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GP Academy > 03. KFP: Respiratory > Flashcards

03. KFP: Respiratory Flashcards

1
Q

Causative organisms for community-acquired pneumonia?

A
  • Streptococcus pneumoniae: most common cause of bacterial CAP
  • Legionella (environmental sources)
  • Mycoplasma pneumoniae (atypical - young adult, nonproductive cough and bilateral lower zone infiltrates)
  • Chlamydia pneumoniae (atypical - young adult, nonproductive cough and bilateral lower zone infiltrates)
  • Pseudomonas aeruginosa (chronic suppurative lung disease)
  • Respiratory viruses
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2
Q

Features that may suggest bronchiectasis in a patient presenting with chronic respiratory symptoms?

A
  • Digital clubbing (rare in COPD and asthma)
  • Lack of a significant history (less than an average of 20 cigarettes per day for 10 years)
  • Presence of “unusual organisms” in sputum (e.g. Aspergillus, atypical/nontuberculous mycobacteria, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae)

Clinical features:
- Chronic productive cough
- Recurrent bronchial infection
- Sputum is usually purulent and may be intermittently bloodstained
- Fatigue
- Breathlessness
- Pleuritic chest pain
- Coarse crackles on auscultation
- Clubbing (present in <5%)

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3
Q

What is bronchiectasis?

A

Bronchiectasis is a disease characterised morphologically by the abnormal dilatation of bronchi and bronchioles, and clinically by recurrent bronchial infection, and chronic cough (often with sputum)

It is classified under chronic suppurative lung disease

Clinical features:
- Chronic productive cough
- Recurrent bronchial infection
- Sputum is usually purulent and may be intermittently bloodstained
- Fatigue
- Breathlessness
- Pleuritic chest pain
- Coarse crackles on auscultation
- Clubbing (present in <5%)

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4
Q

What is the gold standard for diagnosis of bronchiectasis?

A

High resolution computed tomography chest

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5
Q

Features of interstitial lung disease?

A

History:
- Insidious/exertional nature of breathlessness
- Non-productive cough
- Decreased exercise tolerance

Exam:
- Finger clubbing
- Low level SpO2
- Fine bibasal inspiratory crepitations

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6
Q

Differentials for restrictive pattern on spirometry?

A
  • Lung parenchymal diseases: interstitial lung disease, pneumonia
  • Pleural disease: pleural effusion, diffuse pleural thickening, malignant pleural mesothelioma
  • Disease of the chest wall or movement: neuromuscular disorders, diaphragm palsy, kyphoscoliosis, obesity
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7
Q

Differentials for causes of interstitial lung disease?

A

Environmental:
- Work: asbestos, dust
- Home or hobby: birds, mould, home brewing

Drugs:
- Chemotherapy
- Amiodarone
- Nitrofurantoin

Connective tissue disease - all can cause it

Granulomatous:
- Sarcoidosis
- Hypersensitivity pneumonitis

Idiopathic pulmonary fibrosis

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8
Q

What is sarcoidosis and what are some common clinical manifestations?

A

Sarcoidosis is a multisystem granulomatous disorder.

Common presentations:
- Bilateral hilar adenopathy
- Pulmonary reticular and/or nodular opacities
- Skin, joint or eye lesions
- Lung or thoracic lymph node involvement
- Sx - pulmonary: cough, dyspnoea, fatigue, chest pain
- Sx - systemic: fatigue, malaise, fever, weight loss, muscle weakness, exercise intolerance

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9
Q

ACEi cough: when can it start, when may it stop and how can it present?

A

Starts: one week to 6 months
Resolution after cessation: usually one to four weeks but can last up to 3 months
Presentation: tickling, scratchy or itchy sensation in the throat

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10
Q

Red flags for hospital admission in adults with community acquired pneumonia?

A
  • Tachypnoea (RR > 22/min)
  • Tachycardia (HR > 100/min)
  • Hypotension (sBP < 90mmHg)
  • Acute onset confusion
  • Oxygen sats <93% on room air
  • Multilobar involvement on xray

CURB65 tool can be used to identify low risk patients

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11
Q

When is it reasonable to start low molecular weight heparin and arrange imaging the next day for suspected pulmonary embolism?

A

Suspected pulmonary embolism without significant cardiorespiratory signs such as tachypnoea, hypotension, tachycardia or hypoxia

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12
Q

Options for definitive diagnosis of suspected pulmonary embolism?

A
  • Gold standard: computed tomography pulmonary angiogram
  • Pregnant or contrast allergy or low renal function: Ventilation/perfusion (V/Q) scan
  • Severe compromise: bedside echocardiography
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13
Q

List some clinical manifestations of lung cancer.

