In a clinic scenario, a 59-year-old lifelong smoker presents with concerning symptoms. A CT scan reveals an abnormality, prompting consideration of tumor staging. The second case involves a 67-year-old ex-smoker with COPD, where treatment decisions based on GOLD stage are explored.
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Question 1 You see a 59 year old lifelong smoker in clinic. Over the last 3 months they have had a cough, intermittent mild left sided chest pain, and lost around 2.5kg in weight. You arrange an urgent CT scan of their chest and the result is flagged to you as abnormal.
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Question 1 You see a 59 year old lifelong smoker in clinic. Over the last 3 months they have had a cough, intermittent mild left sided chest pain, and lost around 2.5kg in weight. You arrange an urgent CT scan of their chest and the result is flagged to you as abnormal. Based on the image, what is the stage of this tumor? T2bN1M0 1. T4N1M1c 2. T2aN0M0 3. T1N1M1a 4. T3N3M0 5.
Question 1 You see a 59 year old lifelong smoker in clinic. Over the last 3 months they have had a cough, intermittent mild left sided chest pain, and lost around 2.5kg in weight. You arrange an urgent CT scan of their chest and the result is flagged to you as abnormal. Based on the image, what is the stage of this tumor? T2bN1M0 1. T4N1M1c 2. T2aN0M0 3. T1N1M1a 4. T3N3M0 5.
Question 2 A 67 year old ex smoker was admitted to the respiratory ward with an exacerbation of COPD and following treatment is getting ready for discharge. His background eMRCD score is 4. He is normally on Tiotropium daily. He has an FEV1 of 37% predicted on recent primary care spirometry. He has not been hospitalised with COPD, though has used two courses of prednisolone and doxycycline from his GP over the last year. His COPD assessment test gives a score of 21. He most recent bloods show Hb 132, WCC 9.8 (Neutrophils 5.4, Eosinophils 0.4), CRP 13. Based on his GOLD Stage, which inhaler combination would you recommend? LAMA + SABA 1. LABA/LAMA/ICS + SABA 2. LABA or LAMA 3. LABA/LAMA 4. LABA/LAMA/ICS + Azithromycin 5.
Question 2 A 67 year old ex smoker was admitted to the respiratory ward with an exacerbation of COPD and following treatment is getting ready for discharge. His background eMRCD score is 4.He is normally on Tiotropium daily. He has an FEV1 of 37% predicted on recent primary care spirometry. He has not been hospitalised with COPD, though has used two courses of prednisolone and doxycycline from his GP over the last year. His COPD assessment test gives a score of 21. He most recent bloods show Hb 132, WCC 9.8 (Neutrophils 5.4, Eosinophils 0.4), CRP 13. Based on GOLD guidelines, which inhaler combination would you recommend? LAMA + SABA 1. LABA/LAMA/ICS + SABA 2. LABA or LAMA 3. LABA/LAMA 4. LABA/LAMA/ICS + Azithromycin 5.
Answer 2 Already on LAMA, still symptomatic and exacerbating so should increase Given eosinophils are >0.3, probably lean towards ICS being given. Could give LABA+ICS, but was not an option
Question 3 A 45 year old gentleman comes to clinic with cough and having noticed breathlessness on exertion over the last few months. He is a current smoker, has 2 cats and keeps birds. He works as as a metal turner. His FEV1 is 62% predicted, FVC is 71% predicted, and KCO is 81% predicted. On examination there is mild finger clubbing, inspiratory crackles and occasional end inspiratory squeaks. His CT is shown.
Question 3 A 45 year old gentleman comes to clinic with cough and having noticed breathlessness on exertion over the last few months. He is a current smoker, has 2 cats and keeps birds. He works as as a metal turner. His FEV1 is 62% predicted, FVC is 71% predicted, and KCO is 81% predicted. On examination there is mild finger clubbing, inspiratory crackles and occasional end inspiratory squeaks. His CT is shown. What is the most likely diagnosis? Lympangioleomyomatosis 1. Idiopathic pulmonary fibrosis 2. Hypersensitivity Pnuemonitis 3. Severe Asthma 4. Caroli disease 5.
Answer 3 A 45 year old gentleman comes to clinic with cough and having noticed breathlessness on exertion over the last few months. He is a current smoker, has 2 cats and keeps birds. He works as as a metal turner. His FEV1 is 62% predicted, FVC is 71% predicted, and KCO is 81% predicted. On examination there is mild finger clubbing, inspiratory crackles and occasional end inspiratory squeaks. His CT is shown. What is the most likely diagnosis? Lympangioleomyomatosis (mostly women of childbearing age, cysts, pneumothorax, (sometimes) tuberous sclerosis) 1. Idiopathic pulmonary fibrosis 2. Hypersensitivity Pnuemonitis restrictive ratio, low KCO, clubbing, ground glass changes on CT with some mosacisism, squeaks. 3. Severe Asthma (story doesn t really fit) 4. Caroli disease (congenital cystic dilation of the biliary tree) 5.
Question 4 Dr Forrest has invented a new test blood for diagnosing Hypersensitivity Pneumonitis. He runs the test on 156 patients and compares it to the patients known (and irrefutable!) diagnoses. The results of the Forrest Test are shown in the table. What is the Sensitivity and Specificity of the test? Forrest test Forrest positive Forrest negative Disease Present 54 9 Disease Absent 22 71 Sensitivity 76.3%, Specificity 85.7% 1. Sensitivity 82.7%, Specificity 67.3% 2. Sensitivity 93.6%, Specificity 31% 3. Sensitivity 85.7%, Specificity 76.3% 4. Sensitivity 40.4%, Specificity 59.6% 5.
