Which of the following increases ciclosporin levels? (more than one answer)

The recommended inhaler for Group B Gold criteria is:

Pt is admitted with an acute exacerbation of asthma.  SOB and wheezy despite back to back nebs. Looks exhausted, Sats 92% HR 120 

ABG on 5l. PH 7.35 PCO2 6.2 PO2 8.0 

Severity is ?

Which of the following nodes are not accessible with EUS?

What is the dose of adrenaline you give to stop a bleed during bronchoscopy?

A CT chest shows a 8mm solid pulmonary nodule. What is the next step?

Which of the following is NOT part of the Brock model calculation?

A 23 year old female who is 30 weeks pregnant has been referred to the respiratory clinic due to “uncontrolled asthma”. She has a history of atopy and has experienced symptoms of wheeze, cough, and breathlessness of varying severity since the age of 5 years old. 

Since her late teens, her symptoms have been well managed by her GP with beclomethasone 200mcg BD and salbutamol MDI PRN, however over the past 2 months she has struggled with nocturnal symptoms of cough and chest tightness. She has trialled a LABA in the past to no benefit.

With regards to this scenario, which of the following is true?

A 70 year old gentleman with severe COPD is admitted to the emergency department with a pneumonic exacerbation of COPD. On examination he is drowsy, RR 26/min, HR 140bpm, BP 90/60, O2 Sats87% on 60% FiO2, Temp 38.4C. He has coarse inspiratory crackles on auscultation of the right lower zone, expiratory wheeze throughout, and oedema to his knees.

His ABG on 60% FiO2 is:

Ph: 7.15, PaO2 8.0kPa, PaCO2 8.0kPa, HCO3 29mmol/L

With regards to this scenario, which of the following is true?

A 64 year old female attends the lung cancer clinic after presenting to her GP with a chronic cough. A chest radiograph revealed a right upper lobe mass, and you request further imaging (see adjacent).

From the images seen, what would her TNM classification be?

Which of the following TB drugs is bacteriostatic?

How do you treat Ethambutol resistant TB?

Reaction to the mantoux test may be suppressed by: (more than one answer)

Which of the following forms part of the Herder Model risk assessment score? (more than one answer)

Using the LIS lung injury score to quantify severity of ARDS, a score above what would indicate the need for ECMO?

What percentage of survivors of ITU stay with ARDS have returned to work at 12 months?

What is involved in the pathophysiology of ARDS?

What is a classical CT feature of bronchiectasis?

What childhood illness can lead to bronchiectasis? 

In patients with COPD, when should we investigate for bronchiectasis ?

63 year old man with bronchiectasis. Previous 2x sputum with pseudomonas while stable. Exacerbation 3 time per year, not tolerated colistin nebs. PMH of hypertension, hearing aids, diabetes. 

What treatment would be the next step? 

70 year old woman with known asthma and bronchiectasis comes to see you due to deterioration of her symptoms over the last 2 years. She has had frequent exacerbations and complains of intermittently coughing up orange coloured mucous plugs. 

Chest Xray shows bilateral pulmonary opacities. Blood tests show high eosinophils, high IGE of 2000 and  elevated IGE and IGG to Aspergillus. You start treatment and she is clinically improving. 

How would you assess for treatment response?

65 year old lady with known bronchiectasis comes to clinic. She has been clinically deteriorating for the last 3 years. Over the last year she has had 3 exacerbations. A recent sputum has grown pseudomonas for the first time. You treat for eradication with PO antibiotics for 2 weeks and during this time need to arrange for a test dose of nebuliser colistin. 

When should you carry out spirometer during the trial?

What is the most frequently occurs in CF patients? 

Which mutation leads to defective channel ion transport (class IV)?

62 year old lady with IPF is being considered for lung transplantation opinion. Her IPF was diagnosed 4 years ago and in the last year her TLCO has dropped to 35% and is clinically more symptomatic. Her MRC dysponea score is 3 with a 6MWT of 350m and desaturates to 88% on mobilising. She has a BMI of 20. She stopped smoking 7 months ago. She has a history of CKD 2, breast cancer stage 2, which was treated with wide local excision and radiotherapy 2 years ago, and hypertension. 

