SCE Questions

1. SCE Questions Sarcoidosis

2. Question 4 A 32 year old Irish gentleman comes to clinic complaining of a dry cough and exertional breathlessness. He breeds racing pigeons as a hobby and is a non smoker. There has been no recent foreign travel. Clinical examination is normal. Blood tests reveal lymphopenia and normal serum ACE. A CT scan was obtained: What is the most likely diagnosis? • Hypersensitivity pneumonitis • Lymphangitis carcinomatosis • Miliary TB • Non tuberculous mycobacterium • Sarcoidosis

3. Which of the following patterns of lymphadenopathy is most consistent with sarcoid a) Asymmetrical axillary, mediastinal and hilar nodes b) Symmetrical axillary, mediastinal and hilar nodes c) Asymmetrical mediastinal and hilar nodes d) Symmetrical mediastinal and hilar nodes e) Asymmetrical axillary, anterior mediastinal, mediastinal and hilar nodes

4. Question 5 A 32 year old gentleman attends clinic due to a chronic cough. He is also complaining of some pain in his joints. He is a non-smoker. Clinical examination is normal. He goes on to have an x-ray, which shows bilateral hilar lymphadenopathy. Blood tests show normal full blood count but abnormal kidney function. Urine dipstick is +protein but otherwise normal. CT scan confirms enlarged hilar and mediastinal lymphadenopathy. A highly competent thoracic registrar performs an EBUS FNA and a pathology specimen is shown below: What is the most likely diagnosis? • TB • Hypersensitivity pneumonitis • Sarcoidosis • Granulomatosis with polyangiitis • Aspergillosis

5. A 28 year old lady presents with Heerfordt’s syndrome. Consistent clinical features would be a) erythema nodosum, arthralgia, fatigue, and BHL on a CXR b) splenomegaly, arthralgia and neutropenia c) anterior uveitis, high temperature and enlarged parotid glands d) anterior uveitis, erythema nodosum and BHL on a CXR e) anterior uveitis, splenomegaly and arthralgia

6. Question 1 A 29 year old Scandinavian woman presents with breathlessness, dry cough, low-grade fever, and painful red lesions on the anterior aspects of her lower legs. Given the most likely diagnosis, what is the radiographic staging of her thoracic disease? • Stage 0 • Stage I • Stage II • Stage III • Stage IV

7. Question 6 A 35 year old patient is being monitored in clinic for pulmonary sarcoidosis and has a chest radiograph which shows hilar node enlargement but nil else – which stage of disease do they have? • Stage 0 • Stage I • Stage II • Stage III • Stage IV

8. Question 3 A 48-year-old woman attends clinic for follow-up of a diagnosis of sarcoidosis that was made three years ago. She has developed a cough and some aching in the knees and wrists. Her chest X-ray does not demonstrate hilar lymphadenopathy, but there are upper zone pulmonary infiltrates. What stage of sarcoidosis does the chest X-ray suggest? • Stage 0 • Stage 1 • Stage 2 • Stage 3 • Stage 4

9. Infliximab acts directly on a) Tumour necrosis factor alpha b) Transforming growth factor beta c) T cell receptors d) Type 2 interferon e) T regulatory lymphocytes

10. Question 2 A 29 year old Scandinavian woman presents with breathlessness, dry cough, low-grade fever, and painful red lesions on the anterior aspects of her lower legs. A thoracic HRCT reveals fissural nodularity, upper lobe predominant ground glass change and bilateral hilar lymphadenopathy. In relation to further investigations for sarcoidosis: • Bronchoalveolar lavage shows a neutrophilic cellular pattern • Bronchoalveolar lavage shows a CD4:CD8 ratio of >4.5 • EBUS TBNA is required to confirm diagnosis in this case • Serum ACE is a reliable marker of disease activity • Spirometry will likely reveal a restrictive pattern in this case

11. Which of the following is false in relation to sarcoid? a) Hypercalciuria is commoner than hypercalcaemia b) Hypercalcaemia is caused by 25 OH-vitamin D, 1a-hydroxylase c) Hypercalcaemia is an indication for steroids d) Bone lesions in sarcoid are more commonly picked up on MRI than CT e) Granulomatous nephritis leads to renal failure in 30% of cases