A

Intrathoracic:
- Cough
- Dyspnoea
- Haemoptysis
- Pleural disease

Extrathoracic (metatases - liver, bone, brain and paraneoplastic syndromes):
- Bone pain
- Hypercalcaemia (parathyroid hormone-related protein, bony mets) - can lead to constipation, anorexia, nausea, lethargy, polyuria, polydipsia, dehydration
- SIADH: hyponatraemia

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14
Q

First line investigations for suspected interstitial lung disease?

A
  • Spirometry: likely restrictive
  • Chest xray: may show interstitial changes bibasally
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15
Q

Requirements for the diagnosis of sarcoidosis?

A
  • Compatible clinical and radiographic manifestations
  • Exclusion of other diseases that may present similarly
  • For most patients, histopathologic detection of noncaseating granulomas
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16
Q

What is involved with testing for occult extrapulmonary disease in sarcoidosis?

A
  • FBC and peripheral blood smear
  • EUC, LFT, calcium, glucose
  • Ophthalmologic examination
  • ECG
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17
Q

What would you ask to screen for work-related asthma (i.e. work-exacerbated asthma where asthma control worsens due to workplace conditions or occupational asthma)

A

Asking if symptoms improve when away from work

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18
Q

What investigations may be relevant when investigating for work-related asthma?

A
  • Serial peak expiratory
  • Skin prick tests
  • Bronchial provocation challenge testing
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19
Q

What are some features of sensitiser induced occupational asthma?

A
  • Onset: onset or recurrence during working life. Usually first develops some weeks to months after first exposure
  • Relation to work schedule: symptoms worse during or after a work shift and improve when away from work
  • Other: exposure to a known sensitiser
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20
Q

What are some features of irritant induced occupational asthma?

A
  • Onset: Usually within 24 hours of exposure to large quantity of respiratory irritant
  • Relation to work schedule: often none
  • Other: persistence of symptoms for at least 12 weeks, but no previously documented asthma or chronic lung disease
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21
Q

What are some features of work exacerbated asthma?

A
  • Onset: Before or during working life
  • Relation to work schedule: worse on one or more days while at work
  • Other: exposure at work to asthma exacerbating factors such as dust, smoke, fumes, cold
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22
Q

When is pleurodesis recommended in the context of primary spontaneous pneumothorax?

A
  • If pneumothorax recurs in the same lung
  • Risk of recurrence is 30-50%. higher in smokers
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23
Q

What ECG changes can you see in pulmonary embolism?

A
  • Sinus tachycardia
  • S1Q3T3: deep S wave in lead I, Q wave in III, inverted T wave in III
  • Non-specific ST segment and T wave changes, including ST elevation and depression
24
Q

Pharmacological management of VTE in pregnancy?

A

If good renal function, Clexane/enoxaparin:
- 1.5mg/kg subcut daily OR
- 1mg/kg subcut BD

25
Q

Which steroid inhalers can be used for preventer and reliever medication in asthma?

A
  • Symbicort turbuhaler DPI: 100/6microg or 200/6microg
  • Symbicort rapihaler MDI 50/3microg or 100/3microg

Maximum 72 microg of formoterol per day in total

26
Q

How does acute cardiogenic pulmonary oedema present?

A
  • Rapid onset of severe dyspnoea (often first occurring at night)
  • Tachpnoea
  • Tachycardia
  • Poor peripheral perfusion (ashen colour, sweaty, cool peripheries and reduced capillary return)
  • Agitation
  • Restlessness
  • Widespread lung crackles
  • Cough
27
Q

Initial treatment of acute cardiogenic pulmonary oedema in the prehospital?

A
  • Sit as upright as possible during treatment
  • Frusemide 20 to 80mg IV or IM, Q20minutely if needed
  • Supplemental oxygen if sats < 92%
  • High flow oxygen via an oxygen mask fitted with a reservoir
  • If not responding well to oxygen and frusemide, consider adding glyceryl trinitrate (use with caution in patients with systolic blood pressure below 100mmHg) —- GTN spray 400-800microg sublingually Q5minute up to 3 sprays (1200microg)
28
Q

When can radiation pneumonitis occur?

A

Typically occurs between 4 and 12 weeks following completion of radiotherapy course

29
Q

Clinical presentation of radiation pneumonitis?

A
  • Dyspnoea
  • Non-productive cough
  • Low grade fever
  • Excessive fatigue/malaise
  • Tachycardia
  • Pleuritic chest pain
  • Occasionally moist crackles
  • A pleural friction rub or evidence of consolidation in region corresponding to radiation field
30
Q

Management of radiation pneumonitis?

A
  • Corticosteroids depending on severity (e.g. prednisone starting at 20mg to 40mg once in the morning with food for 14 days then taper slowly over a minimum of 6 weeks)
  • Pneumonitis due to infection should be considered as a differential diagnosis before starting patients on high dose steroids
31
Q

What clinical features would suggest a high pre-test probability for obstructive sleep apnoea?