What would be the main contraindication to lung transplant? 

18 year old asthmatic presents to ED with acute SOB. wheeze and cough. She has had symptoms for one week and have progressed despite her starting a rescue pack of prednisolone 2 days ago. On examination she can speak in full sentences, her RR is 30 and oxygen saturations are 94% on room air. She is well otherwise, has a BMI of 17 and is taking seretide inhaler BD plus salbutamol PRN in addition to montelukast at night and sertraline for depression. She is an ex-smoker but uses an electronic vape. 

She is treated for an acute exacerbation of her asthma and clinically improves enough to be discharged after 3 days. 

What puts her at increased risk of future asthma attacks? 

You see a 50 year old lady in clinic. She was diagnosed with asthma by her GP 1 year ago following complaining of intermittent coughs and wheeze. She had a FENO of 40 and was started on salbutamol PRN and beclomethasone inhaler. She improved slightly with this but continued to cough a lot at night. The GP therefore switched her to a long acting B2 Agonist and Steroid (low dose) combination inhaler. Her control is still not optimal so she was referred to secondary care. She has no other comorbidites but has a BMI of 35. She is an ex-smoker and had a dog at home which she has had for 10 years. 

What would the most appropriate next step be? 

18 year old asthmatic presents to ED with acute SOB wheeze and cough. She has had symptoms for one week and they have progressed despite her starting a rescue pack of prednisolone 2 days ago. On examination she can speak in full sentences, her RR is 29 and her oxygen saturations are 94% on room air. Heart rate is 100 BPM and her BP is 110/60. Her peak flow rate is 200 (best 400). PaO2 is 8.4 PCO2 is 3.5. She is able to tell you the history and has bilateral wheeze on examination . She is well otherwise, has a BMI of 17 and is taking seretide inhaler BD plus salbutamol PRN in addition to montelukast at night and sertraline for depression. She is an ex-smoker but uses an electronic vape. 

What severity was her asthma attack at presentation?

76 year old man attends ED complaining of breathlessness. He describes it has been progressively worsening for the last week. He has an episode of chest pain the day before attending ED. He has a history of 2 previous MI's, hypertension and prostate cancer for which he is on hormone treatment. He is an ex-smoker with a 40 pack year history and used to work as a plumber for his whole life prior to retirement. On examination his RR is 20 with oxygen satirations of 90% on room air. His BP is 110/60 and HR is 106, sinus tachycardia on ECG. 

CXR shows:

What would be the most appropriate next step? 

What is incorrect about pleural effusions? 

60 year old woman with RA presents with progressive breathlessness. She takes methotrexate for her RA which is well controlled. CXR showed a moderate right sided effusion and you arranged an USS guided aspiration. She recently had cardiotheroacic surgery but felt well post op.  

Results 

Serous colour  

Protein 35 

LDH 225

Glucose 3.0

Pleural fluid cholesterol 4.5

Serum cholesterol 4.5

Triglycerides 110mg/dl / 1.5mmol 

Sample was contaminated in lab so visualisation under microscope unable to be performed. 

What's the cause of her pleural effusion?

Diagnostic yield from a malignant effusion is 60% but is higher is certain malignancy. Which cancer has a higher diagnostic rates?

Which of these is not true?

78 year old lady admitted with progressive breathlessness. On examination she had dull to percuss right hemithorax. CXR confirmed large volume pleural effusion. She underwent a therapeutic/diagnostic  aspiration and was diagnosed with adenocarcinoma. She lives alone but has support from family for shopping and does not leave the house on her own. Her BMI is 17 and she has a background of COPD, angina and hypertension. Following her therapeutic aspiration she has good response symptomatically. She returned to clinic 1 month later complaining of worsening SOB. What would you advise as the next step in management? 

What is not an independent risk factor for empyema?

32 year old lady from India recently moved to the uk. She has no significant past medical history underwent a CXR as part of an employment health check. 

What would be the most appropriate next step for this patient? 

35 year old woman presented with a history of low grade fever and cough for 8 weeks. See CT scan

What is the most likely diagnosis?

18 year old man presented with a 9 week history of dry unproductive cough. See CT

What is the diagnosis?

