight loss over the past few months and there is a nodular rash on her shins. Blood testing reveals mild hypercalcaemia, a non-specific increase in immunoglobulins, normochromic normocytic anaemia and a raised serum ACE level. A chest X-ray reveals bilateral hilar lymphadenopathy. Tuberculin skin testing is negative. What diagnosis fits best with this clinical picture? Sarcoidosis Tuberculosis Lymphoma Lymphangitis carcinomatosa Cryptogenic fibrosing alveolitis Your answer

Sarcoid is most common in young women and the UK prevalence is approximately 19 per 100,000 of the population. It is a multisystem granulomatous disorder: 50% of sufferers present with respiratory symptoms, or abnormalities on chest X-ray; 10% of cases are associated with erythema nodosum; 25% with uveitis; and 10% of established cases are associated with hypercalcaemia. A definitive diagnosis is usually obtained via transbronchial biopsy in over 90% of cases. The disease severity varies amongst racial groups, and is more severe in Black populations. Treatment with corticosteroids is usual for severe disease or persistent changes on chest X-ray, but mortality in the UK from sarcoidosis is probably less than 5%.

34. A 65-year-old man complains of lethargy, fever, dry cough, headache, chest pain and increasing shortness of breath. He returned from a cruise 2 days ago. His chest X-ray shows bilateral infiltrates, the p(O2) is 8.35 kPa. What is the most likely diagnosis? Tuberculosis Pulmonary embolism Small-cell carcinoma of the lung Sarcoidosis Legionella pneumonia

Your answer

Legionella infection is the cause of around 25% of cases of community-acquired pneumonia admitted to hospital, although there is wider geographical and seasonal variation. Infection tends to lead to moderate or severe infection rather than mild illness, and most patients require hospital admission within 57 days of the start of symptoms. The incubation period is usually 210 days, with a mean of 7 days; males are two to three times more frequently affected than females. Infection at the extremes of age is rare and the highest incidence is in 40- to 70-year-old people, with a mean age of 53 years. People particularly at risk include cigarette smokers, alcoholics, diabetics and those with a chronic illness or who are receiving corticosteroids or immunosuppressive therapy. Consequently, the type of patient who requires admission to hospital is particularly at risk from a nosocomial source. Typically, the illness starts fairly abruptly with high fever, shivers, bad headache and muscle pains. Upper respiratory tract symptoms, herpes labialis and skin rashes are uncommon. The cough is usually dry initially, but dyspnoea is common and the illness often progresses quickly. Sometimes there may be a history of a recent hotel holiday abroad or a stay in hospital, which can alert the clinician to the possible diagnosis. The patient commonly looks toxic and ill, with a high fever over 39 C. Confusion and delirium or diarrhoea can dominate the clinical picture, masking the true diagnosis of pneumonia. Focal neurological signs, particularly of a cerebellar type, are well described. Amnesia on recovery is common.

35. A patient presents with shortness of breath. His transfer coefficient (KCO) is 160% of predicted. What is the most likely cause? Fibrosing alveolitis Asthma Pulmonary haemorrhage Pulmonary embolus Pneumonia

Your answer

The transfer coefficient (Kco), which is obtained along with the TLco, represents the uptake of carbon monoxide per litre of effective alveolar volume (VA), that is, Kco = TLco /VA. To a large extent, Kco allows correction for any real or effective reduction of alveolar volume, tending to be normal after lung resection, when both TLco and VA are reduced approximately to the same degree. In some conditions Kco may increase. The latter usually results from an increase in red blood cells in the lungs due to greater blood flow, haemorrhage, or polycythaemia. Kco is similarly increased in these conditions, as it is if, at full inflation, the density of pulmonary capillaries per unit alveolar volume is greater than normal. This occurs most commonly in patients with extrapulmonary volume restriction, when the density of pulmonary capillaries is unusually high in relation to the (restricted) lung volume at which the measurement is made.

