Blackboard EMQs Respiratory Flashcards
70 yr old retired boiler maker presents with a 5 year history of exertional dyspnoea and a dry cough. The patient is non-smoker. Examination reveals fine crackles heard at the lung bases
What is the most likely diagnosis? A. Pernicious anaemia B. Iron deficiency anaemia C. Pulmonary TB D. Bronchopneumonia E. Congestive cardiac failure F. Chronic lymphatic leukaemia G. Pulmonary fibrosis H. COPD I. PE J. Acute lymphoblastic leukaemia K. Sarcoidosis
G. Pulmonary fibrosis
Idiopathic pulmonary fibrosis (previously known as Cryptogenic fibrosing alveolitis) progresses over several years and is characterised by pulmonary scar tissue formation and dyspnoea. Patients complain of a non-productive cough and typically reproducible and predictable SOB on exertion. Boiler makers can come into contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. While this patient does not smoke, another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. End expiratory basal crackles are found on examination. These are described as ‘Velcro-like’ in quality. IPF is also associated with clubbing.
25 yr old HIV positive man has a productive cough for the last 3 months with haemoptysis and night sweats. CXR shows hilar lymphadenopathy.
What is the most likely diagnosis? A. Pernicious anaemia B. Iron deficiency anaemia C. Pulmonary TB D. Bronchopneumonia E. Congestive cardiac failure F. Chronic lymphatic leukaemia G. Pulmonary fibrosis H. COPD I. PE J. Acute lymphoblastic leukaemia K. Sarcoidosis
C. Pulmonary TB
HIV infection is a key risk factor for pulmonary TB. It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, cough, haemoptysis and erythema nodosum are all suggestive. In the first half of the 20th century, tuberculosis accounted for over 90% of cases of erythema nodosum. Other key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis.
12 yr old boy has become increasingly tired over the last month. On examination he looks pale, has a large bruise over his right thigh and a firm palpable liver and spleen.
What is the most likely diagnosis? A. Pernicious anaemia B. Iron deficiency anaemia C. Pulmonary TB D. Bronchopneumonia E. Congestive cardiac failure F. Chronic lymphatic leukaemia G. Pulmonary fibrosis H. COPD I. PE J. Acute lymphoblastic leukaemia K. Sarcoidosis
J. Acute lymphoblastic leukaemia
ALL presents in children with bone marrow involvement and the associated symptoms or in adults with an anterior mediastinal mass. Bone marrow infiltration leads to a pancytopenia leading to anaemia (reduced red blood cells), haemorrhage (reduced platelets) and infections (reduced mature white blood cells). In ALL, bone marrow is replaced by lymphoblasts. There may also be spread to CNS and testes. ALL is associated with Down’s syndrome. In contrast, CLL presents in older adults and is often asymptomatic, discovered by chance when a FBC is ordered. Smear/smudge cells are seen in peripheral blood smear. CLL is associated with a warm-type AIHA and there is peripheral blood lymphocytosis.
60 yr old publican smokes 20 a day. He has a 10 year history of having a ‘smoker’s morning cough’ when he expectorates clear sputum. This is worse in winter when it turns green and he has to go to his GP for antibiotics. Examination reveals poor air entry over both lung fields and his PEFR is 210 L/min (reduced by 60%)
What is the most likely diagnosis? A. Pernicious anaemia B. Iron deficiency anaemia C. Pulmonary TB D. Bronchopneumonia E. Congestive cardiac failure F. Chronic lymphatic leukaemia G. Pulmonary fibrosis H. COPD I. PE J. Acute lymphoblastic leukaemia K. Sarcoidosis
H. COPD
Smoking is the most important risk factor, accounting for 90% of COPD. COPD has an insidious onset and usually presents in older people with a history of cough, wheeze and SOB. This patient appears to have infective exacerbations of his COPD every winter. Patients with COPD are at a higher risk of infections and are vaccinated against influenza annually and pneumococcal pneumonia every 5 years. Spirometry is the gold standard for diagnosis, with FEV1/FVC ratio <70% with no evidence of reversibility (unlike asthma) being indicative.
A 58-year-old man, who smoked 30 cigarettes a day, presents with a 6-week history of cough, malaise, anorexia and weight loss. Past medical history includes hypertension for which he has taken lisinopril and bendrofluazide for 4 years.
