Respiratory Medicine in Dundee
Presenting Signs and Symptoms in Respiratory Disease
EMI Questions
Answers List:
A. Cystic Fibrosis
B. Idiopathic Pulmonary Fibrosis
C. COPD
D. Asthma
E. Pneumonia
F. Extrinsic Allergic Alveolitis
G. Bronchiectasis
H. Tuberculosis
From the list below, please select the most appropriate diagnosis for each set of presenting symptoms
1. A 30 year old non-smoking man presents with a dry cough, worse at night. Skin prick testing shows that he is allergic to house dust mite.
D – This man has asthma. Nocturnal cough is a sensitive marker of asthma, and most young people with asthma will be house dust mite sensitive.
2. A 75 year old Indian, non-smoking man who has recently moved to the UK, presents with haemoptysis, night sweats and some weight loss.
H – Tuberculosis. Anyone returning from a TB endemic area who presents with a productive cough, haemoptysis and/or weight loss, must have investigations to confirm or refute the diagnosis of TB. The spectrum of disease in TB is wide, ranging from “Typical” pulmonary TB to so called “Cold abscesses” containing the TB mycobacterium. Any patient with sputum smear positive TB must be kept in hospital until they are sputum smear negative, this is a legal requirement. Smear positive TB is on of the few diseases in which we are allowed, as doctors, to detain patients.
We do not, however, have the power to force patients to take their anti-TB chemotherapy. Once kept in a negative pressure room, with no access to or from the outside world, the patients usually decide to take therapy quite quickly.
3. A 50 year old man who races pigeons presents with increasing blreathlessness, and a dry cough.
F – Extrinsic Allergic Alveolitis (EAA). Hypersensitivity pneumonitis is the acute phase of EAA, as is typical of a type 3 hypersensitivity response mediated disease. Antibodies to the pigeon antigens pass through the fenestrations in the pulmonary capillaries, and enter the alveoli. Here they bind with the pigeon antigen – the antigen-antibody complex is then deposited in the alveolar wall, complement is activated, and cell damage occurs. If the stimulus (the pigeons) are removed, the diseases is reversible.
If the pigeons are not removed, the stimulus continues, and EAA occurs. EAA is typical of a type 4 hypersensitivity response mediated disease. T cells are activated at the site of the antigen, these T cells return to the lymph node tissue. The result is a release of monocytes which move to the area of antigen deposition, activating macrophages, forming giant cells, and ultimately granulomata. If the stimulus is removed, the disease usually halts progress, but irreversible pulmonary fibrosis has usually occurred by this point. We treat with steroids, and steroid sparing immunosupressive agents, with varying degrees of success.
Multiple Choice Questions
1. Which of the following signs would you expect to find in a patient with a pleural effusion? (Click the answer to see further info)
Yes – often described as stony dull
No – TVF would be reduced in a pleural effusion
Yes – just above the upper level of the effusion
No – the trachea will be central, or pushed away if the the effusion is large
No – this is a sign in the abdomen
No – this is a symptom, not a sign
2. Your patient has dullness to percussion in the right apex, crepitations in the right apex with bronchial breathing and a right sided Horner’s syndrome. Which of the following diagnoses are likely? (Click for the answer and more information)
No – an effusion alone would not cause apical signs
No – this is a predominately lower lobe interstitial lung disease
Yes – the most likely diagnosis
Yes – TB may compress the sympathetic chain, although this is far less common than in malignancy
No
3. Your patient has the following positive signs: respiratory rate of 35, sinus tachycardia, central cyanosis, right basal pleural rub. The differential diagnosis includes (Click the answer to get more information)
No – the hallmark sign is fine inspiratory crepitations
Yes – the signs in PE are often non-specific, but a pleural rub is very suggestive
No – Pleural rub is not found in pneumothorax. Textbooks tell of a mid systolic click associated with pneumothorax
Yes – there may be no crepitations in early pneumonia
No – dullness to percussion over the pleural thickening, and the associated pleural effusion are the usual findings
4. Clubbing is a common finding in (select all that apply)
Yes – notably squamous cell carcinoma
Yes – notably usual interstitial pneumonia
No – clubbing is not a usual finding in uncomplicated emphysema
Yes – Cystic Fibrosis and non-cystic fibrosis bronchiectasis are both associated with clubbing
No – although reported in fibrotic sarcoid, it is not a common finding
