Cough, Pneumonia, Lung Cancer

Question 1

Is a COPD exacerbation a type of pneumonia?

Answer 1

No

Question 2

What scoring system is used for community acquired pneumonia?

Answer 2

CURB-65
C confusion
U urea >7
RR >30
BP sBP <90 or dBP <60
65 over 65yr

Question 3

What is the management of pneumonia with a CURB-65 of 0-1?

Answer 3

Manage at home unless high risk
Antibiotics
1st line PO amoxicillin 1mg TDS for 5d
2nd line PO doxycycline for 5d

Question 4

What is the management of pneumonia with a CURB-65 of 2?

Answer 4

Usually treat at home

Consider hospital referral, use clinical judgment

Question 5

What is the management of pneumonia with a CURB-65 of 3?

Answer 5

Severe CAP = admit
1st line IV co-amoxiclav + PO doxycycline
2nd line IV levofloxacin
Step down to PO doxycycline

(If transferring from primary care give single dose oral amoxicillin before transfer)
(Review need for IVs daily)

Question 6

What is the management of pneumonia with a CURB-65 of 4?

Answer 6

Severe CAP = admit to ICU/HDU
1st IV co-amoxiclav + IV clarithromycin
2nd line IV levofloxacin

(If transferring from primary care, give single dose oral amoxicillin before transfer)
(Review need for IVs daily)

Question 7

Why isn’t alcohol recommended with amoxicillin?

Answer 7

Causes N+V

Question 8

What follow up investigation is done after discharging patients with inpatient pneumonia?

Answer 8

Repeat CXR 6wk after

Question 9

What is the test for legionella?

Answer 9

Urinary legionella antigen tests

Question 10

What investigations are done for all inpatient pneumonias?

Answer 10

Bloods
Blood culture
CXR
Sputum culture
Throat swab culture
Legionella urine Ag
Virology PCR

Question 11

What is the commonest infective agent in CAP?

Answer 11

Strep pneumoniae

Question 12

What infectious agent in CAP is cultured on chocolate agar?

Answer 12

Haemophilus influenzae

Question 13

What infectious agent in CAP is associated with air conditioning units?

Answer 13

Legionella

Question 14

What infectious agent in CAP is associated with sheep / goats?

Answer 14

Coxiella burneti
(Also associated with endocarditis)

Question 15

What infectious agent in CAP is associated with alcoholics and in upper lobes?

Answer 15

Klebsellia

Strep pneumoniae is also associated with alcoholics

Question 16

What infectious agent in CAP is associated with herpes labialis?

Answer 16

Strep pneumonia

Question 17

What infectious agent in CAP is associated with birds?

Answer 17

Chlamydophilia psittaci

Question 18

What infectious agent in CAP is associated with HIV?

Answer 18

PCP pneumocystis

Question 19

Is increased white cell count associated with increased severity of pneumonia

Answer 19

No

Question 20

By definition for HAP how long must the patient have been in hospital for?

Answer 20

At least 5 days

Question 21

What is an empyema?

Answer 21

Pus in the pleural space

Question 22

How would an empyema present following CAP?

Answer 22

Poor response to antibiotics

Persisting effusion on CXR

Question 23

What is the management of a empyema? When do you drain it?

Answer 23

Pleural tap

Check pH of aspirate, if <7.2 = infected = drain

Question 24

What is Pemberton’s test?

Answer 24

For SVCO, raise arms, positive if facial flushing face goes red

Question 25

What is the management of SVCO caused by a tumour?

Answer 25

High flow oxygen + dexamethasone

Question 26

"Permanent dilatation and thickening of airways, chronic airway inflammation" describes what disease?

Answer 26

Bronchiectasis

Question 27

Is smoking a RF for bronchiectasis?

Answer 27

No | CF, immunodeficiency and asthma are RFs

Question 28

Pneumonia with what infectious agent should raise suspicion of bronchiectasis?

Answer 28

Pseudomonas

Question 29

What is the CXR appearance of bronchiectasis?

Answer 29

No specific changes

Question 30

What is the gold standard investigation for bronchiectasis?

Answer 30

HRCT - signet ring sign (bronchial lumen diameter greater than pulmonary artery)

Question 31

Does bronchiectasis cause fine or coarse crackles? In inspiration or expiration? In lower or upper zones?

Answer 31

Coarse inspiratory crackles in lower zones

Question 32

What is a pleural effusion?

Answer 32

Fluid in pleural space between lung and chest wall

Question 33

What is a haemothorax?

Answer 33

Blood in pleural space

Question 34

Bilateral pleural effusions and cardiomegaly on CXR is a sign of what?

Answer 34

Heart failure

Question 35

What are the signs and symptoms of a pleural effusion?