What is the most likely cause of the symptoms? A. ACE inhibitor B. Foreign body C. Bronchiectasis D. Carcinoma of bronchus E. Asthma F. Postnasal drip G. COPD H. Tuberculosis I. Sarcoidosis J. Oesophageal reflux
D. Carcinoma of bronchus
The history of smoking and weight loss point to a bronchial carcinoma. Initial investigation is with a CXR. Diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome.
A 45-year-old woman who smokes 25 cigarettes a day is reviewed in the diabetic clinic. She has had a dry cough for 2 months. She is on numerous tablets as her diabetes is complicated by microalbuminuria and hypertension. Her GP had given her a course of antibiotics 2 weeks previously.
What is the most likely cause of the symptoms? A. ACE inhibitor B. Foreign body C. Bronchiectasis D. Carcinoma of bronchus E. Asthma F. Postnasal drip G. COPD H. Tuberculosis I. Sarcoidosis J. Oesophageal reflux
A. ACE inhibitor
A dry cough is a side effect of ACE inhibitors due to the build up of bradykinin which is normally degraded by ACE. ARB such as losartan will be indicated in this case. ARBs are insurmountable antagonists of AT1 receptors for angiotensin II, preventing its renal and vascular effects.
A 40-year-old Afro-Caribbean woman presents with bilateral parotid swelling, and painful nodules on the front of the shins. She has a dry cough and slight shortness of breath on exertion.
What is the most likely cause of the symptoms? A. ACE inhibitor B. Foreign body C. Bronchiectasis D. Carcinoma of bronchus E. Asthma F. Postnasal drip G. COPD H. Tuberculosis I. Sarcoidosis J. Oesophageal reflux
I. Sarcoidosis
Sarcoidosis is a chronic multisystem disease with an unknown aetiology. The painful (mauve) nodules are erythema nodosum. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. Parotid enlargement is a classic feature (involvement of exocrine glands). The dry cough and SOB on exertion indicate pulmonary involvement. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.
An 18-year-old man presents with a night-time cough and shortness of breath while playing football. This has got progressively worse over the previous 2 months.
What is the most likely cause of the symptoms? A. ACE inhibitor B. Foreign body C. Bronchiectasis D. Carcinoma of bronchus E. Asthma F. Postnasal drip G. COPD H. Tuberculosis I. Sarcoidosis J. Oesophageal reflux
E. Asthma
SOB and the cough, which may wake the patient from sleep combined with the patient’s age and progessive course suggest asthma. Examination can show an expiratory wheeze but may be normal and treatment is step-wise based on BTS guidelines. It is worth noting that in severe exacerbations, the chest may be silent. Night symptoms occur in more severe asthma and symptoms can be exacerbated by exercise. Diagnosis is supported by PEFR variation of at least 20% over 3 days in a week over several weeks or an increase of at least 20% to treatment. New guidelines were published in 2018 and can be found on the NICE website.
A 30-year-old man, a lifelong non-smoker, presents with a history of at least 6 months of purulent sputum. He has had regular chest infections since an attack of measles at the age of 14.
What is the most likely cause of the symptoms? A. ACE inhibitor B. Foreign body C. Bronchiectasis D. Carcinoma of bronchus E. Asthma F. Postnasal drip G. COPD H. Tuberculosis I. Sarcoidosis J. Oesophageal reflux
C. Bronchiectasis
Bronchiectasis is permanent bronchi dilatation due to bronchial wall damage and loss of elasticity. It is often as a consequence of recurrent/severe infections and most present with chronic productive mucopurulent cough. The most common identifiable cause is CF. Chest CT is the diagnostic test. Diagnosis is aided by sputum analysis. Have a think about what you would expect to hear on ascultation of the chest.
50 yr old male smoker presents with 3 month hx of cough, haemoptysis and wt loss. Chest examination = unremarkable
What is the most likely diagnosis? A. Extrinsic allergic alveolitis B. Chronic bronchitis C. Fibrosing alveolitis D. Right ventricular failure E. Pneumonia F. Bronchial carcinoma G. TB H. ACE inhibitor I. Left ventricular failure J. Influenza K. Asthma
F. Bronchial carcinoma
The history of smoking, weight loss, cough and haemoptysis point to a bronchial carcinoma. Initial investigation is with a CXR. Diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome.