36. A 65-year-old woman has been diagnosed as having lung cancer. Which of the following statements is most appropriate? Hypertrophic pulmonary osteoarthropathy (HPOA) is commonly seen patients with small-cell carcinoma Inappropriate secretion of antidiuretic hormone (ISADH) is commonly seen in patients with squamous-cell carcinoma Hypercalcaemia may occur without bone metastasis Paraneoplastic syndromes occur more commonly with squamouscell carcinomas Hypercalcaemia associated with bone metastasis is best treated with intravenous steroids

Your answer

Paraneoplastic syndromes are a variety of non-metastatic metabolic or neuromuscular manifestations of lung cancer. They are commonly associated with small-cell carcinoma. HPOA is characterised by painful symmetrical arthropathy involving the wrist, ankle and knee joints. It is most commonly seen in patients with squamous-cell carcinoma and is virtually unknown in those with small-cell carcinoma.

Inappropriate secretion of ADH is most common in patients with small-cell carcinoma. Hypercalcaemia may occur as a paraneoplastic syndrome with squamous-cell carcinoma. This is due to the production of a parathyroid hormone-related peptide by the tumour, which increases bone resorption, and renal tubular reabsorption of calcium. This is best treated with intravenous fluids and bisphosphonates. Steroids are mainly used for treating hypercalcaemia associated with sarcoidosis.

37. A 45-year-old man who races pigeons becomes breathless. Which of the following features is suggestive of extrinsic allergic alveolitis? Almost immediate onset after exposure Eosinophilia of sputum Positive skinprick testing Type 1 hypersensitivity reaction Circulating IgG precipitins

Your answer

Extrinsic allergic alveolitis (EAA) is characterised by type 3 (immune-complex) and type 4 (cell-mediated) hypersensitivity reactions to inhaled antigen(s). Despite its name, EAA is not allergic and therefore items associated with allergy tend to be false in EAA eg wheeze, immediate symptoms (not a type 1 reaction), raised IgE, positive skinprick test, eosinophilia of blood or sputum. In the acute form fever, cough and marked shortness of breath (SOB) occurs between 46 h after exposure. Subacutely there is weight loss and fatigue and in the chronic form exertional SOB and pulmonary fibrosis (typically upper lobe). The CXR shows fine reticular/nodular shadowing progressing eventually to a fibrotic pattern with shrunken lungs.

38. A 55-year-old man presents with increasing shortness of breath. He has been working in the sandblasting industry and exposed to quartz particles. What is the most likely diagnosis? Asbestosis Sarcoidosis Silicosis Your answer

Eosinophilic pneumonitis Asthma Silicosis is a fibrotic disease of the lungs due to inhalation of crystalline silicon dioxide, usually in the form of quartz. Silicosis may affect anyone involved in quarrying, carving, mining, tunnelling, grinding or sandblasting, if the dust generated contains quartz. Between 50 and 60 cases are diagnosed in the UK each year, generally in people involved in the production of slate or granite, among miners cutting through rock and in fettlers in foundries. Crystalline silica is present in the earths crust usually as quartz, although other forms such as crystobalite and tridymite occur occasionally. All are extremely toxic to macrophages. Quartz seems to be most toxic when freshly fractured, suggesting that its surface properties are important in toxicity. Silicosis presents a spectrum of clinical appearances depending on the circumstances in which it is contracted. The most severe, acute silicosis, may be acquired after very heavy exposure over just months, such as sandblasting without respiratory protection. These patients become intensely breathless and die within months. The X-ray shows appearances resembling pulmonary oedema. Less heavy exposure causes progressively less dramatic symptoms, ranging from a progressive upper lobe fibrosis with slowly increasing exertional dyspnoea over several years (accelerated silicosis) to radiographic nodular change similar to coal-workers pneumoconiosis unassociated with any symptoms or physical signs. The latter type of silicosis is the most common, and is usually associated with exposure to dust containing 1030% silica over a prolonged period. Simple nodular silicosis differs from coal-workers pneumoconiosis in that the lesions tend to be larger (35 mm) and that it is progressive even after dust exposure ceases. Lesions increase in size and become more profuse. Moreover, extensive simple silicosis may be associated with some restriction of lung volumes. Accelerated silicosis and progressive massive fibrosis cause lung restriction and lead to cor pulmonale and cardiorespiratory failure.