12. Which of the following is false in relation to sarcoid a) Erythema nodosum contains non-caseating granulomas b) 2nd degree heart block may occur c) Lupus pernio is commoner in African Americans than Caucasian Americans d) Heart disease is characterised by subendocardial late-gadolinium enhancement on MRI e) Lofgren’s syndrome usually resolves spontaneously

13. SCE Questions Pulmonary Embolism

14. Question 5 Following a standard treatment duration of anticoagulation for a first venous thromboembolism the risk of recurrence in 1 year in the first 1 year following an unprovoked or idiopathic PE is estimated at: • 1% • 2% • 5% • 10% • 20%

15. Question 9 In an unprovoked PE, what is the chance of recurrence three years down the line from the initial PE? • 5% • 10% • 15% • 20% • 25%

16. Which of the following is true in relation to recurrence of unprovoked VTE a) Recurrence is equally likely whether the primary event was DVT or PE b) Recurrence is more likely after a right leg DVT than a left PE c) If PE is unilateral, recurrence is more likely to be in the same lung d) Recurrence is as likely as it is for recurrence of cancer-related PE e) Recurrence is more likely in men than in women

17. What happens when we stop anticoagulation? Prandoni et al. Ann Int Med 1996

18. Recurrence after VTE is extremely common Prandoni et al, Haematologica 2007

19. Recurrence of VTE is commoner in men Kyrle et al, N Engl J Med 2004

20. Recurrence more likely after PE than after DVT Eichinger et al, Ann Intern Med 2004

21. Fibrin in a clot is enzymatically dissolved by a) Fibrinogen b) Antithrombin III c) Tissue-type plasminogen activator d) Plasmin e) Thrombin

22. Tissue-type plasminogen activator (t-PA) Urokinase (u-PA) Plasmin Plasminogen Fibrin Fibrin Fibrin degradation products eg D-dimer Fibrin Fibrinogen Thrombin Xa/Va Prothrombin

23. The mode of action of heparin is a) Co-factor for antithrombin III b) Co-factor for factor Xa c) Thromboxane inhibitor d) Conversion of plasminogen to plasmin e) Inhibits conversion of thrombin to factor Xa

24. Which of the following 30 year old ladies could reasonably have rivaroxaban after a PE? a) Breast-feeding b) Pregnant c) 115kg d) Taking ritonavir e) eGFR 20

25. Which of the following is false? a) A V/Q scan involves iv injection of Tc-labelled macro-aggregated albumin b) A V/Q scan involves inhalation of radioactive xenon c) A CTPA is performed with the patient supine d) A CTPA is performed in inspiration e) Hampton hump is a dome-shaped pleural opacity

26. Question 1 A 59 year old man presents to the acute medical unit with left sided chest pain, haemoptysis and breathlessness, 7 days following an uncomplicated right total hip replacement. His observations are listed below: HR 100bpm, RR 20/min, BP 99/67, O2 sats 94%. In relation to risk stratification and management of a suspected PE: • He has a PESI score of II and should be managed as an inpatient • He has a PESI score of III and should be managed as an inpatient • He has a PESI score of IV and should be managed as an inpatient • He has a PESI score of II and should be managed as an outpatient • He has a PESI score of III and should be managed as an outpatient

27. Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) Aujesky D et al, Am J Respir Crit Care Med 2005;172:1041-46 Jimenez D et al, Arch Intern Med 2010;170:1383-89

28. Question 2 A 32 year old accountant who is 31 weeks pregnant is admitted with acute onset breathlessness and right sided pleuritic chest pain. Examination reveals a warm, swollen right calf. Which of the following statements regarding PE in pregnancy is true? • CTPA gives a lower radiation dose to maternal breast tissue than VQ • D-dimer can be used to exclude PE in pregnancy • PE is most common in the third trimester • PE occurs in 1 in 1000 pregnancies • There is significant risk of foetal growth restriction following VQ