5yr old coughs most nights. He has frequent courses of antibiotics for a ‘bad chest’ especially in winter. He also has eczema
What is the most likely diagnosis? A. Extrinsic allergic alveolitis B. Chronic bronchitis C. Fibrosing alveolitis D. Right ventricular failure E. Pneumonia F. Bronchial carcinoma G. TB H. ACE inhibitor I. Left ventricular failure J. Influenza K. Asthma
K. Asthma
These are infective exacerbations of asthma. The eczema is an atopic disease which is a strong risk factor for the development of asthma. A dry night time cough is commonly seen and suggestive. The hyperexpanded chest suggests persistent asthma. A Harrison’s sulcus, though rare, may also be seen. Treatment will be based on paediatric guidelines which differs from adult asthma. If you are really keen, you can look these up.
50 yr old male smoker has a productive cough with clear sputum most days, especially winter. He has not lost wt. On examination he has hyperexpanded chest and a few scattered wheezes and crackles
What is the most likely diagnosis? A. Extrinsic allergic alveolitis B. Chronic bronchitis C. Fibrosing alveolitis D. Right ventricular failure E. Pneumonia F. Bronchial carcinoma G. TB H. ACE inhibitor I. Left ventricular failure J. Influenza K. Asthma
B. Chronic bronchitis
This patient has COPD, which is a progressive disease characterised by not fully reversible airflow limitation. COPD encompasses both emphysema and chronic bronchitis. Cigarette smoking is the most important risk factor. The hyperexpanded chest implies trapping of air due to incomplete expiration. Wheezes and coarse crackles are commonly seen in exacerbations. The cough is often the first symptom a patient complains of and is usually a morning event which is normally productive. The sputum can change quality with exacerbations/infection. Treatment aims at stopping smoking and vaccinating the patient against influence and pneumococcus with options such as bronchodilators or ICS. LTOT improves survival in those with severe COPD with a low PaO2. Lung function tests are key in diagnosis with an obstructive FEV1/FVC ratio <70% being the finding seen.
40 yr old Asian male has a 2 month hx of cough, haemoptysis, wt loss and night sweats. He has swollen cervical lymph nodes and his trachea deviated to the left.
What is the most likely diagnosis? A. Extrinsic allergic alveolitis B. Chronic bronchitis C. Fibrosing alveolitis D. Right ventricular failure E. Pneumonia F. Bronchial carcinoma G. TB H. ACE inhibitor I. Left ventricular failure J. Influenza K. Asthma
G. TB
It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, weight loss, cough, haemoptysis and erythema nodosum are all suggestive. This patient’s tracheal deviation may be due to apical fibrosis or a cavitating lesion. The swollen lymph nodes in this patient’s neck may well represent a scrofula. Other key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis.
40 yr old man has a hx of hypertension. His anti-hypertensive meds were recently changed due to ankle swelling. He has now developed a dry cough.
What is the most likely diagnosis? A. Extrinsic allergic alveolitis B. Chronic bronchitis C. Fibrosing alveolitis D. Right ventricular failure E. Pneumonia F. Bronchial carcinoma G. TB H. ACE inhibitor I. Left ventricular failure J. Influenza K. Asthma
H. ACE inhibitor
A dry cough is a side effect of ACE inhibitors due to the build up of bradykinin which is normally degraded by ACE. ARB such as losartan will be indicated in this case. ARBs are insurmountable antagonists of AT1 receptors for angiotensin II, preventing its renal and vascular effects.
A 62 year old man presents with progressive breathlessness over many years. He worked in power stations. He has finger clubbing and his chest xray shows a honeycomb apperance.