39. A patient with lung cancer underwent radiotherapy 2 weeks ago, he now complains of a severe dry cough, increasing dyspnoea and tachypnoea. On examination there are local crepitations, his chest X-ray shows hazy consolidation that correspond to the irradiation field. What is the most likely diagnosis?

Pulmonary embolism Mycoplasma pneumonia Radiation pneumonitis Your answer Legionella pneumonia Cancer progression Symptoms begin within a few weeks of radiotherapy and may persist for weeks or months. They occur in 1030% of patients following radiotherapy for lung cancer. A cough (which can be severe and may produce thick sputum) and breathlessness are the principal symptoms, but may be accompanied by fever of variable degree. On examination there may be tachypnoea, cyanosis in severe disease, and local crepitations. Telangiectases, the result of cutaneous radiation damage, are often observed in the overlying skin. The most characteristic X-ray feature is an area of hazy consolidation demarcated by a sharp margin (crossing anatomical pulmonary planes) that corresponds to the limits of the irradiation field, though additional effects are usually detectable beyond these boundaries. Computed tomography provides the best means of early identification, ground-glass attenuation and interalveolar septal thickening being the early characteristic features. Dense local fibrosis may develop up to a year or two after radiation, and magnetic resonance imaging may be required to allow differentiation from tumour recurrence.

40. A 60-year-old smoker is being evaluated for a coronary bypass graft. Which is the best preoperative screen of pulmonary function for this patient? Arterial pH Arterial p(CO2) Arterial p(O2) Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) Your answer ratio Oxygen saturation

Pulmonary function tests provide the best preoperative screen, because they reflect dynamic measurements of pulmonary function in the patient. The arterial blood gas measurements reflect acidbase disorders, but they do not predict pulmonary complications in the postoperative state.

41. A 40-year-old male complains of increasing shortness of breath, his chest X-ray shows an elevated hemidiaphragm on the left side. Which feature shows the sniff test? Decreased vital capacity in a supine position Decreased vital capacity while standing Paradoxical hemidiaphragm movement Decreased transfer coefficient (Kco) Increased transfer coefficient (Kco)

Your answer

The diagnosis of unilateral paralysis, suggested by asymmetric elevation of the affected hemidiaphragm on X-ray, can be confirmed by fluoroscopy. During a forced inspiratory manoeuvre (the sniff test), the unaffected hemidiaphragm descends forcefully, increasing intra-abdominal pressure and pushing the paralysed hemidiaphragm cephalad (paradoxical motion).

42. A 40-year-old man presents with a 2-month history of cough and breathlessness. He has also noted haemoptysis, which he says has gradually worsened. On examination he has bilateral basal crepitations. His chest X-ray shows diffuse shadowing. He has moderate renal failure. What is the most likely diagnosis? Tuberculosis Goodpastures disease Your answer Bronchial carcinoma Legionella pneumonia Pulmonary embolism Goodpasture described a man with renal failure, glomerulonephritis and pulmonary haemorrhage. Goodpastures disease consists of diffuse pulmonary haemorrhage and glomerulonephritis with linear deposition of antibody (90% of which are directed against the a-3 chain of type-IV collagen) along the glomerular basement membrane. In practice, glomerulonephritis proves to be a much commoner threat to survival than lung haemorrhage, and the diagnosis of Goodpastures disease is reached more conveniently by serological testing (for anti-GBM antibodies) and from kidney rather than lung biopsy. In some cases, however, lung disease dominates the clinical picture, where the majority of

