A 30-year-old woman is admitted to the Emergency Department with an exacerbation of asthma. On arrival her peak flow is 30% of predicted, respiratory rate is 36/min and oxygen saturations are 98% on 100% high-flow oxygen. She is given back-to-back nebulizers, intravenous hydrocortisone and started on a magnesium infusion.
Which one of the following would be the strongest indicator of a need for intubation and ventilation?
Correct Answer B: A falling pH likely represents carbon dioxide retention in a tiring patient as is an ominous sign in acute asthma. Performing serial peak flows in a patient with life-threatening asthma is neither practical nor desirable.
Asthma: acute severe: Patients with acute severe asthma are stratified into moderate, severe or life-threatening :
British Thoracic Society guidelines:
You are reviewing a man with haemoptysis in the rapid-access lung clinic.
Which one of the following is the most significant risk factor for developing lung cancer?
Correct Answer D:
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 72-year-old man presents with gradually increasing shortness-of-breath on exertion over the past six months. He stopped smoking around 20 years ago and had a number of jobs including a builder and miner when he was younger. On auscultation of his chest fine crackles can be heard in both bases. Oxygen saturations are 95% on room air.
A number of tests are arranged:
What is the most likely diagnosis?
Correct Answer C: Asbestosis is the only one of the above diagnoses that predominately affects the lower zones. Cryptogenic fibrosing alveolitis is of course a differential diagnosis in this scenario.
Lung fibrosis:
It is important in the exam to be able to differentiate between conditions causing predominately upper or lower zone fibrosis. It should be noted that the more common causes (cryptogenic fibrosing alveolitis, drugs) tend to affect the lower zones.
Fibrosis predominately affecting the upper zones:
Fibrosis predominately affecting the lower zones:
A 34-year-old steelworker presents complaining of episodic shortness of breath. This is particularly noted whilst at work where he describes feeling wheezy and having a tendency to cough.
Which one of the following is the most appropriate diagnostic investigation?
Correct Answer C: Serial peak flow measurements at work and at home are used to detect occupational asthma.
Asthma: occupational:
Causes:
Diagnosis:
A 35-year-old patient with a history of asthma and epilepsy presents with haemoptysis and a worsening of his asthma. Blood tests reveal an eosinophilia and a positive pANCA.
Which of the following drugs is most likely to have precipitated the likely diagnosis?
Correct Answer A: This patient probably has Churg-Strauss syndrome, which is associated with the use of leukotriene receptor antagonists.
Churg-Strauss syndrome:
Churg-Strauss syndrome is an ANCA associated small-medium vessel vasculitis.
Features:
Leukotriene receptor antagonists may precipitate the disease.
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