What is the most likely diagnosis? A. Tuberculosis B. Streptococcal pneumonia C. Sinusitis D. Bronchiectasis E. Cystic fibrosis F. Asthma G. Idiopathic pulmonary fibrosis H. Sarcoidosis I. Granulomatosis with polyangitis J. Mycoplasma pneumonia
G. Idiopathic pulmonary fibrosis
Idiopathic pulmonary fibrosis (previously known as Cryptogenic fibrosing alveolitis) progresses over several years and is characterised by pulmonary scar tissue formation and dyspnoea. Patients complain of a non-productive cough and typically reproducible and predictable SOB on exertion. Work in power stations can involve contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. Another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. End expiratory basal crackles are found on examination. These are described as ‘Velcro-like’ in quality. IPF is also associated with clubbing. A CXR in most will show reticulonodular shadowing consistent with fibrosis. This can be described as a ‘honeycomb’ pattern.
A 35 year old lady presents with a rash over her face and raised levels of ACE
What is the most likely diagnosis? A. Tuberculosis B. Streptococcal pneumonia C. Sinusitis D. Bronchiectasis E. Cystic fibrosis F. Asthma G. Idiopathic pulmonary fibrosis H. Sarcoidosis I. Granulomatosis with polyangitis J. Mycoplasma pneumonia
J. Sarcoidosis
Sarcoidosis is a chronic multisystem disease with an unknown aetiology. The lesion described is lupus pernio which is a typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. Erythema nodosum is another dermatological manifestation. Additionally, serum calcium and ACE levels may be raised. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.
A 28 year old homeless man presents with tiredness and cough for over 3 months. His CXR showed patchy shadows in the upper zones. His sputum grew positive culture on Lowenstein-jensen medium after 4 weeks
What is the most likely diagnosis? A. Tuberculosis B. Streptococcal pneumonia C. Sinusitis D. Bronchiectasis E. Cystic fibrosis F. Asthma G. Idiopathic pulmonary fibrosis H. Sarcoidosis I. Granulomatosis with polyangitis J. Mycoplasma pneumonia
A. Tuberculosis
This patient should be placed in isolation. His sputum culture results suggest TB which is an AFB growing on Lowenstein-Jensen medium. A sputum culture is the most sensitive and specific test for TB and whilst growth takes a long time, the positive culture is diagnostic of TB. Sputum cultures will be repeated during treatment until 2 consecutive negative cultures. Treatment consists of anti-TB medication. Ethambutol should be stopped if the AFB is sensitive to isoniazid and rifampicin. Pyridoxine should be given with isoniazid to help prevent neuropathy. Pyrazinamide is not recommended in acute gout or pregnancy. Treatment of MDR TB involves additional therapy with agents such as amikacin and ethionamide.
A 19 year old presents with headache and malaise for 1 week. His chest was clear on auscultation. He subsequently developed a cough and was given erythomycin for 1 week
What is the most likely diagnosis? A. Tuberculosis B. Streptococcal pneumonia C. Sinusitis D. Bronchiectasis E. Cystic fibrosis F. Asthma G. Idiopathic pulmonary fibrosis H. Sarcoidosis I. Granulomatosis with polyangitis J. Mycoplasma pneumonia
L. Mycoplasma pneumonia
The atypical presentation (a week of headache and malaise before the cough) and the prescription of erythromycin, a macrolide antibiotic, point to infection with an atypical pneumonia. However, depending on local prescribing policies, first line therapy for a CAP like pneumococcus may also be with a macrolide. Young people who ‘live together’ are commonly affected. The cough often does not resolve and is dry in nature. Symptoms tend to be prolonged and a low-grade fever is a common finding. Mycoplasma is the only atypical pneumonia on the list although there is no reason why this cannot be Legionella or Chlamydia. All can be treated with macrolides although in EMQs Chlamydia tends to be treated with doxycyline. All 3 atypicals are to some extent sensitive to fluoroquinolones and tetracylines too although these cannot be used in pregnancy. Whether they are first or second line therapy depends on the organism.
A newborn child presents with small bowel obstruction due to meconium ileus
What is the most likely diagnosis? A. Tuberculosis B. Streptococcal pneumonia C. Sinusitis D. Bronchiectasis E. Cystic fibrosis F. Asthma G. Idiopathic pulmonary fibrosis H. Sarcoidosis I. Granulomatosis with polyangitis J. Mycoplasma pneumonia
F. Cystic fibrosis
CF can present in newborns with a failure to pass meconium (early stools) which can even result in bowel obstruction as in this patient. The bowel may even perforate if the patient is very unlucky resulting in a meconium peritonitis. The most conclusive diagnostic test is the sweat test which is pisitive if sweat chloride is >60mmol/L. Serum IRT from a heel prick blood spot allows screening of newborns. CF is a genetic condition with abnormal salt and water transport due to mutations in the CFTR (an apical anion channel). Heterozygotes generally do not demonstrate disease.
