A 58-year-old man is investigated for a chronic cough and is found to have lung cancer. He inquires whether it may be work related.
Which one of the following is most likely to increase his risk of developing lung cancer?
Correct Answer C: Whilst many chemicals have been implicated in the development of lung cancer passive smoking is the most likely cause. Up to 15% of lung cancers in patients who do not smoke are thought to be caused by passive smoking.
Lung cancer: risk factors: Smoking:
Other factors:
Factors that are NOT related:
Smoking and asbestos are synergistic, i.e. a smoker with asbestos exposure has a 10 * 5 = 50 times increased risk.
A 54-year-old man is admitted with suspected pulmonary embolism. He has no past medical history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min. The chest x-ray is normal.
Following treatment with low molecular weight heparin, what is the most appropriate initial lung imaging investigation to perform?
Correct Answer E: CTPA is the first line investigation for PE according to current BTS guidelines.
This is a difficult question to answer as both computed tomographic pulmonary angiography (CTPA) and ventilation-perfusion scanning are commonly used in UK clinical practice. The 2003 British Thoracic Society (BTS) guidelines, however, recommended that CTPA is now used as the initial lung imaging modality of choice. Pulmonary angiography is of course the 'gold standard' but this is not what the question asks for.
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:
PE:
CTPA:
Pulmonary angiography:
A 39-year-old man presents with shortness of breath following one week of flu-like symptoms. He also has a nonproductive cough but no chest pain. A chest x-ray shows bilateral consolidation and examination reveals erythematous lesions on his limbs and trunk.
Which one of the following investigations is most likely to be diagnostic?
Correct Answer D: Mycoplasma? - serology is diagnostic.
The flu-like symptoms, bilateral consolidation and erythema multiforme point to a diagnosis of Mycoplasma. The most appropriate diagnostic test is Mycoplasma serology.
Mycoplasma pneumoniae: Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger patients. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae classically occur every 4 years. It is important to recognize atypical pneumonias as they may not respond to penicillins or cephalosporins.
Features:
Complications:
Diagnosis:
Management:
Which type of hypersensitivity reaction predominates in the acute phase of extrinsic allergic alveolitis?
Correct Answer C: Although it is known that the pathogenesis of extrinsic allergic alveolitis involves a type IV (delayed) hypersensitivity reaction, a type III hypersensitivity reaction is thought to predominate, especially in the acute phase.
Extrinsic allergic alveolitis:
Extrinsic allergic alveolitis (EAA, also known as hypersensitivity pneumonitis) 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:
Presentation:
Investigation:
*Here the terminology is slightly confusing as thermophilic actinomycetes is an umbrella term covering strains such as Micropolyspora faeni.
A 60-year-old woman who has recently been diagnosed with chronic obstructive pulmonary disease (COPD) presents for review. She is still occasionally breathless despite using a short-acting muscarinic antagonist (SAMA) as required. Her FEV1 is 45% of predicted and she has managed to stop smoking.
Of the following options, which one is the most appropriate next step in management?
Correct Answer C: Another option here is a long-acting muscarinic antagonist (LAMA), for example tiotropium. Please see the 2010 NICE guidelines for more details.
COPD: stable management:
NICE updated it's guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2010.
General management:
Bronchodilator therapy:
FEV1 > 50%:
FEV1 < 50%:
For patients with persistent exacerbations or breathlessness:
Oral theophylline:
Mucolytics:
Cor pulmonale:
Factors which may improve survival in patients with stable COPD:
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