MEDICINE 2014 pulmonology last1

Question 1 PULMONOLOGY Which of the following factors is least useful in assessing patients with a poor prognosis in community-acquired pneumonia? A. Mini-mental score of 6/10 B. Urea of 11.4 mmol/l C. C-reactive protein of 154 D. Respiratory rate of 30 E. Aged 75 years old The C-reactive protein is the least useful of the above in predicting mortality in patients with community- acquired pneumonia. The rest of the answers are part of the CURB-65 criteria Pneumonia: prognostic factors CURB-65 criteria of severe pneumonia Confusion (abbreviated mental test score 8/10) Urea 7 mmol/L Respiratory rate = 30 / min BP: systolic 90 or diastolic 60 mmHg age 65 years Patients with 3 or more (out of 5) of the above criteria are regarded as having a severe pneumonia Other factors associated with a poor prognosis include: presence of coexisting disease hypoxaemia (pO2 8 kPa) independent of FiO2 Question 2 A 24-year-old female presents with episodic wheezing and shortness of breath for the past 4 months. She has smoked for the past 8 years. Examination of her chest is unremarkable. What is the most appropriate management of her symptoms? A. Peak flow diary B. Spirometry C. Baseline FEV1 repeated following inhaled corticosteroids D. Baseline FEV1 repeated following inhaled salbutamol E. Trial of salbutamol inhaler Asthma diagnosis - if high probability of asthma - start treatment The new British Thoracic Society guidelines take a more practical approach to diagnosing asthma. If a patient has typical symptoms of asthma a trial of treatment is recommended. The smoking history is unlikely to be relevant at her age Asthma: diagnosis in adults sqweqwesf erwrewfsdfs adasd dhe The 2008 British Thoracic Society guidelines marked a subtle change in the approach to diagnosing asthma. It suggests dividing patients into a high, intermediate and low probability of having asthma based on the presence or absence of typical symptoms. A list can be found in the external link but include typical symptoms such as wheeze, nocturnal cough etc Example of features used to assess asthma (not complete, please see link) Increase possibility of asthmaDecrease possibility of asthma • Wheeze, breathlessness, chest tightness and cough, worse at night/early morning • History of atopic disorder • Wheeze heard on auscultation • Unexplained peripheral blood eosinophilia• Prominent dizziness, light-headedness, peripheral tingling • Chronic productive cough in the absence of wheeze or breathlessness • Repeatedly normal physical examination • Significant smoking history (i.e. 20 pack-years) • Normal PEF or spirometry when symptomatic Management is based on this assessment: high probability: trial of treatment intermediate probability: see below low probability: investigate/treat other condition For patients with an intermediate probability of asthma further investigations are suggested. The guidelines state that spirometry is the preferred initial test: FEV1/FVC 0.7: trial of treatment FEV1/FVC 0.7: further investigation/consider referral Recent studies have shown the limited value of other 'objective' tests. It is now recognised that in patients with normal or near-normal pre-treatment lung function there is little room for measurable improvement in FEV1 or peak flow. A 400 ml improvement in FEV1 is considered significant before and after 400 mcg inhaled salbutamol in patients with diagnostic uncertainty and airflow obstruction present at the time of assessment if there is an incomplete response to inhaled salbutamol, after either inhaled corticosteroids (200 mcg twice daily beclometasone equivalent for 6-8 weeks) or oral prednisolone (30 mg once daily for 14 days) It is now advised to interpret peak flow variability with caution due to the poor sensitivity of the test diurnal variation % = [(Highest – Lowest PEFR) / Highest PEFR] x 100 assessment should be made over 2 weeks greater than 20% diurnal variation is considered significant Question stats A23.3% B12.9% C3.4% D24.5% E35.8% 35.8% of users answered this question correctly External links British Thoracic Society 2008 Asthma guidelines All contents of this site are ©2008 - Terms and Conditions Reference ranges End session Question 14 of 1500 Which one of the following is a contraindication to surgical resection in lung cancer?ia A.AHaemoptysisia B.AFEV 1.9 litresia C.AHistology shows squamous cell canceria D.AVocal cord paralysisia E.ACalcium = 2.84 mmol/Lia Contraindications to lung cancer surgery include SVC obstruction, FEV 1.5, MALIGNANT pleural effusion, and vocal cord paralysis Paralysis of a vocal cord implies extracapsular spread to mediastinal nodes and is an indication of inoperability. Lung cancer: non-small cell management sqweqwesf erwrewfsdfs adasd dhe Management only 20% suitable for surgery mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement curative or palliative radiotherapy poor response to chemotherapy Surgery contraindications assess general health stage IIIb or IV (i.e. metastases present) FEV1 1.5 litres is considered a general cut-off point* malignant pleural effusion tumour near hilum vocal cord paralysis SVC obstruction * However if FEV1 1.5 for lobectomy or 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results Question stats A2.1% B20% C8.5% D62.2% E7.2% 62.2% of users answered this question correctly External links British Thoracic Society BTS guidelines on selection for surgery SIGN Lung cancer management guidelines All contents of this site are ©2008 - Terms and Conditions Reference ranges End session Question 46 of 1500 Which one of the following is responsible for farmer's lung?ia A.AAspergillus clavatusia B.AMicropolyspora faeniia C.AThermoActinomyces candidusia D.AMycobacterium aviumia E.AAvian proteinsia Micropolyspora faeni causes farmer's lung, a type of EAA Extrinsic allergic alveolitis sqweqwesf erwrewfsdfs adasd dhe Extrinsic allergic alveolitis (EAA) is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase Examples bird fanciers' lung (avian proteins) farmers lung (spores of Micropolyspora faeni) malt workers' lung (Aspergillus clavatus) mushroom workers' lung (thermophilic actinomycetes*) Presentation acute: occur 4-8 hrs after exposure, SOB, dry cough, fever chronic Investigation CXR: upper lobe fibrosis BAL: lymphocytosis blood: NO eosinophilia *here the terminology is slightly confusing as thermophilic actinomycetes is an umbrella term covering strains such as Micropolyspora faeni Question stats A18.5% B57.4% C14.9% D5% E4.2% 57.4% of users answered this question correctly All contents of this site are ©2008 - Terms and Conditions Reference ranges End session Question 59 of 1500 Which one of the following causes of lung fibrosis predominately affect the upper zones?ia A.ABleomycinia B.ARheumatoid arthritisia C.ACryptogenic fibrosis alveolitisia D.AMethotrexateia E.AExtrinsic allergic alveolitisia Lung fibrosis sqweqwesf erwrewfsdfs adasd dhe It is important in the exam to be able to differentiate between conditions causing predominately upper or lower zone fibrosis. It should be noted that the more common causes (cryptogenic fibrosing alveolitis, drugs) tend to affect the lower zones Fibrosis predominately affecting the upper zones extrinsic allergic alveolitis coal worker's pneumoconiosis/progressive massive fibrosis silicosis sarcoidosis ankylosing spondylitis (rare) histiocytosis tuberculosis Fibrosis predominately affecting the lower zones cryptogenic fibrosing alveolitis most connective tissue disorders (except ankylosing spondylitis) drug-induced: amiodarone, bleomycin, methotrexate asbestosis