A 42 year old man has a 3 year history of concurrent progressive SOB and joint pains. His bloods show positive rheumatoid factor.
What is the most likely diagnosis? A. Tuberculosis B. Streptococcal pneumonia C. Sinusitis D. Bronchiectasis E. Cystic fibrosis F. Asthma G. Idiopathic pulmonary fibrosis H. Sarcoidosis I. Granulomatosis with polyangitis J. Mycoplasma pneumonia
I. Granulomatosis with polyangitis
Granulomatosis with polyangitis is a systemic vasculitis affecting the small and medium vessels and presents with the classic triad of upper respiratory tract involvement, lower respiratory tract involvement and GN. It is a multisystem disease which can manifest with symptoms ranging from cutaneous, musculoskeletal, ocular and neurological features. Joint swelling and tenderness may all be present. It is associated with a positive cANCA and rhematoid factor is positive in around half.
If the shortness of breath began some time after the joint pains, instead of occurring concurrently, you might consider lung fibrosis secondary to rheumatoid arthritis
A 38 year old woman with a history of multiple allergies is given intravenous contrast medium for a urogram. Within a couple of minutes, she has become breathless, with wheeze & stridor, & her blood pressure is 80/40 mmHg.
What is the most likely diagnosis? A. Pneumothorax B. Exacerbation of COPD C. Asthma D. Acute anxiety E. Left ventricular failure F. Anaphylaxis G. Pulmonary embolus H. Inhaled foreign body I. Epiglotitis J. Viral pneumonia
F. Anaphylaxis
There is a sudden onset of both respiratory and cardiovascular complaints with the recently given IV contrast agent. This patient is having an anaphylactic reaction and the airway needs to be promptly secured with prompt treatment with adrenaline. IM adrenaline must not be delayed and the anterolateral thigh is the preferred location, with repeated doses as necessary every 10 minutes or so. A 1:1000 solution is used of 0.3-0.5mg adrenaline. Fluid replacement with IV saline is also indicated to correct the intravascular volume redistribution.
A 69 year old man with a history of hypertension & stable angina wakes up severely short of breath. He is slightly more comfortable sitting upright. On examination, his blood pressure is 195/115 mmHg & there are crepitations at the bases of both lungs.
What is the most likely diagnosis? A. Pneumothorax B. Exacerbation of COPD C. Asthma D. Acute anxiety E. Left ventricular failure F. Anaphylaxis G. Pulmonary embolus H. Inhaled foreign body I. Epiglotitis J. Viral pneumonia
E. Left ventricular failure
This patient has LVF and pulmonary oedema. This accounts for the basal crepitations heard on ascultation and the SOB which is better on sitting upright. Patients need to be sat upright for this reason and IV access needs to be established. Oxygen, morphone, diuretics (frusemide or another loop diuretic) and nitrates will be given. Once stable, medical treatment of heart failure should be started which involves in the first instance, an ACE inhibitor followed by beta blockade. Ongoing diuretics are necessary if the patient has persistent symptoms of fluid overload.
A 73 year old woman is recovering in hospital 3 days after an operation to replace her right hip. On going to the toilet she suddenly becomes extremely short of breath & rapidly loses consciousness. Blood pressure is 60/20 mmHg.
What is the most likely diagnosis? A. Pneumothorax B. Exacerbation of COPD C. Asthma D. Acute anxiety E. Left ventricular failure F. Anaphylaxis G. Pulmonary embolus H. Inhaled foreign body I. Epiglotitis J. Viral pneumonia
G. Pulmonary embolus
This patient should be thrombolysed immediately if not contraindicated due to her haemodynamically unstable and critical state. Treatment should not be delayed in this obvious PE. This patient is now at a serious risk of cardiac arrest. Anticoagulation should also be started. The underlying pathophysiology is based on Virchow’s triad. SOB is a common symptom and there may also be chest pain and haemoptysis. This patient has had recent surgery, particularly orthopaedic surgery, which is a strong risk factor for PE. Other strong risk factors include DVT, obesity, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis. The study of choice is a CTPA with direct visualisation of the thrombus. If there is a contraindication to a CT scan such as contrast allergy or pregnancy, then a V/Q scan is indicated. If a V/Q scan is not possible, alternatives such as MRA can be requested. It is worth noting that in patients with cardiopulmonary disease, these tests may not be accurate. A TTE can also be used to detect RV strain seen with PE.
