1 / 37

SCE Revision Asthma and pleural disease

SCE Revision Asthma and pleural disease. Andrew Stanton Freeman Hospital. Disclaimer. I’ve not sat the SCE I am not involved in the SCE Lots of involvement in undergrad assessment esp MCQ writing / exam compilation / management Principles of assessment should be no different in SCE

Mercy
Download Presentation

SCE Revision Asthma and pleural disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. SCE RevisionAsthma and pleural disease Andrew Stanton Freeman Hospital

  2. Disclaimer • I’ve not sat the SCE • I am not involved in the SCE • Lots of involvement in undergrad assessment esp MCQ writing / exam compilation / management • Principles of assessment should be no different in SCE • So hopefully what I say next is correct

  3. Some golden rules for high quality MCQ’s - hopefully some reassurance for what you’ll get • Assesses what’s meant to have been learnt Avoids niche knowledge, in curriculum ?? New evidence • Test the application of knowledge – not simple recall • Stem is developed appropriately No “sneaky” omissions, no “noise”, no “can you tell what I’m thinking?”, avoid bad practice • Lead in asks clear unambiguous question • Question must pass the “cover test” • Options should be homogenous, salient and plausible • Correct answer must be correct! Not “what so and so always does”, absolute lack of ambiguity • Item has been through rigorous QA (best ones refined in light of performance – not too easy, not too hard, discriminates)

  4. SCE Questions Asthma

  5. Question 1 What is mechanism of action of mepolizumab? • Anti CD20 • Anti-IgE inhibitor • IL-3 inhibitor • IL–5 inhibitor • IL–7 inhibitor

  6. Question 2 A 51 year old lady with a confirmed diagnosis of asthma has had five exacerbations over the last year each requiring prednisolone. Her regular asthma treatment consists of Budesonide/formoterol 400/12 2 puffs BD, montelukast and has failed trials of aminophylline and tiotropium. Her inhaler technique is good and is compliant with treatment. She weighs 110kg. CT of the thorax is normal. No prior blood tests are available. HADS score is 7 (anxiety), 5 (depression), ACQ7 2.5 Investigations show: Eosinophil count 0.55 Total IgE 1100 RAST positive to House dust mite, aspergillus, grass What would be the most appropriate next step to try to reduce her exacerbation frequency? • Change ICS/LABA to Relvar 184 one puff OD • Commence prednisolone 10mg/day • Commence Mepolizumab • Commence Omalizumab • Refer for Cognitive Behavioural therapy

  7. Possible variations on the theme, considerations • Investigation questions? • Hard to do in this context but look out for • Aspergillussensitised, v high IgE / eos - ? CT for ABPA • ? Occupational asthma PEFR assessment • Remember clues to alternative diagnoses / assessments • High VCD questionnaire score (< 30 VCD v unlikley) • High HADS >9 • Dysfunctional breathing (may get given Nijmegen score) • Physiology – reversibility / FEno • Management questions • Remember extremes of IgE • Low IgE but sensitised • IgE < 1500 but obviously too heavy • NICE guidleinesMepo / Res / Benra / Omalizumab • Dupilumab on the horizon • BT…?

  8. Know your NICE…..

  9. Know your NICE…..

  10. Question 3 A 50-year-old woman attends asthma clinic. She has had a diagnosis of asthma since childhood which was well controlled with an inhaled corticosteroid until 12 months ago. She now complains of daily cough with green sputum, wheeze and breathlessness despite treatment escalation to high dose ICS, LABA and montelukast. Courses of oral steroids from her GP only temporarily improve her symptoms. Investigations show: Eosinophils 0.25 x 109/L (0.0-0.4)IgE 135 IU/mL (< 80)HRCT No bronchiectasis. Some bronchial wall thickeningRAST Positive to C Herbarum, P Chrysogenum, Aspergillus; negative to house dust mite, dog hair, cat hair, grass/pollen How should her asthma phenotype be described? • Asthma with Allergic bronchopulmonaryaspergillosis • Asthma with fungal sensitisation • Mixed eosinophilic / allergic asthma • Severe allergic asthma • Severe eosinophilic asthma

  11. SAFS • RCT evidence of benefit from itraconazole • Most labs will do “mixed mould” RAST • Overlap with allergic asthma

  12. Question 4 Which of the following genes are associated with asthma? • ADAM33 • BMPR2 • BRAF • BTNL2 • MUC5B

  13. Question 5 A 45 year old ex-smoker has intermittent cough, wheeze and breathlessness. Examination and CXR are normal. Various lung function tests are arranged. Which of the following results would be most strongly predictive of a diagnosis of asthma? • A PD20 of 0.5µmol • A PC20 of >16mg/ml • An increase in FEV1 of 8% (and 100ml) after 400mcg salbutamol • An increase in FEV1 of 15% (and 200ml) after 6 weeks of ICS therapy • Feno 35 ppb

