A chest x-ray of a patient with sarcoidosis shows bilateral hilar lymphadenopathy accompanied with interstitial infiltrates.
What chest x-ray stage does this correspond to?
Correct Answer C:
Sarcoidosis CXR:
Sarcoidosis: investigation:
There is no one diagnostic test for sarcoidosis and hence diagnosis is still largely clinical. ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity. Routine bloods may show hypercalcaemia (seen in 10% if patients) and a raised ESR.
A chest x-ray may show the following changes:
Other investigations*:
*The Kveim test (where part of the spleen from a patient with known sarcoidosis is injected under the skin) is no longer performed due to concerns about cross-infection.
A 66-year-old man with a history of chronic obstructive pulmonary disease (COPD) is referred by his GP to the Rapid Access Chest Clinic. He was recently treated with several courses of antibiotics and steroids for an exacerbation of COPD which failed to completely resolve. A chest x-ray was reported as follows:
Recent blood tests are also reviewed:
On examination there is no evidence of clubbing. Examination of chest demonstrates a fixed monophonic wheeze in the right lung.
What is the most likely underlying cause?
Correct Answer D: The presence of hyponatraemia strongly points towards a diagnosis of small cell lung cancer.
Lung cancer: small cell:
Features:
Management:
*An acronym for:
A 49-year-old female is admitted to the Emergency Department with shortness of breath. On examination the pulse is 114 bpm with blood pressure 106/66 mmHg, temperature 37.7ºC and respiratory rate 30/min. Examination of the cardiorespiratory system is unremarkable with a peak expiratory flow rate of 400 l/min.
Arterial blood gases on air reveal:
Following the initiation of oxygen therapy, what is the next most important step in management?
Correct Answer C: Type 1 respiratory failure in a tachycardic, tachypnoeic female with an absence of chest signs points towards a diagnosis of pulmonary embolism.
Low-grade pyrexia is common in pulmonary embolism.
Pulmonary embolism: management:
The NICE guidelines of 2012 provided some clarity on how long patients should be anticoagulated for after a pulmonary embolism (PE). Selected points are listed below.
Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a PE is diagnosed. An exception to this is for patients with a massive PE where thrombolysis is being considered. In such a situation unfractionated heparin should be used.
Thrombolysis:
A middle-aged woman is admitted to the Emergency Department with pleuritic chest pain ten days after having a hysterectomy. There is a clinical suspicion of pulmonary embolism.
What is the most common chest x-ray finding in patients with pulmonary embolism?
Correct Answer B: Pulmonary embolism - normal CXR.
The vast majority of patients with a pulmonary embolism have a normal chest x-ray.
Pulmonary embolism: investigation:
2012 NICE guidelines:
All patients with symptoms or signs suggestive of a PE should have a history taken, examination performed and a chest x-ray to exclude other pathology.
If a PE is still suspected a two-level PE Wells score should be performed:
Clinical probability simplified scores:
If a PE is 'likely' (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular weight heparin until the scan is performed.
If a PE is 'unlikely' (4 points or less) arranged a D-dimer test. If this is positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular weight heparin until the scan is performed.
If the patient has an allergy to contrast media or renal impairment a V/Q scan should be used instead of a CTPA.
CTPA or V/Q scan?
The British Thoracic Society (BTS) published guidelines back in 2003 on the management of patients with suspected pulmonary embolism (PE). Key points from the guidelines include:
Some other points:
D-dimers:
ECG:
V/Q scan:
Pulmonary angiography:
A 25-year-old man is referred due to pain and swelling in his knees and ankles. On examination he has a painful, erythematous rash on his legs. The following results are obtained:
What is the most likely outcome?
Correct Answer C: The majority of patients with sarcoidosis get better without treatment.
This man has an acute form of sarcoidosis. There are no indications for steroid therapy and his symptoms will resolve spontaneously in the majority of cases.
Sarcoidosis is a multisystem disorder of unknown aetiology characterized by non-caseating granulomas. It is more common in young adults and in people of African descent. Sarcoidosis remits without treatment in approximately two-thirds of people.
Factors associated with poor prognosis:
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