A 77 year old former coal miner has 30 year history of cough, mostly productive of sputum. He suddenly becomes breathless after a bout of coughing & complains of right sided chest pain. On examination, he is cyanosed, the trachea is deviated to the left & no breath sounds are audible over part of the right side of the chest.
What is the most likely diagnosis? A. Pneumothorax B. Exacerbation of COPD C. Asthma D. Acute anxiety E. Left ventricular failure F. Anaphylaxis G. Pulmonary embolus H. Inhaled foreign body I. Epiglotitis J. Viral pneumonia
A. Pneumothorax
This patient has developed a right sided tension pneumothorax and will need emergency intervention in the form of the insertion of a large bore cannula into the 2nd intercostal space in the MCL of the affected side. This will need to be followed by the insertion of a chest drain.
Otherwise if this was not a tension pneumothorax, for secondary spontaneous pneumothoraces, if large enough for a chest drain or the patient is clinically unstable, chest drain insertion is indicated. Simple aspiration success rate is reduced in secondary spontaneous pneumothoraces. Primary pneumothoraces occur in young people without known lung conditions. This patient has pulmonary fibrosis. Those who suffer recurrent pneumothoraces may have to undergo pleurodesis to stick the parietal and visceral pleural together by an inflammatory reaction.
A 33 year old airline steward presents with a 1 week history of fever, dry cough, & shortness of breath. On examination, he is tachypnoeic. His lungs are clear to auscultation.
What is the most likely diagnosis? A. Atypical pneumonia B. Exacerbation of chronic bronchitis C. Metastatic carcinoma D. Acute pulmonary oedema E. Anaemia F. Valvular disease G. Bronchial asthma H. Bronchial carcnioma I. Pulmonary embolus
A. Atypical pneumonia
This is an atypical pneumonia demonstrated by the history and examination findings. Atypicals include Mycoplasma, Chlamydophila and Legionella. Each one has their own associations, for instance, Mycoplasma is associated with a cold type AIHA. Chlamydophila pneumoniae is associated with otitis, pharyngitis and hoarseness prior to respiratory symptoms and psittaci is associated with birds as vectors. Legionella is associated with hyponatraemia, deranged LFTs and altered consciousness.
A 65 year old man with a history of chronic productive cough now presents to A&E short of breath & drowsy.
What is the most likely diagnosis? A. Atypical pneumonia B. Exacerbation of chronic bronchitis C. Metastatic carcinoma D. Acute pulmonary oedema E. Anaemia F. Valvular disease G. Bronchial asthma H. Bronchial carcinoma I. Pulmonary embolus
B. Exacerbation of chronic bronchitis
This is an exacerbation of COPD. A SABA is indicated as first line with corticosteroids. Antibiotics should be commenced.
A 60 year old woman presents with dyspnoea. On examination, she has a firm mass in the left breast & decreased breath sounds in the right lower lung fields. Chest x-ray reveals a pleural effusion.
What is the most likely diagnosis? A. Atypical pneumonia B. Exacerbation of chronic bronchitis C. Metastatic carcinoma D. Acute pulmonary oedema E. Anaemia F. Valvular disease G. Bronchial asthma H. Bronchial carcinoma I. Pulmonary embolus
C. Metastatic carcinoma
This is pulmonary involvement secondary to a breast primary i.e. metastatic breast cancer. The effusion in this case would be exudative (it is a malignant pleural effusion). Make sure you know the difference between a transudate and an exudate and some causes of each. Metastases are normally round in appearance on CXR. A biopsy can help in identifying the source if unclear.
A 50 year old male patient on the ward awakes with dyspnoea & frothy sputum. He had suffered an MI a week earlier. On examination, he is cyanosed & tachypnoeic. Auscultation of the lung reveals crepitations.
