1. A 27-year-old woman with a known history of asthma who lives in the
countryside comes to the clinic for review.She has progressively worsening
disease and is currently taking high dose Seretide and montelukast.
Apparently she coughs every night, occasionally with frank haemoptysis and
is finding it impossible to do any regular exercise at all.On examination her BP
is 128/82 mmHg, pulse is 74 and regular. There is extensive wheeze and
scattered coarse crackles on auscultation of the chest. Her peak flow is 320
(580 predicted).Investigations show:
Haemoglobi 127 g/L (115 -
n 160
)
White cell 7.9 (4 - 11)
count ×10
9/L
Eosinophil 1.2 (0.04 -
count ×10 0.4)
9/L
Platelets 173 (150 -
×10 400
9/L )
Sodium 137 (135 -
mm 146
ol/L )
Potassium 4.2 (3.5 -
mm 5)
ol/L
Creatinine 98 (79 -
µmo 118
l/L )
Which of the following is the best investigation?
A. Aspergillus precipitins
, B. Sputum culture
C. CXR
D. IgE
E. CT thorax
Answer: A
Key learning points
Respiratory Medicine
● Aspergillus precipitins can contribute significantly to confirming the diagnosis
of allergic bronchopulmonary aspergillosis (ABPA).
Explanation
The most likely diagnosis here is allergic bronchopulmonary aspergillosis (ABPA); as
such aspergillus precipitins can contribute significantly to confirming the diagnosis.
Oral steroids are the mainstay of initial treatment and anti-fungals such as
itraconazole may also improve resolution of symptoms in some cases.
Whilst both chest x ray and CT thorax may show evidence of infiltrates this is
relatively non-specific and therefore would not be optimal investigations; they may,
however, prove useful in assessing severity of disease.
IgE is elevated in ABPA but is not as specific an investigation as aspergillus
precipitins.
Sputum culture may be positive but negative culture would not exclude the disease.
2. A 17-year-old girl with known cystic fibrosis presents with a chest infection.
Which antibiotic would be most suitable for her?
A. Cefotaxime
B. Ceftazidime
C. Gentamicin
D. Augmentin
E. Amoxicillin
Answer: B
,Explanation: Explanation
In cystic fibrosis the airways become obstructed by thick mucus due to defective
chloride secretion and increased sodium resorption. This leads to bacterial
colonisation early in life.
The bacteria present depend on the age of the patient: infants and young children
become colonised by Staphylococcus aureus and then Haemophilus influenzae. In
teenagers, Pseudomonas aeruginosa colonisation occurs.
Other organisms which can cause infection include Streptococcus pneumoniae,
Burkholdia cepacia (which confers a worse prognosis), Mycobacterium tuberculosis,
other mycobacteria, Aspergillus fumigatus, and viruses.
In the UK, antibiotics are usually given when the sputum becomes purulent,
pulmonary function deteriorates, or the patient is unwell (e.g. weight loss). In this age
group, Pseudomonal cover is needed and a combination of intravenous antibiotics is
used to reduce the risk of resistance developing. The usual combination is
ceftazidime and tobramycin, for a period of two weeks.
Cefotaxime, augmentin, and amoxicillin do not have pseudomonal cover. Gentamicin
can be used in place of tobramycin, but has poorer pseudomonal cover and is
associated with significant side effects (nephrotoxicity and ototoxicity).
Sputum samples should be obtained, and organism identification and sensitivities
can be used to guide treatment of future exacerbations.
Reference:
UK Cystic Fibrosis Trust Antibiotic Working Group. Antibiotic treatment for cystic
fibrosis. Third edition. London: Cystic Fibrosis Trust; 2009.
3. A 50-year-old lady presented to the Emergency department with cough and
dyspnoea for the past two days.
She was previously well. She smokes 20 cigarettes per day.
, She has a temperature of 38.3°C and is agitated and confused. Her pulse is 110/min
and her blood pressure is 88/60 mmHg. Her oxygen saturation is 89% on air and she
has a respiratory rate of 40/min.
Chest x ray shows left basal consolidation.
Results show:
Sodium 143 (137-
mmol/L 144)
Potassiu 3.8 mmol/L (3.5-4.9)
m
Urea 9.2 mmol/L (2.5-7.5)
Creatinin 85 µmol/L (60-110)
e
Her CURB score is documented and she is admitted to hospital with severe
pneumonia.
Which of the following would count towards her CURB score?
A. Peak expiratory flow rate
B. Temperature
C. Consolidation on chest x ray
D. Oxygen saturation
E. Raised blood urea
Answer: E
Explanation: Key learning points
Respiratory Medicine
● The CURB score is calculated by assessment of core adverse prognostic
features which are used in assessment of severity of pneumonia, one of
which is blood urea.