  14. Sensiitivity Specificity PPV NPV

  15. Sensiitivity Specificity PPV NPV

  16. Question 6 Which of the following are the top two causes of allergic occupational asthma in the UK? • Cleaning products • Bakery dust and isocyanate • Mouldy hay and birds • Wood dust and PVA glue • Latex gloves and chlorine gas

  17. SCE Questions Pleural disease

  18. Question 1 An 18 year old man presents to the emergency department with sudden onset right sided chest pain and breathlessness. He does not have any co-morbidities and is not on regular medications. He occasionally smokes cannabis but does not drink alcohol. He is haemodynamically stable and oxygen sats are 95% on air and is comfortable on mobilsation around the ED with no change in oxygenation. An urgent chest x-ray is performed: What is the most appropriate management option? • Insert a 12fr seldinger chest drain • Large bore surgical chest drain • Observation • Therapeutic aspiration • Urgent referral to cardiothoracic surgery

  19. Question 1a An 30 year old respiratory registrar presents to the emergency department with sudden onset right sided chest pain which has resolved by the time of your review. He is not breathless. He does not have any co-morbidities and is not on regular medications. He occasionally smokes cannabis but does not drink alcohol. He is haemodynamically stable and oxygen sats are 95% on air An urgent chest x-ray is performed: What is the most appropriate management option? • Insert a 12fr seldinger chest drain • Large bore surgical chest drain • Observation • Therapeutic aspiration • Urgent referral to cardiothoracic surgery

  20. Question 2 A 31 year old female, smoker of 20 cigarettes a day presents to the medical assessment unit with fevers, productive cough and shortness of breath. She had been treated for a lower respiratory tract infection by her GP 2 weeks before admission. She has a background of rheumatoid arthritis. Blood tests reveal a high WCC, elevated neutrophil count and CRP of 180. Chest x-ray shows left lower lobe consolidation and she is started on IV antibiotics as per the local guidelines. The following day she becomes more breathless and starts spiking temperatures. A chest x-ray shows a moderate pleural effusion. Ultrasound confirms presence of a moderate free flowing pleural effusion. Diagnostic aspiration reveals dark straw coloured fluid The results are shown below pH 7.21, pleural fluid glucose 2.0, pleural protein 39g/L (serum protein 72 g/L), LDH 1100  What is the most appropriate treatment option? • Chest drain insertion • Discharge and request CT scan • Discuss with consultant microbiologist regarding antimicrobial therapy • Therapeutic aspiration • Thoracoscopy

  21. Question 3 A 60 year old gentleman with COPD presented to hospital with sudden onset left sided chest pain and breathlessness. Chest x-ray revealed a large pneumothorax. A 12fr seldinger chest drain was inserted with some symptom relief. 72 hours after insertion a repeat chest x-ray showed a persistent pneumothorax despite the chest drain being on suction of - 20cmH20. What is the most appropriate treatment option? • Continue current management • Refer for immediate VATS • Increase suction • Insert large bore chest drain • Insert pleural vent

  22. Question 4 A 24-year-old man presents to A+E with a 24-hour history of right-sided chest pain and persistent shortness of breath. He has no significant past medical history and has smoked 10 cannabis joints a day for the last 4 years. He is 190cm tall and has a BMI of 21. He is haemodynamically stable and oxygen sats are 94% on air and is slightly more breathless on mobilsation around the ED with no change in oxygenation. Chest X-ray demonstrates a right-sided pneumothorax that measures 1cm at the hilum. What is the most appropriate course of action? • Admit for observation • Chest drain insertion • Discharge with repeat CXR in 1 week • Pleural aspiration • Refer for immediate VATS

  23. Question 5 A 70 year old man presents to clinic with a 7 month history of increased breathlessness and chest pain. His chest radiograph reveals a large, left sided pleural effusion with pleural nodularity. Thoracoscopic biopsy confirms the diagnosis of epithelioid mesothelioma. His performance status is 1. What is the most appropriate management option: • Cisplatin and pemetrexed chemotherapy • Extrapleuralpneumonectomy • Hemithorax radiotherapy • Prophylactic radiotherapy should be administered to his procedure tract • VATS partial pleurectomy

  24. Question 6 A 40 year old female with multiple comorbidities presents with breathlessness, and chest radiograph reveals a moderate left sided pleural effusion. A diagnostic pleural aspiration reveals the following: ph 7.19, glucose 1.0mmol/L, protein 31g/L (serum protein 60g/L), LDH 350u/L Which of the following would most likely fit this clinical picture? • Chylothorax • Dressler’s syndrome • Hepatic hydrothorax • Rheumatoid pleuritis • Sarcoidosis