What is the most likely diagnosis? A. Atypical pneumonia B. Exacerbation of chronic bronchitis C. Metastatic carcinoma D. Acute pulmonary oedema E. Anaemia F. Valvular disease G. Bronchial asthma H. Bronchial carcinoma I. Pulmonary embolus
D. Acute pulmonary oedema
This patient has acute pulmonary oedema (the classic finding of pink frothy sputum). This is likely to be caused by LVF secondary to his MI a week earlier. This accounts for the basal crepitations heard on ascultation. Patients need to be sat upright to improve the SOB and IV access needs to be established. Oxygen, morphone, diuretics (frusemide or another loop diuretic) and nitrates will be given. Once stable, medical treatment of heart failure should be started which involves in the first instance, an ACE inhibitor followed by beta blockade. Ongoing diuretics are necessary if the patient has persistent symptoms of fluid overload.
A 40 year old man presents with cough & breathlessness. Chest x-ray demonstrates diffuse consolidation of the right lower lobe. Despite treatment with iv co-amoxiclav, the fever persists. Chest x-ray shows expansion.
What is the most likely diagnosis? A. Atypical pneumonia B. Exacerbation of chronic bronchitis C. Metastatic carcinoma D. Acute pulmonary oedema E. Anaemia F. Valvular disease G. Bronchial asthma H. Bronchial carcinoma I. Pulmonary embolus
A. Atypical pneumonia
Again, this is an atypical pneumonia which is not responding to a common antibiotic given for CAP with broad spectrum action. A macrolide is indicated for atypical pneumonia although the current guidelines do recommend the empiral use of a macrolide for CAP to ensure atypical cover, although local prescribing guidelines do vary.
A 25 year old man has a 3 day history of shivering, general malaise & productive cough. The x-ray shows right lower lobe consolidation.
What is the most likely cause? A. Mixed growth of organisms B. Mycoplasma pneumoniae C. Streptococcus pneumoniae D. Mycobacterium tuberculosis E. Bacteroides fragilis F. Haemophilus influenzae G. E coli H. Staphylococcus aureus I. Pneumocystis jirovecii J. Legionella pneumophila K. Coxiella burnetii
C. Streptococcus pneumoniae
Classic lobar pneumonia with no signs and symptoms to suggest an atypical organism is most likely to due to pneumococcus. Symptoms include chills, fever, cough, SOB and pleuritic chest pain. A CXR is the most specific and sensitive test available and antibiotics are indicated.
A 26 year old man presents with severe shortness of breath and a dry cough which he has had for several weeks. He is an IV drug user. There are purple patches on the arms and in the mouth. CXR shows reticular perihilar opacities. Chest examination is unremarkable.
What is the most likely cause? A. Mixed growth of organisms B. Mycoplasma pneumoniae C. Streptococcus pneumoniae D. Mycobacterium tuberculosis E. Bacteroides fragilis F. Haemophilus influenzae G. E coli H. Staphylococcus aureus I. Pneumocystis jirovecii J. Legionella pneumophila K. Coxiella burnetii
I. Pneumocystis jirovecii
PCP is caused by Pneumocystis jirovecii, previously called Pneumocystis carinii. It is a fungal organism and an AIDS defining illness. Signs and symptoms occur in a patient who is immunosuppressed especially HIV with a CD4 count <200 with the risk increasing with lower CD4 counts. Currently, those who get PCP are either unaware they have HIV, fail to seek help for their HIV or fail to comply with HAART. PCP does also occur in HIV negative patients (with a more rapid and severe course), but rarely, in conditions such as inflammatory conditions, organ transplant recipients on immunosuppressants or those with blood malignancies. This patient is an IVDU which is a risk factors for HIV. Other risks include unprotected sexual intercourse, especially receptive anal intercourse. The purple patches are KS which is another AIDS defining condition. HIV positive patients tend to present with an insidious onset of symptoms such as non-productive cough and SOB over many weeks. CXR can show opacities in the perihilar region but may be diffuse and the picture is highly variable from a normal CXR to lobar consolidation or nodular lesions. Diagnosis is made on detecting the ‘boat-shaped’ organisms on BAL or induced sputum. Treatment is with co-trimoxazole, which is a 1:5 ratio of trimethoprim/sulphamethoxazole.
