A 31-year-old woman is referred to the acute medical unit with a 4 day history of polyarthritis and a low-grade pyrexia. Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum.
What is the most likely diagnosis?
Correct Answer B: Loffler's syndrome is a cause of pulmonary eosinophilia thought to be caused by parasites such as Ascaris lumbricoides.
Lofgren's syndrome:
Lofgren's syndrome is an acute form sarcoidosis characterized by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia.
It typically occurs in young females and carries an excellent prognosis.
A 24-year-old female comes for review. She was diagnosed with asthma two years ago and is currently using a salbutamol inhaler 100mcg prn combined with beclometasone dipropionate inhaler 200mcg bd. Despite this her asthma is not well controlled. On examination her chest is clear and she has a good inhaler technique.
What is the most appropriate next step in management?
Correct Answer D: The British Thoracic Society recommend adding a long-acting B2 agonist if there is an inadequate response to the addition of inhaled steroid. The inhaled steroid dose should be increased if there is an inadequate response to the long-acting B2 agonist.
Asthma: stepwise management in adults.
The management of stable asthma is now well established with a step-wise approach:
*Beclometasone dipropionate or equivalent.
Additional notes:
Leukotriene receptor antagonists:
Fluticasone is more lipophilic and has a longer duration of action than beclometasone Hydrofluoroalkane is now replacing chlorofluorocarbon as the propellant of choice. Only half the usually dose is needed with hydrofluoroalkane due to the smaller size of the particles.
Long acting B2-agonists acts as bronchodilators but also inhibit mediator release from mast cells. Recent metaanalysis showed adding salmeterol improved symptoms compared to doubling the inhaled steroid dose.
A 31-year-old female with no past medical history of note is admitted to hospital with dyspnoea and fever. She has recently returned from holiday in Turkey. A clinical diagnosis of pneumonia is made. On examination she is noted to have an ulcerated lesion on her upper lip consistent with reactivation of herpes simplex.
Which organism is most associated with this examination finding?
Correct Answer C: Streptococcus pneumoniae is associated with cold sores.
Streptococcus pneumoniae commonly causes reactivation of the herpes simplex virus resulting in 'cold sores'
Pneumonia: community-acquired:
Community acquired pneumonia (CAP) may be caused by the following infectious agents:
Klebsiella pneumoniae is classically in alcoholics.
Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia.
Characteristic features of pneumococcal pneumonia:
Management:
The British Thoracic Society published guidelines in 2009:
A 24-year-old woman who is 34 weeks pregnant presents with pleuritic chest pain and shortness of breath. She has noticed some pain in her left calf for the past 3 days and on examination she has clinical signs consistent with a left calf deep vein thrombosis.
What is the most appropriate investigation?
Correct Answer B: Confirming a DVT is the first step as this may provide indirect evidence of a pulmonary embolism. As both conditions require anticoagulation this may negate the need for further radiation exposure.
Pregnancy: DVT/PE investigation:
Guidelines were updated in 2010 by the Royal College of Obstetricians. Key points include:
Comparing CTPA to V/Q scanning in pregnancy:
D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.
Which one of the following paraneoplastic features is least commonly seen in patients with squamous cell lung cancer?
Correct Answer A: Lambert-Eaton syndrome occurs almost exclusively in small cell lung cancer.
Lung cancer: paraneoplastic features: Small cell:
Squamous cell:
Adenocarcinoma:
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