Question 4 Dr Forrest has invented a new test blood for diagnosing Hypersensitivity Pneumonitis. He runs the test on 156 patients and compares it to the patients known (and irrefutable!) diagnoses. The results of the Forrest Test are shown in the table. What is the Sensitivity and Specificity of the test? Forrest test Forrest positive Forrest negative Disease Present 54 9 Disease Absent 22 71 Sensitivity 76.3%, Specificity 85.7% - wrong way around 1. Sensitivity 82.7%, Specificity 67.3% made up 2. Sensitivity 93.6%, Specificity 31% made up 3. Sensitivity 85.7%, Specificity 76.3% 4. Sensitivity 40.4%, Specificity 59.6% - sensitivity here is prevalence and spec is absence 5.
Disease Present A (54) B (9) Disease Absent C (22) D (71) TEST POSITIVE TEST NEGATIVE Sensitivity = The probability that a test result will be positive when the disease is present (True positive rate) = A / (A+B) =54 / (54+9) =85.7 Specificity = the probability that a test will be negative when the disease is not present (True negative rate) = D / (C+D) = 71 (71+22) = 76.3
Question 5 A 45 year old man comes to clinic with worsening productive cough and breathlessness. He has been treated for asthma since childhood, and often uses antihistamines/nasal steroids for sinusitis and seasonal hay fever. He is currently on Symbicort 200/6 two puffs daily. He is married and he and his wife have one child born via IVF. He has never left the UK. Spirometry shows he has an FEV1/FVC ratio of 0.67. Examination reveals no peripheral stigmata of respiratory disease, basal crackles on auscultation. His CT shows the following.
A 45 year old man comes to clinic with worsening productive cough and breathlessness. He has been treated for asthma since childhood, and often uses antihistamines/nasal steroids for sinusitis and seasonal hay fever. He is currently on Symbicort 200/6 two puffs daily. He is married and he and his wife have one child born via IVF. He has never left the UK. Spirometry shows he has an FEV1/FVC ratio of 0.67. Examination reveals no peripheral stigmata of respiratory disease, basal crackles on auscultation. His CT shows the following You think you know the diagnosis. What is the next best diagnostic test to help confirm this? Diffusion capacity 1. CT Sinuses 2. BAL for white cell differential 3. Examination of spermatozoa 4. Nasal NO measurement 5.
A 45 year old man comes to clinic with worsening productive cough and breathlessness. He has been treated for asthma since childhood, and often uses antihistamines/nasal steroids for sinusitis and seasonal hay fever. He is currently on Symbicort 200/6 two puffs daily. He is married and he and his wife have one child born via IVF. He has never left the UK. Spirometry shows he has an FEV1/FVC ratio of 0.67. Examination reveals no peripheral stigmata of respiratory disease, basal crackles on auscultation. His CT shows the following. You think you know the diagnosis. What is the next best diagnostic test to help confirm this? Diffusion capacity 1. CT Sinuses 2. BAL for white cell differential 3. Examination of spermatozoa 4. Nasal NO measurement 5.
A 45 year old man comes to clinic with worsening productive cough and breathlessness. He has been treated for asthma since childhood, and often uses antihistamines/nasal steroids for sinusitis and seasonal hay fever. He is currently on Symbicort 200/6 two puffs daily. He is married and he and his wife have one child born via IVF. He has never left the UK. Spirometry shows he has an FEV1/FVC ratio of 0.67. Examination reveals no peripheral stigmata of respiratory disease, basal crackles on auscultation. His ECG is shown, along with his CT. You think you know the diagnosis. What is the next best diagnostic test to help confirm this? Diffusion capacity (not diagnostic, though may be low) 1. CT Sinuses (not able to differentiate PCD from other causes) 2. BAL (may be of help, but wont give a diagnosis) 3. Examination of spermatozoa (may be of use, but not going to diagnose) 4. Nasal NO measurement 5. History of sinusitis, fertility difficulties, sputum production, situs inversus CT Kargatender syndrome (Primary Ciliary Dyskinesia). Nasal nitric oxide <30 highly suggestive of PCD and differentiates well between non PCD and PCD bronchiectasis (BTS bronchiectasis guideline). Can also do nasal brushing and examine ciliary beat frequency (normally 11-20 Hz), but not widely available.
A 23 year old man presents to the ED with sudden onset chest pain and breathlessness. His chest X-ray shows a moderate sized right sided pneumothorax which the SHO in ED aspirates with success, leaving only a very small residual PTx. He is booked back into your clinic after two weeks for follow up. CXR shows complete resolution of the pneumothorax and he feels well. He is planning a last minute holiday and wants to know when he can fly. What do you tell him is safest? Anytime from today 1. After one further week 2. After two further weeks 3. After 6 weeks from initial presentation 4. Any time after a second CXR confirming resolution 5.
A 23 year old man presents to the ED with sudden onset chest pain and breathlessness. His chest X-ray shows a moderate sized right sided pneumothorax which the SHO in ED aspirates with success, leaving only a very small residual PTx. He is booked back into your clinic after two weeks for follow up. CXR shows complete resolution of the pneumothorax and he feels well. He is planning a last minute holiday and wants to know when he can fly. What do you tell him is safest? Anytime from today (Maybe, but not an emergency and better to be prudent ) 1. After one further week BTS guidelines: must have CXR showing resolution and prudent to wait a further 7 days from this. 2. After two further weeks If it d been traumatic PTx, wait 14 days from resolution. 3. After 6 weeks from initial presentation 4. Any time after a second CXR confirming resolution 5.