A 35 year old previously healthy man returned from a conference in the USA 5 days ago. He travels frequently and gives a 30 pack year history. He presents with mild confusion, a productive cough, diarrhoea and is pyrexic. His chest examination is normal. CXR shows infiltrates in the RUL.
What is the most likely cause? A. Mixed growth of organisms B. Mycoplasma pneumoniae C. Streptococcus pneumoniae D. Mycobacterium tuberculosis E. Bacteroides fragilis F. Haemophilus influenzae G. E coli H. Staphylococcus aureus I. Pneumocystis jirovecii J. Legionella pneumophila K. Coxiella burnetii
J. Legionella pneumophila
Legionella is a gram negative rod. Legionella infecting the lungs is legionnaires’ disease or Legionella pneumonia whereas non-lung infection is known as Pontiac fever. This bacteria is found in aqueous environments such as lakes and almost all cases are from contaminated water systems, which relates to the risk factors of getting Legionella (recent water exposure like a hot tub). Smoking is also a risk factor. It can cause confusion as well as hyponatraemia, abdominal pain, diarrhoea and bradycardia. Legionella does not grow on routine culture media and diagnosis relies on urine antigen detection, serology or culture on special media.
A 20 year old previously healthy woman presents with general malaise, severe cough & breathlessness which has not improved with a 7 day course of amoxicillin. There is nothing significant to find on examination. The x-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins.
What is the most likely cause? A. Mixed growth of organisms B. Mycoplasma pneumoniae C. Streptococcus pneumoniae D. Mycobacterium tuberculosis E. Bacteroides fragilis F. Haemophilus influenzae G. E coli H. Staphylococcus aureus I. Pneumocystis jirovecii J. Legionella pneumophila K. Coxiella burnetii
B. Mycoplasma pneumoniae
The cold agglutinins is what gives this question away. Mycoplasma is associated with with cold type agglutinins and a cold AIHA. Humans are thought to be the only host for Mycoplasma. The most commonly affected are young adults living in close proximity to each other. PCR can be used in diagnosis.
A 63 year old tramp presents to the A&E department with a 4 day history of haemoptysis. He has felt unwell for about 2 months with a cough, loss of weight & generalised weakness. He attributes his diplopia, which started a fortnight ago, to excessive alcohol consumption. On examination he has bilateral ptosis & proximal weakness in the limbs which improves on repeated testing.
What is the most likely diagnosis? A. Mesothelioma B. Streptococcal pneumonia C. Goodpasture’s disease D. Pulmonary abscess E. Microscopic polyarteritis F. Pulmonary metastases G. Squamous cell carcinoma H. Tuberculosis I. Myaesthenia gravis J. Pulmonary embolism K. Small cell carcinoma
K. Small cell carcinoma
First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is also associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome which this patient has (though weakness of the eye muscles is uncommon in Lambert-Eaton and is more prominent in myasthenia gravis). This classically presents with weakness which improves on repeated testing (in contrast to myasthenia gravis) and is more commonly associated with small cell lung cancer than other lung cancers. It is for this reason that the most likely diagnosis is small cell and not squamous cell lung cancer.
A 20 year old man with cystic fibrosis presents to the chest clinic with haemoptysis. He has felt unwell for a fortnight with increased sputum production, fever & rigors. Gram stain of the sputum shows Gram-positive cocci in clusters.
What is the most likely diagnosis? A. Mesothelioma B. Streptococcal pneumonia C. Goodpasture’s disease D. Pulmonary abscess E. Microscopic polyarteritis F. Pulmonary metastases G. Squamous cell carcinoma H. Tuberculosis I. Myaesthenia gravis J. Pulmonary embolism K. Small cell carcinoma
D. pulmonary abscess
A lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which a patient with CF is at risk of is a risk factor. Of gram positive cocci, staphylococcus occurs in grape-like clusters (this patient) whereas streptococcus occurs in chains. It is worth learning your gram stains for the main organisms. It is worth noting that Staphylococcus aureus is coagulase positive (also Yersinia pestis which causes plague) and Streptoccus pneumoniae is optochin sensitive. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.