29. Question 3 A 73-year-old man with a background of diabetes and chronic kidney disease has been diagnosed with a pulmonary embolism. His eGFR is 26 ml/min/1.73m2. He is adamant that he will not take warfarin because his partner had a gastrointestinal bleed while on warfarin, although he will accept the risk of bleeding from other drugs. Which is the best course of treatment? • Apixaban • Clopidogrel • Dabigatran • Fondaparinux • IVC filter

30. Question 4 A 28 year old on the oral contraceptive pill presents to the emergency department with sudden onset breathlessness and right sided pleuritic chest pain. Clinical examination is normal but initial observations show pulse 123, BP 80/40, RR 26, Saturations of 93% on 15L. Initial blood tests and chest x-ray are normal. What treatment would you recommend? • Catheter directed thrombolysis • Embolectomy • IV heparin • Low molecular weight heparin • Thrombolysis

31. Question 6 A 56 year old gentleman presents to ambulatory care with sudden onset breathlessness. He has no co-morbidities and is not on any regular medications. He states he is “fine” and was persuaded to come to hospital by his wife. Chest x-ray and blood tests including a troponin are normal. Initial observations show heart rate 115, BP 125/70, sats 95% on air, temp 36.5, RR 14. A conscientious junior doctor organises a CTPA, which confirms a pulmonary embolism. There is no evidence of RV dilatation on echocardiography. Arterial blood gas reveals a blood oxygen saturation of 94%. The patient is desperate to go home, what is the best treatment option: • Discharge on oral anticoagulation and arrange an outpatient review • IV heparin • Start on low molecular weight heparin and admit to hospital • Surgical embolectomy • Thrombolysis

32. Question 7 A 45year old male presents with breathlessness of sudden onset and haemoptysis. He has a past medical history of essential hypertension and previous left leg deep vein thrombosis 6 years previously. His only regular prescribed medication is Amlodipine 5mg OD. Observations: 95/52, HR 108, RR 18, Sats 97% (breathing air), Temp 37.2. You suspect an acute pulmonary embolism. What is the most appropriate course of action? • Arrange immediate CTPA • Check D-Dimer and if positive arrange CTPA • Check D-Dimer and if positive arrange V/Q scan • Offer LMWH and arrange bilateral lower limb ultrasound. • Thrombolysis

33. Question 8 A 23 year old female medical student is diagnosed with a provoked left sided proximal DVT following orthopaedic surgery. You review her case and recommend treatment with Rivaroxaban. She asks how the drug works to ‘thin the blood’. Which statement most acutely describes the mechanism of action of Rivaroxaban? • Antithrombin III agonist • Direct thrombin inhibitor. • Factor Xa inhibitor • P2Y12 adenosine diphosphate inhibitor • Vitamin K antagonist

34. Question 10 38 year old man with a history of ulcerative colitis has an unprovoked DVT. Recently felt fatigued and general unwell, but has had no focal symptoms. Your consultant is concerned that he may have an underlying malignancy. They ask you to arrange appropriate investigations. According to 2012 NICE guidance for patients with VTE, which one of the following sets of investigations should all patients with unprovoked VTE (without previous history of cancer) be offered? • Full blood count (FBC), calcium and chest X-ray • FBC, liver function tests (LFT), calcium, chest X-ray and abdominal pelvis CT • FBC, U&E, calcium, urinalysis and chest x-ray • FBC, U&E, calcium, chest x-ray and abdominal ultrasound scan • FBC, U&E, LFTs, calcium, carcinoembryonic antigen test and chest x-ray

35. Question 11 A 25 year old man develops delirium 24 hours after he has a fractured femur pinned following a road traffic accident. Auscultation of the chest is normal. Chest X-ray reveals no abnormality. He has developed conjunctival petechiae. His ABG shows: pH 7.54, PaCO2 3.6, PaO2 9.1, HCO3 18, FiO2 0.5 What is the single best management plan? • Low-molecular-weight heparin treatment dose • Prednisolone 40mg • Supportive treatment with oxygen only • Thrombolysis with alteplase • Unfractionated heparin aiming for activated partial thromboplastin time ration (APPTr) 1.5