Which of these about air travel is not true? 

Which of these are false for emergency oxygen? 

78 year old man presented to ED with progressive SOB and productive cough. He is an ex-smoker with 40 pack year history. He was diagnosed with COPD by his GP 4 years ago and has been on spiriva inhaler since diagnosis. He is very breathless usually and says he is a slower walker than his wife and needs to stop a few times when walking to the shops. He has had no exacerbations within the last year. He tells you that he has a chronic cough with some sputum but it has become a lot worse in the last 5 days. He has mild limitation with activities in the house and has noticed some night-time symptoms and loss of energy over the last year. His CXR was clear. He was treated as an acute exacerbation of COPD with nebulisers and PO steroids and clinically improved. You are asked to review him prior to discharge and assess his COPD medication. What is the most appropriate management plan? 

68 year old woman presented with change of character of cough and weight loss. She is a current smoker with 60 pack year history and has stable COPD. She cares for herself at home and is up and about >50% of the time but struggles with any significant work and retired early due to her COPD symptoms. 

Her CT shows large mass in in her right lung congruent with mediastinal lymph nodes.

Bronchoscopy shows narrowing of the right main bronchus. Biopsy confirms small cell lung cancer. 

PET and MRI head confirm no distant metastases. But there is evidence of contralateral enlarged lymph nodes with high uptake. She has been referred to the oncologist for urgent review but asks you what is likely treatment offered initially? 

60 year old female exsmoker was discussed in MDT. She has a PS of 0 and is still working as a nurse in a nursing home. She had an FEV1 of 65% predicted with a ratio of 68%. Her 6MWT had a distance of 450 meters. 

On CT she was found to have a 4cm peripheral lesion in left upper lobe. CT suggests chest wall invasion. PET showed high uptake in hilar lymph nodes bilaterally lymph nodes so EBUS was carried out which showed station 10L positive for adenocarcinoma and 10R negative. 

What is the staging? 

60 year old female exsmoker was discussed in MDT. She has a PS of 0 and is still working as a nurse in a nursing home. She had an FEV1 of 65% predicted with a ratio of 68%. Her 6MWT had a distance of 450 meters. 

On CT she was found to have a 4cm peripheral lesion in left upper lobe. CT suggests chest wall invasion. PET showed high uptake in hilar lymph nodes bilaterally lymph nodes so EBUS was carried out which showed station 10L positive for adenocarcinoma and 10R negative. 

What is the staging? 

A 63 year old man presented to ED following a road traffic accident. He had a trauma CT scan which picked up a 6mm solid pulmonary nodule. The ED team arranged a 3 month follow up CT scan and he is seeing you in clinic following this. The nodule has increased in size with a volume doubling time of 600 days. He has a PS of 0 and is still working as a plumber part time. He is an ex-smoker with 40 pack years history. 

 What would be your management plan? 

78 year old smoker found to have incidental finding of 6mm nodule which was sub solid. He is fit and well otherwise. The solid component of the lesion was 4mm with surrounding ground glass 

On review he has a previous CT 1 year ago which showed a 6mm nodule in the same place but this was fully ground glass. 

What is your initial treatment plan? 

Which is not a risk factor for OSA?

Which of these is not true about pulmonary AVMs?

Which of these statements are not true about the BCG vaccination? 

24 year old man presented to ED with 2 months of dry cough. He was originally from Poland and had moved to the UK 6 months ago. On examination he had crepitations and reduced breath sound on auscultation of the left side. CXR showed pleural effusion with pneumothorax and large cavitation in left upper lobe. He had no family history of TB but used to work in an abattoir in Poland. Pleural fluid was sent for AFB which was positive in addition sputum was smear positive.  

Following culture it was found that he had MTB which was resistant to ethambutol but sensitive to all other antibiotics.

How would you manage his TB? 

Which is true about contract tracing for this patient? 

24 year old woman attends ED. She is 34 weeks pregnant and has been complaining of SOB for 48 hours with no cough but some mild chest pains. She has also complained of some left calf pain since an exercise class she took the week prior.  He saturations are 92% on room air and heart rate is 110BPM and RR is 24. You suspect a PE. 