  25. Question 7 A 76 year old female is admitted with a large unilateral pleural effusion and a diagnosis of metastatic adenocarcinoma of ovarian origin is made. Following discussion of treatment options with the patient a Seldinger chest drain is agreed. Her past medical history includes atrial fibrillation for which she has been taking warfarin for many years. She appears comfortable at rest wi a respiratory rate of 15 breaths per minute and oxygen saturations of 95% on 2 litres of oxygen. International Normalised Ratio is 1.8, Platelet count is 72 What is the most appropriate course of action as regards drain insertion? • Administer platelet transfusion. • Administer vitamin K and platelet transfusion • Proceed to chest drain insertion immediately. • Reverse Warfarin with Vitamin K and fresh frozen plasma. • Withhold Warfarin and insert when INR is <1.5

  26. Question 8 A 32 year old man has been on the ward with a pneumothorax which occurred 2 days ago. He has a 12Fr drain in situ, which was put on suction 24 hours ago at a pressure of 5kPa. 24 hours later the CXR is unchanged from immediately post ICD insertion. What would be the most appropriate ongoing management? • Connect heimlich valve to drain • Increase the suction • Insert a larger drain • Refer to cardiothoracics • Remove and reinsert the drain

  27. Question 9 A 35 year old man is admitted with a primary pneumothorax, fails aspiration and has good initial symptomatic response to intercostal drainage. 12 hours later 450 mls of blood is present in the bottle and the drain has stopped swinging and bubbling. He is haemodynamically stable. CXR is shown What is the most appropriate immediate course of action? • Commence suction at 15-20kpa • Insert large bore chest drain • Insert pleural vent • Pull drain back 2 cm • Refer for immediate VATS

  28. Question 10 A 72 year old man with COPD is admitted with sudden onset severe breathlessness. He denies any significant change to his background cough and has no increasing purulence of sputum. His temperature is 37ºC, respiratory rate 20bpm, pulse 120 and blood pressure 120/80. His oxygen saturations are 84% (On NIV pressures of 20/4 with 4l O2) His chest reveals minor scattered wheeze. Following initial assessment in ED he has been commenced on Non-invasive ventilation (NIV) and a repeat ABG shows: pH 7.30 (7.35–7.45)PO2 7.2kPa (11-15)PCO2 7.6 kPa (4.6–6.4)Bicarbonate 25 mmol/L (22–30) CXR is shown Which is the most appropriate immediate step in management? • Increase NIV pressures to 25/4 • Increase entrained oxygen through NIV to 6l/mi • Call ITU team to intubate and ventilate patient • Stop non-invasive ventilation (NIV) • Administer intravenous hydrocortisone

  29. Question 11 A 76 year old man has progressively increasing breathlessness and a dry cough. He is an ex-smoker (10 pack years) and cannot recall any asbestos exposure. He has signs of a pleural effusion which is confirmed on CXR and a CT scan shows a moderate effusion with occasional calcified pleural plaques but no other abnormality. Diagnostic pleural aspiration confirms an exudate, with no growth on culture. Cytology shows a predominantly lymphocytic cell population but no malignant cells. What is the most appropriate course of action? • Interval CT in 3 months • Bronchoscopy • PET scan • Repeat pleural aspiration • Thoracoscopy

  30. Question 11a A 76 year old man has progressively increasing breathlessness and a dry cough. He is an ex-smoker (10 pack years) and cannot recall any asbestos exposure. He has signs of a pleural effusion which is confirmed on CXR and a CT scan shows a moderate effusion with occasional calcified pleural plaques but no other abnormality. Diagnostic pleural aspiration confirms an exudate, with no growth on culture. Cytology shows a predominantly lymphocytic cell population but no malignant cells. Thoracoscopy shows an area of uniformly thickened pleural with biopsies showing evidence of benign fibrinouspleuritis. What is the most appropriate course of action? • Interval CT in 3 months • PET scan • Quanteferon test • Reassure and discharge • Repeat thoracosopy

  31. Question 11b A 76 year old man has progressively increasing breathlessness, a dry cough and persistent chest wall pain that keeps him up at night. He is an ex-smoker (10 pack years) and worked as a mechanic in the railways for 15 years after leaving school. He has signs of a pleural effusion which is confirmed on CXR and a CT scan shows a moderate effusion with occasional calcified pleural plaques and irregular pleural thickening extending into the mediastinum. Diagnostic pleural aspiration confirms an exudate, with no growth on culture. Cytology shows a reactive mesothelial population but no malignant cells Which investigation is most likely to establish a specific diagnosis? • Abrams pleural biopsy • Bronchoscopy • PET scan • Repeat pleural aspiration • Thoracoscopy

More Related