patients are male smokers and some report a recent exposure to volatile hydrocarbons; case reports have additionally identified recent exposure to chlorine and smoked cocaine. This suggests that when there is susceptibility, inhaled toxic agents enhance pulmonary endothelial damage and thus allows the initiation of autoimmunity or the ready access of existing autoantibody to basement membrane. Respiratory presentation is with cough, breathlessness and haemoptysis, which is intermittent and ranges from occasional streaks to massive fatal bleeding. Systemic symptoms of fever, joint pains or weight loss are unusual. The chest X-ray shows patchy or diffuse shadowing due to intra-alveolar blood, usually resolving over the course of 2 weeks unless there is further bleeding. At the time of bleeding there may be arterial hypoxaemia and reduced lung volumes. Serial measurement of TLco can be used to monitor progression, and prolonged bleeding may lead to iron-deficiency anaemia. The carbon monoxide (CO) diffusing capacity or transfer factor (TLco) is widely used as a simple test of the integrity of the alveolar capillary membrane and of the overall gas-exchanging function of the lungs. It has good sensitivity but poor specificity, as impairment can result from a variety of pathological processes. Renal function may be normal initially but then deteriorates over days to weeks. Steroids, other immunosuppressant drugs (cyclophosphamide in particular) and plasmapheresis are all used (in some circumstances) to control renal disease, and are additionally helpful in treating pulmonary haemorrhage. Patients should not smoke and should avoid hydrocarbon exposure.

43. A 38-year-old woman presents with recurrent chest infections. For some time she has noticed that her nails are yellow and misshapen and that she often has oedematous legs after standing all day in the shop where she works. Examination reveals evidence of lower lobe consolidation and possible pleural effusion. This is confirmed on chest X-ray. Her nails are very abnormal, thickened and yellow and she has bilateral lymphoedema affecting her legs. Which diagnosis fits best with this clinical picture? Bronchiectasis Asthma Underlying bronchial carcinoma COPD Yellow-nail Syndrome

Your answer

Yellow-nail syndrome is an abnormality of lymphatic drainage associated with recurrent bronchiectasis, small bilateral pleural effusions, lymphoedema and grossly thickened, yellow nails. Her X-ray changes are chronic and associated with bronchiectasis. Management is with antibiotics to treat episodes of acute infection and regular follow-up.

44. A 46-year-old meat-factory worker is found to have Q fever pneumonia. Which of the following statements is correct? He requires high-dose penicillin for his treatment His occupation is not important for the diagnosis There is no long-term sequel of the disease The organism responsible is Coxiella pneumoniae The organism is usually inhaled from infected dust

Your answer

Q fever is due to Coxiella burnetii and is acquired through contact with animals. The organism is very resistant to drying and is inhaled from infected dust. It is not notifiable, but can occur in outbreaks in farming communities and in abattoirs. A chest X-ray may show multi-lobar consolidation. Treatment is with prolonged courses of tetracyclines. Rarely, infection can be persistent leading to chronic symptoms including fatigue, malaise and sweats. In cases of chronic disease, culture-negative endocarditis should be suspected. Lengthy antibiotic courses can be curative.

45. A 65-year-old man came to clinic with a history of proximal muscle weakness. He has had a cough for 8 weeks. There is associated pain in the small joints of the hands, and has small haemorrhages in the nail folds. He is apyrexic and on examination there is no lymphadenopathy or clubbing. Bibasal crackles can be heard and his chest X-ray reveals diffuse reticular infiltrates. Lung function tests show a restrictive pattern. What is the underlying cause of his interstitial lung disease? Cryptogenic fibrosing alveolitis SLE Ankylosing spondylitis Polymyositis Rheumatoid arthritis

Your answer

Polymyositis and dermatomyositis are inflammatory conditions involving the muscle and skin, respectively. Patients often complain of proximal muscle weakness. Pain in the small joints of the fingers is associated with the condition. The patients may present with ragged cuticles and haemorrhages at the finger-nail folds. Interstitial lung disease can occur in these patients. Underlying malignancy of the lungs, ovaries, breasts or stomach is present in 58% of cases.

