Respiratory

Question 1

What condition is Horner’s syndrome associated with?

Answer 1

Pancoast tumour

Question 2

What are the features of Horner’s syndrome?

Answer 2

Miosis (small pupil)
Ptosis
Enopthalmos (sunken eye)
Anhidrosis (loss of sweating on one side)

Question 3

What drastically increases the risk of pneumothorax in young otherwise healthy men?

Answer 3

Stopping smoking

Reduces risk from 10% to 0.1%

Question 4

What test should be offered to all patients with TB?

Answer 4

HIV testing - latent TB is often pushed into active disease by immunosuppression

Question 5

What lesions are often seen in TB?

Answer 5

Ghon focus

Question 6

What is extrinsic allergic alveolitis?

Answer 6

A hypersensitivity to a variety of inhaled organic particles. It is thought to be caused by largely immune-mediated tissue damage (type III hypersensitivity), though there is some type IV hypersensitivity in the chronic stage

Question 7

What is the presentation in acute EAA?

Answer 7

4-8 hours after exposure
SOB
Dry cough
Fever

Inspiratory crackles/squeaks

Question 8

What is the presentation in chronic EAA?

Answer 8

Progressive exertional breathlessness as a result of pulm. fibrosis
There may be a history of acute episodes

Inspiratory crackles consistent with pulm. fibrosis

Question 9

What would you see on chest x-ray in EAA?

Answer 9

Diffuse ground glass changes with small nodules (acute)

Pulmonary fibrosis in upper/mid zones (chronic)

Question 10

What do you see on bloods in EAA?

Answer 10

Neutrophil leukocytosis

No eosinophilia

Question 11

What do you see on pulmonary function testing in EAA?

Answer 11

A restrictive pattern

Question 12

How do we manage EAA?

Answer 12

Allergen avoidance

Oral prednisolone may help recovery, but not prognosis

Question 13

What is sarcoidosis?

Answer 13

A multisystem disorder of unknown aetiology characterised by non-caseating granulomas

Question 14

What demographic are most likely to get sarcoidosis?

Answer 14

Young adults and people of African descent

HLA B8 gene associated

Question 15

What are the features of sarcoidosis?

Answer 15

Acute:
Erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia

Insidious:
Dyspnoea, non-productive cough (due to pulm. fibrosis), malaise, weight loss

Hypercalcaemia
Lupus pernio
Anterior uveitis
Kidneys have granulomas (70%)

Question 16

What would you see on chest x-ray in sarcoidosis?

Answer 16

A chest x-ray may show the following changes:
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis

Question 17

What would you see on tissue biopsy and spirometry in sarcoidosis?

Answer 17

Tissue biopsy: non-caseating granulomas

Spirometry: may show a restrictive defect

Question 18

How do we treat sarcoidosis?

Answer 18

If just erythema nordosum, arthralgia etc, no treatment, just NSAIDs for pain

If pulm. features/radiological features >6 months, oral steroids

Question 19

What is bronchiectasis?

Answer 19

A permanent dilation of the airways (bronchial wall) secondary to chronic infection/inflammation

Question 20

What are the causes of bronchiectasis?

Answer 20

Post-infective (localised bronchiectasis): TB/measles/pertussis/pneumonia

Generalised bronchiectasis:
CF
Ciliary dyskinetic syndromes (Young’s/Kartagener’s)
Immune deficiency (selective IgA)
RA
Bronchial obstruction (e.g. lung cancer/foreign body)

Question 21

What are the symptoms of bronchiectasis?

Answer 21

Chronic cough
Sputum production (copious, mucopurulent)
50% have haemoptysis
Anaemia
Raised JVP
Clubbing
Cyanosis
Cor pulmonale

Question 22

Kartagener’s syndrome

Answer 22

Mutation in the gene coding for dynein
Causes ciliary dysmotility
Sinusitis
Infertility in men

Question 23

Young’s syndrome

Answer 23

Triad of bronchiectasis, rhinosinusitis and decreased fertility due to viscous mucus

Question 24

Investigations in bronchiectasis?

Answer 24

Chest x-ray:
Tram lines (thickened bronchial walls)

High resolution CT:
‘Signet ring’ sign - thickened bronchial wall larger than adjacent blood vessel (looks like circles with white blob attached on a CT)

Question 25

Management of bronchiectasis?

Answer 25

Physiotherapy - twice daily postural drainage
Bronchodilators - if reversibility has been demonstrated with formal testing
Long-term rotating abx
IImmunisations

Question 26

Common organisms isolated in bronchiectasis?

Answer 26

H. influenzae (most common)
Pseudomonas aeruginosa
Klebsiella
Strep. pneum

Question 27

What is allergic bronchopulmonary aspergillosis?

Answer 27

This is the result of an allergy to aspergillus spores

It is most commonly seen in people with asthma or CF

Question 28

What are the features of bronchopulmonary aspergillosis?

Answer 28

Bronchoconstriction (wheeze, cough, dyspnoea)

Bronchiectasis

Question 29

What investigation findings would there be in ABPA?

Answer 29

Positive test for aspergillus spp. on skin biopsy
Blood test - raised IgE
Chest x-ray - transient x-ray changes

Question 30

How do we manage ABPA?

Answer 30

Steroids

Itraconazole sometimes as 2nd line agent

Question 31

What is an aspergilloma?

Answer 31

A mycetoma (mass-like fungus ball) which often colonises an existing lung cavity (e.g. secondary to TB, lung cancer or CF)

Question 32

What are the features of aspergilloma?

Answer 32

Asymptomatic
Cough
Haemoptysis (75%)
Weight loss, fever, malaise

Question 33

What are the investigation findings in aspergilloma?

Answer 33

Dense opacity, crescent/halo sign may be present

Question 34

How do we treat aspergilloma?

Answer 34

Surgical resection

Question 35

Klebsiella pneumoniae

Answer 35

Most commonly causes a cavitating pneumonia in the upper lobes, particularly in diabetics + alcoholics

Question 36

Wegener’s granulomatosis (granulomatosis with polyangiitis)

Answer 36

URTIs
Rapidly progressive glomerulonephritis
Saddle-shape nose deformity
Vasculitis rash
Proptosis

Treat with:
Steroids
Cyclophosphosphamide