Which is not true about PE in pregnancy/this patient ? 

82 year old man who is on hormone treatment for prostrate cancer but otherwise well and has PS of 0 attended ED with pleuritic chest pain. He is haemodynamically stable and saturations are 95% on room air. 

He lives with his wife who is also fit and well and has a daughter living close by. 

D-dimer is raised and Troponin is normal. All other blood tests are normal and CXR is clear. You cannot get a CTPA until the next day. 

What is your next steps? 

What is not a risk factor for CTEPH? 

78 year old women referred to the chest clinic with 3 month history of cough and expectoration. She weighed 55kg. 

CT showed a left upper lobe cavity 

Sputum was positive for MAC on 3 occasions 

She is started on treatment but there is poor response and you are considering malabsorption of one of her medications as the cause. 

Which of these drugs would you not monitor drug levels in? 

78 year old women referred to the chest clinic with 3 month history of cough and expectoration. She weighed 55kg. She is haemodynamically stable with no severe symptoms or signs of systemic illness.

CT showed moderate tree in bud with some ground glass consolidation.

Sputum was positive for MAC on 3 occasions (AFB smear negative)

What would your initial treatment be?

25 year old admitted to ED following a week of feeling generally unwell with myalgia and temperatures. She became more breathless over the last week which prompted her to present. She recently started smoking but other wise well. She has well controlled epilepsy and has been stable on phenytoin for 4 years. 

CXR showed interstitial infiltrates. 

Blood eosinophils are normal but she underwent a BAL which had high level of eosinophils. 

What is the most appropriate next step?

30 year old asthmatic since childhood comes to clinic. Her asthma has became more difficult to control over the last year with multiple exacerbations needing steroids, antibiotics and 1 hospitalisation. She has been on long term steroids for the last 3 months in an attempt to control her symptoms but she is still complaining of SOB, cough and nasal symptoms including sneezing and runny nose. 

Investigations 

Hb 10.0

Plat 400

WCC 10

Eosinophils 0.8

Urea 4.5

Creat 70 

Aspergillosis skin prick positive 

Total IgE 400

CT shows some mucus in airways but no signs of dilated airways. 

What is the most likely diagnosis? 

18 year old man presents with 3 day history of fever, cough, headache and coryzal symptoms. 

His observations are temperature 39.2, RR 18, saturations 96% RA, BP 115/65 and HR 105bpm. 

ECG sinus tachycardia 

CXR clear 

Flu swab - flu B positive. 

You explain the diagnosis to the patient and advise you can discharge but he has questions about his diagnosis. 

Which would not be true to tell him about the influenza virus? 

45 year old man who is 4 months post liver transplant presents with general malaise, fever, dry cough and SOB. 

He has saturations of 92% on room air, BP110/60 and HR 110 bpm.

Bloods show 

Hb 10

WCC 6

Low leukocytes 

Plt 75 

LFTs mildly deranged 

Urea 8

Crea 100

K 4.0

Na 120

CXR shows BL diffuse interstitial infiltrates 

What is the most likely diagnosis?

41 year old presents to clinic with SOB on exertion. She has 10 pack year history of smoking and previous IVDU of heroin and cocaine. 

Look at her PFT’s and CXR and decide what the most likely diagnosis is? 

35 year old with poorly controlled asthmatic attends ED with SOB and wheeze. He has been on PO steroids for 6 weeks and has had 3 admissions in the last year. You are called to resus urgently due to ongoing desaturation and intensive care doctors decide he needs intubation. CXR - see image

What is the most likely diagnosis?

58 year old woman with COPD attends clinic complaining of worsening SOB on exertion and high pitched noisy breathing. She has had 2 exacerbations this year but neither required hospitalisation. She is a current smoker with a 30 pack year history 

Other past medical history includes hypertension, depression and chronic rhinitis. 

She undergoes CT scan.

What is the most likely diagnosis? 

Asymptomatic 77 year old patient underwent a CXR following a minor RTA. She went on to have a CT scan and the images are below. 

The CT report states : Ground glass nodule in right upper lobe, size 17mm with 5mm solid component. 

 What would be the most appropriate next step?