Question 111#

A 63-year-old man is noted to have a pleural effusion on CXR.

Which one of the following would typically cause a transudate?

A. Pancreatitis

Correct Answer D: 

Pleural effusion:

Exudate (> 30g/L protein):

• Infection: pneumonia, TB, subphrenic abscess
• Connective tissue disease: RA, SLE
• Neoplasia: lung cancer, mesothelioma, metastases
• Pancreatitis
• Pulmonary embolism
• Dressler's syndrome
• Yellow nail syndrome

Transudate (< 30g/L protein): 

• Heart failure
• Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
• Hypothyroidism
• Meigs' syndrome

Question 112#

You are reviewing a patient with chronic obstructive pulmonary disease (COPD) who remains breathless despite using a salbutamol inhaler as required. Their FEV1 is 60%.

What are the two main options?

A. Long-acting beta2-agonist (LABA) or inhaled corticosteroid

Correct Answer E: 

COPD - still breathless despite using inhalers as required?

• FEV1 > 50%: LABA or LAMA
• FEV1 < 50%: LABA + ICS or LAMA

COPD: stable management:
NICE updated it's guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2010.

General management: 

• Smoking cessation advice
• Annual influenza vaccination
• One-off pneumococcal vaccination 

Bronchodilator therapy:

• A short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
• For patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by the FEV1

FEV1 > 50%: 

• Long-acting beta2-agonist (LABA), for example salmeterol, or:
• Long-acting muscarinic antagonist (LAMA), for example tiotropium

FEV1 < 50%: 

• LABA + inhaled corticosteroid (ICS) in a combination inhaler, or:
• LAMA

For patients with persistent exacerbations or breathlessness: 

• If taking a LABA then switch to a LABA + ICS combination inhaler
• Otherwise give a LAMA and a LABA + ICS combination inhaler Oral theophylline
• NICE only recommends theophylline after trials of short an long-acting bronchodilators or to people who cannot used inhaled therapy
• The dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed 

Mucolytics: 

• Should be 'considered' in patients with a chronic productive cough and continued if symptoms improve

Cor pulmonale: 

• Features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
• Use a loop diuretic for oedema, consider long-term oxygen therapy
• ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE

Factors which may improve survival in patients with stable COPD: 

• Smoking cessation - the single most important intervention in patients who are still smoking
• Long term oxygen therapy in patients who fit criteria
• Lung volume reduction surgery in selected patients

Question 113#

A 62-year-old woman with recently diagnosed chronic obstructive pulmonary disease (COPD) presents for review. Her FEV1 is 65% of the predicted value. She has managed to give up smoking and was prescribed a salbutamol inhaler to use as required. Despite this she is still symptomatic and complains of wheeze and shortness of breath.

What is the most appropriate next step?

A. Add an inhaled corticosteroid

Correct Answer B: Following the 2010 NICE guidelines a long-acting beta2-agonist (LABA) would be an alternative option.

COPD: stable management:

NICE updated it's guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2010.

General management: 

• Smoking cessation advice
• Annual influenza vaccination
• One-off pneumococcal vaccination

Bronchodilator therapy:

• A short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
• For patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by the FEV1 

FEV1 > 50%: 

• Long-acting beta2-agonist (LABA), for example salmeterol, or:
• Long-acting muscarinic antagonist (LAMA), for example tiotropium 

FEV1 < 50%: 

• LABA + inhaled corticosteroid (ICS) in a combination inhaler, or:
• LAMA

For patients with persistent exacerbations or breathlessness: 

• If taking a LABA then switch to a LABA + ICS combination inhaler
• Otherwise give a LAMA and a LABA + ICS combination inhaler 

Oral theophylline: 

• NICE only recommends theophylline after trials of short an long-acting bronchodilators or to people who cannot used inhaled therapy
• The dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Mucolytics: 

• Should be 'considered' in patients with a chronic productive cough and continued if symptoms improve 

Cor pulmonale: 

• Features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
• Use a loop diuretic for oedema, consider long-term oxygen therapy
• ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE

Factors which may improve survival in patients with stable COPD: 

• Smoking cessation - the single most important intervention in patients who are still smoking
• Long term oxygen therapy in patients who fit criteria
• Lung volume reduction surgery in selected patients

Question 114#

A 65-year-old life-long smoker with a significant past history of asbestos exposure is investigated for lung cancer.

Given his history of both smoking and asbestos exposure, what is his increased risk of lung cancer?

A. 5

Correct Answer C: Smoking and asbestos are synergistic, i.e. a smoker with asbestos exposure has a 10 * 5 = 50 times increased risk.

Lung cancer: risk factors:

Smoking: 

• Increases risk of lung ca by a factor of 10

Other factors: 

• Asbestos - increases risk of lung ca by a factor of 5
• Arsenic
• Radon
• Nickel
• Chromate
• Aromatic hydrocarbon
• Cryptogenic fibrosing alveolitis

Factors that are NOT related: 

• Coal dust 

Smoking and asbestos are synergistic, i.e. a smoker with asbestos exposure has a 10 * 5 = 50 times increased risk.

Question 115#

A 17-year-old male with a history of cystic fibrosis presents to clinic for annual review.

What is the most appropriate advice regarding his diet?

A. High calorie and low fat with pancreatic enzyme supplementation for every meal

Correct Answer E: 

Cystic fibrosis: management:

Management of cystic fibrosis involves a multidisciplinary approach.

Key points: 

• Regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful
• High calorie diet, including high fat intake*
• Vitamin supplementation
• Pancreatic enzyme supplements taken with meals
• Heart and lung transplant

*This is now the standard recommendation - previously high calorie, low-fat diets have been recommended to reduce the amount of steatorrhoea.