Explanation
The CURB score is calculated by assessment of core adverse prognostic features
which are used in assessment of severity of pneumonia.
countryside comes to the clinic for review.She has progressively worsening
disease and is currently taking high dose Seretide and montelukast.
Apparently she coughs every night, occasionally with frank haemoptysis and
is finding it impossible to do any regular exercise at all.On examination her BP
is 128/82 mmHg, pulse is 74 and regular. There is extensive wheeze and
scattered coarse crackles on auscultation of the chest. Her peak flow is 320
(580 predicted).Investigations show:
Haemoglobi 127 g/L (115 -
n 160
)
White cell 7.9 (4 - 11)
count ×10
9/L
Eosinophil 1.2 (0.04 -
count ×10 0.4)
9/L
Platelets 173 (150 -
×10 400
9/L )
Sodium 137 (135 -
mm 146
ol/L )
Potassium 4.2 (3.5 -
mm 5)
ol/L
Creatinine 98 (79 -
µmo 118
l/L )
Which of the following is the best investigation?
A. Aspergillus precipitins
, B. Sputum culture
C. CXR
D. IgE
E. CT thorax
Answer: A
Key learning points
Respiratory Medicine
● Aspergillus precipitins can contribute significantly to confirming the diagnosis
of allergic bronchopulmonary aspergillosis (ABPA).
Explanation
The most likely diagnosis here is allergic bronchopulmonary aspergillosis (ABPA); as
such aspergillus precipitins can contribute significantly to confirming the diagnosis.
Oral steroids are the mainstay of initial treatment and anti-fungals such as
itraconazole may also improve resolution of symptoms in some cases.
Whilst both chest x ray and CT thorax may show evidence of infiltrates this is
relatively non-specific and therefore would not be optimal investigations; they may,
however, prove useful in assessing severity of disease.
IgE is elevated in ABPA but is not as specific an investigation as aspergillus
precipitins.
Sputum culture may be positive but negative culture would not exclude the disease.
2. A 17-year-old girl with known cystic fibrosis presents with a chest infection.
Which antibiotic would be most suitable for her?
A. Cefotaxime
B. Ceftazidime
C. Gentamicin
D. Augmentin
E. Amoxicillin
Answer: B
,Explanation: Explanation
In cystic fibrosis the airways become obstructed by thick mucus due to defective
chloride secretion and increased sodium resorption. This leads to bacterial
colonisation early in life.
The bacteria present depend on the age of the patient: infants and young children
become colonised by Staphylococcus aureus and then Haemophilus influenzae. In
teenagers, Pseudomonas aeruginosa colonisation occurs.
Other organisms which can cause infection include Streptococcus pneumoniae,
Burkholdia cepacia (which confers a worse prognosis), Mycobacterium tuberculosis,
other mycobacteria, Aspergillus fumigatus, and viruses.
In the UK, antibiotics are usually given when the sputum becomes purulent,
pulmonary function deteriorates, or the patient is unwell (e.g. weight loss). In this age
group, Pseudomonal cover is needed and a combination of intravenous antibiotics is
used to reduce the risk of resistance developing. The usual combination is
ceftazidime and tobramycin, for a period of two weeks.
Cefotaxime, augmentin, and amoxicillin do not have pseudomonal cover. Gentamicin
can be used in place of tobramycin, but has poorer pseudomonal cover and is
associated with significant side effects (nephrotoxicity and ototoxicity).
Sputum samples should be obtained, and organism identification and sensitivities
can be used to guide treatment of future exacerbations.
Reference:
UK Cystic Fibrosis Trust Antibiotic Working Group. Antibiotic treatment for cystic
fibrosis. Third edition. London: Cystic Fibrosis Trust; 2009.
3. A 50-year-old lady presented to the Emergency department with cough and
dyspnoea for the past two days.
She was previously well. She smokes 20 cigarettes per day.
, She has a temperature of 38.3°C and is agitated and confused. Her pulse is 110/min
and her blood pressure is 88/60 mmHg. Her oxygen saturation is 89% on air and she
has a respiratory rate of 40/min.
Chest x ray shows left basal consolidation.
Results show:
Sodium 143 (137-
mmol/L 144)
Potassiu 3.8 mmol/L (3.5-4.9)
m
Urea 9.2 mmol/L (2.5-7.5)
Creatinin 85 µmol/L (60-110)
e
Her CURB score is documented and she is admitted to hospital with severe
pneumonia.
Which of the following would count towards her CURB score?
A. Peak expiratory flow rate
B. Temperature
C. Consolidation on chest x ray
D. Oxygen saturation
E. Raised blood urea
Answer: E
Explanation: Key learning points
Respiratory Medicine
● The CURB score is calculated by assessment of core adverse prognostic
features which are used in assessment of severity of pneumonia, one of
which is blood urea.
Explanation
The CURB score is calculated by assessment of core adverse prognostic features
which are used in assessment of severity of pneumonia.