Answer 35

``` May be asymptomatic Stony dull percussion Reduced chest expansion Breathlessness Pleuritic chest pain ```

Question 36

What are the 2 types of pleural effusion?

Answer 36

Transudate and exudate

Question 37

Transudate or exudate - which is due to high venous pressures?

Answer 37

Transudate

Question 38

Transudate or exudate - which has high / low cell count?

Answer 38

Transudate low cell count | Exudate cell rich

Question 39

Transudate or exudate - which has high / low protein count?

Answer 39

Transudate low protein count <30 | Exudate protein rich >30

Question 40

Transudate or exudate - which has high LDH?

Answer 40

Exudate

Question 41

Benign ovarian tumour with ascites + transudate pleural effusion is what syndrome?

Answer 41

Meigs syndrome

Question 42

What is the diagnostic criteria for exudate pleural effusion?

Answer 42

Protein ratio >0.5 or fluid: LDH ratio >0.6

Question 43

Metastatic cancer causes what type of pleural effusion?

Answer 43

Exudate

Question 44

Heart failure causes what type of pleural effusion?

Answer 44

Transudate

Question 45

Fluid overload causes what type of pleural effusion?

Answer 45

Transudate

Question 46

Pneumonia causes what type of pleural effusion?

Answer 46

Exudate

Question 47

What is the CXR appearance of a pleural effusion?

Answer 47

Blunting of the costophrenic angles | If large - white out

Question 48

Does the trachea deviate towards or away from a pleural effusion?

Answer 48

Away

Question 49

What is the management of a pleural effusion?

Answer 49

Pleural aspiration thoracentesis

Question 50

What test are done on the pleural aspirate of a pleural effusion?

Answer 50

Cytology, protein, LDH, gram stain culture sensitivity

Question 51

If pleural aspiration thoracentesis doesn't relieve symptoms in the Mx of a pleural effusion, what is the next step?

Answer 51

Chest drain | can't drain more than 1.5L in a single procedure

Question 52

Pleurodesis involves injecting a sclerosing agent - is it used in the Mx of what type of pleural effusion?

Answer 52

Malignant pleural effusion

Question 53

90% of TB is latent or active? | TB affects the lung bases or apex?

Answer 53

90% latent | Apex

Question 54

Caseating granulomas are due to what infection?

Answer 54

TB

Question 55

Night sweats, weight loss, malaise, cough, haemoptysis, SOB and upper zone crackles are all features of what?

Answer 55

TB

Question 56

What investigation is done for latent TB?

Answer 56

Mantoux skin test

Question 57

What investigation is done for active TB?

Answer 57

CXR + sputum culture (ZN stain acid fast bacilli)

Question 58

What is the management of active TB?

Answer 58

2 months RIPE + 4 months RI

Question 59

What is the management of latent TB?

Answer 59

6 months isoniazid or 3 months isoniazid + rifampicin

Question 60

Which TB drug causes optic neuritis?

Answer 60

Ethambutol

Question 61

Which TB drug causes orange urine/tears?

Answer 61

Rifampicin

Question 62

Which TB drug causes gout?

Answer 62

Pyrazinamide

Question 63

Which TB drug causes neuropathy?

Answer 63

Isoniazid

Question 64

Miosis, ptosis, anhydrosis describes what syndrome

Answer 64

Horner's syndrome (due to cervical sympathetic plexus disruption) (associated with pancoast tumours)

Question 65

What type of lung cancer is commonest in non-smokers?

Answer 65

Adenocarcinoma

Question 66

What type of lung cancer is commonest?

Answer 66

Adenocarcinoma

Question 67

A patient with known lung cancer presenting with acute breathlessness, headache, swollen neck with distended veins and racial reddening - what is the Dx

Answer 67

SVC obstruction

Question 68

What type of lung cancer is associated with pancoast tumours?

Answer 68

Small cell

Question 69

What is the management of metastatic malignant raised ICP?

Answer 69

IV dexamethasone

Question 70

What type of scan do you do if you suspect metastatic bone disease?

Answer 70

Bone scan

Question 71

Are bone mets from lung cancer lytic or sclerotic?

Answer 71

Lytic

Question 72

You suspect someone has lung cancer, what investigation do you order next?

Answer 72

CXR

Question 73

What type of lung cancer is associated with gynaecomastia?

Answer 73

Adenocarcinoma

Question 74

What type of lung cancer is associated with LEMS Eaton Lambert?

Answer 74

Small cell

Question 75

What type of lung cancer is associated with hypertrophic osteoarthropathy

Answer 75

Squamous

Question 76

What type of lung cancer is associated with paraneoplastic Cushing syndrome?

Answer 76

Small cell through ectopic ACTH secretion

Question 77

What type of lung cancer is associated with paraneoplastic hypercalcemia and through what mechanism?

Answer 77

Squamous Ectopic PTH secretion Bones stones groans moans

Question 78

What type of lung cancer is associated with: SIADH secretion

Answer 78

Small cell

Question 79

What type of lung cancer is associated with paraneoplastic hyponatremia and through what mechanism?

Answer 79

Ectopic ADH secretion | Small cell

Question 80

Clubbing and onion skin XR are signs of what paraneoplastic syndrome in lung cancer?

Answer 80

Hypertrophic osteoarthropathy

Question 81

Proximal weakness that improves with muscle use, diplopia, ptosis, haemoptysis, weight loss, chronic cough and breathlessness - what is the diagnosis?

Answer 81

Eaton Lambert LEMS paraneoplastic small cell lung cancer

Question 82

When investigating lung cancer, after a positive CXR, what investigation is done next

Answer 82

CT + biopsy | Biopsy bronchoscopy EBUS central lesions, CT guided biopsy if peripheral

Question 83

Does small cell lung cancer have a poor or good prognosis?

Answer 83

Small cell poor prognosis

Question 84

What type of lung cancer is second commonest?

Answer 84

Squamous

Question 85

What type of lung cancer is more chemo responsive?

Answer 85

Small cell

Question 86

What type of lung cancer is suitable for surgery?

Answer 86

Stage 1 or 2 non-small cell lung cancer

Question 87

Does a normal CXR exclude lung cancer?

Answer 87

No

Question 88

What treatment is used in conjunction with surgery for lung cancer?

Answer 88

Radiotherapy

Question 89

What is the function of a radiotherapy simulator?

Answer 89

To plan the area for treatment