46. A 45 year old man, presenting with weight loss and cough, is found to have small cell lung cancer. Which of the following best describes the additional biocemical and clinical features that may occur in this condition? Cushing's syndrome, if present, is characterised by buffalo hump, striae and central obesity Hypercalcaemia is commonly seen Hypertrophic pulmonary osteoarthropathy is a very rare feature Acidois is commonly seen Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs in >60% of cases Small-cell carcinoma is uncommonly associated with hypercalcaemia and the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Due to the short natural history, Cushings syndrome in small-cell carcinoma does not manifest classically by buffalo hump, striae or central obesity. Its presence is suspected by arterial hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness. Chemotherapy is the treatment of choice. Hypertrophic pulmonary osteoarthropathy is very rare in small-cell carcinoma of the lung. Your answer

47. A 67-year-old patient with lung cancer complains of difficulty breathing, coughing and swelling of his face, neck, upper body and arms. Superior vena cava syndrome is diagnosed. Which of the following treatments is most likely to be successful in giving early relief of symptoms? Corticosteroids Radiotherapy Surgery Chemotherapy Antihypertensive drugs

Your answer

Superior vena cava syndrome (SVCS) is a collection of symptoms caused by the partial blockage of the vein that carries blood from the head, neck, chest and arms to the heart. Symptoms that may indicate this syndrome include difficulty breathing, coughing and swelling of the face, neck, upper body and arms. In rare instances, patients may complain of hoarseness, chest pain, difficulty swallowing and coughing up blood. Physical signs of SVCS include swelling of the neck or chest veins, collection of fluid in the face or arms and rapid breathing. The syndrome of superior vena cava obstruction is relieved in about 80% of sufferers, but usually requires a more conventional course of 510 fractions of

radiotherapy. Pain from bone secondaries can be relieved in more than 50% of sufferers by a single fraction of 8 Gy, often given at the same time as a clinic visit. Brain metastases generally respond poorly to radiotherapy. A 48-hour trial of dexamethasone, 4 mg orally four times daily, is recommended as initial management in the case of brain metastases.

48. A 72-year-old woman who smokes 510 cigarettes per day and has a past history of whooping cough presents with chronic cough and recurrent chest infections for review. She admits to producing frequent amounts of purulent sputum and of intermittently suffering night sweats for a number of months. There have also been occasional episodes of haemoptysis. Chest X-ray reveals hyperinflation, crowded lung markings and small cystlike spaces at the lung bases. What is the most likely underlying pathology? Tuberculosis Asthma Bronchiectasis Chronic lung abscess Bronchial carcinoma

Your answer

The past history of whooping cough and smoking, coupled with the X-ray changes are very suggestive of bronchiectasis. Non-pharmacological management involves selfphysiotherapy and adequate hydration. Chronic-intermittent, oral antibiotic therapy is used by some physicians, although it may encourage multi-drug resistance and its use is not endorsed by all. Influenza and pneumococcal vaccinations are strongly recommended. Surgical referral may be recommended for patients with chronic severe localised infection that fails to resolve after iv antibiotic therapy.

49. A 46-year-old woman is admitted to hospital with a left basal, communityacquired pneumonia. She is on the appropriate antibiotics. She is still pyrexial four days after admission and a chest X-ray confirms a left pleural effusion. The house officer has performed a diagnostic tap. Which of the following is an indication to insert a chest drain? Pleural fluid protein level more than 50% of serum protein level Pleural fluid LDH more than 60% of serum LDH Haemorrhagic pleural fluid

Pleural fluid pH < 7.2 Your answer Pleural fluid glucose < 1.6 mmol/l

This woman has a parapneumonic effusion. The indications for chest tube insertion in patients with infected pleural effusions are: presence of organisms on a Gram stain of the pleural fluid, a frankly purulent pleural fluid, pleural pH < 7.2 in the setting of an infected pleural effusion, loculated pleural effusions and poor clinical progress despite antibiotic treatment.

50. A 25-year-old male is admitted with dyspnoea. Pulmonary function tests reveal a reduced peak expiratory flow rate 55% below the normal range for his height and age. What could be the probable diagnosis? Asthma Bronchial carcinoma Kyphoscoliosis Bronchiectasis Whooping cough Your answer

The peak expiratory flow (PEF) is an indicator of small airways disease. It is measured by a maximal forced expiration through a peak flow meter. It correlates well with the forced expiratory volume in one second (FEV1) and is used as an estimate of airway caliber. PEF can be monitored by patients at home to assess asthma control and is of value in both the diagnosis and the management of asthma.