A
  • BMI > 40
  • BMI > 35 and (hypertension requiring 2 or more medications OR type 2 diabetes)
  • Excessive sleepiness during the major wake period
  • Habitual snoring during sleep
  • Witnessed apnoeic events or falling asleep inappropriately
  • Feeling tired despite adequate time in bed
  • Thick neck (>42cm in men, >41cm in women)
32
Q

What is a moderate to severe excessive daytime sleepiness score for the Epworth Sleepiness Scale

A

16-24

33
Q

For commercial vehicle drivers with obstructive sleep apnoea, what is the minimally acceptable adherence with treatment?

A

4 hours or more per day with use on 70% or more of days

34
Q

What factors are part of the Well’s Criteria for consideration of pulmonary embolism?

A
  • Clinical signs and symptoms of DVT
  • Pulmonary embolism most likely diagnosis
  • Tachycardia
  • Immobilisation atleast 3 days or surgery within past 4 weeks
  • Previous DVT or pulmonary embolism
  • Haemoptysis
  • Malignancy treated within 6 months or palliative
35
Q

What constitutes the PERC rule?

A
  • Age <50
  • Normocardia
  • Oxygen sats >/= 95%
  • No haemoptysis
  • No oestrogen use
  • No surgery or trauma requiring hospitalisation within 4 weeks
  • No prior venous thromboembolism
  • No unilateral leg swelling
36
Q

What is first line management for nicotine dependence in adolescents (12-17yo)?

A

Nicotine replacement therapy + behavioural interventions

37
Q

What are some indicators of nicotine dependence?

A
  • Smoking within 30 minutes of waking
  • Smoking more than 10 cigarettes per day
  • History of withdrawal symptoms in previous quit attempts
38
Q

What situations would you consider in-flight oxygen for?

A
  • History of respiratory problems during air travel (e.g. breathlessness, chest pain, confusion, syncope)
  • Severe asthma or COPD (FEV1 < 30% predicted)
  • Severe restrictive lung disease (FVC < 1L)
  • Oxygen saturation < 95% on room air
  • Within 6 weeks of hospital discharge for acute severe or acute-on-chronic respiratory illness
  • With a comorbidty that is worsened by hypoxaemia (e.g. cerebrovascular disease, coronary artery disease, heart failure)
  • With a pre-existing requirement for supplemental oxygen or ventilator support, including non-invasive ventilation
39
Q

When is supplemental in-flight oxygen indicated after performing a hypoxic challenge test (AKA high-altitude simulation test)?

A
  1. Oxygen saturation < 85% OR
  2. Patient becomes distressed during the hypoxic challenge test
40
Q

Indicators of severe injury in a forearm wound

A
  • Presence of foreign bodies in the wound
  • Limited joint ROM
  • Deep wound to muscle
  • Decreased sensation to fingers or hand
  • Decreased grip strength or finger strength or wrist strength
41
Q

What situations should presumptive antibiotic therapy be given for bites?

A
  • Delayed presentation to medical care by 8 hours or more
  • Puncture wound that cannot be debrided adequately
  • Wound is on hands, feet or face
  • Wound involves deeper tissue
  • Open wound
  • Immunocompromised
  • Wound is a cat bite
42
Q

Management of a simple clavicle fracture?

A
  • Broad arm sling for 2-3 weeks
  • Simple analgesia
43
Q

Indications for orthopaedic consult in the management of clavicle fractures?

A
  • Open fractures
  • Displaced medial third fractures
  • Neurovascular injury with fracture
  • Skin integrity at risk over fracture
  • Displaced lateral third fractures
  • Pathological fractures
44
Q

Differentials for acute abdominal pain in a 7 year old?

A
  • Diabetic ketoacidosis
  • Acute appendicitis
  • Lower lobe pneumonia
  • Pyelonephritis
  • Mesenteric adenitis
45
Q

Clinical features of acute rheumatic fever?

A
  • Tonsillar exudate
  • Erythema marginatum
  • Polyarthritis
  • Sydenham chorea
  • Carditis or cardiac murmur
  • Palpable subcutaneous nodules
46
Q

Barriers to healthcare for the Indigenous community?

A
  • Shortage of specialist medical services
  • Lack of affordable health care services
  • Poor health literacy
  • Lack of health services available in other languages
  • Mistrust in Western medicine practice
  • Distance to available health services
  • Perceived lack of confidentality in rural and remote areas
  • Lack of culturally safe health care services
47
Q

Routine investigations for new AF?

A
  • FBC
  • EUC
  • CMP
  • TSH
  • TTE
  • 24 hour holter
  • Polysomnography (in patients with symptomatic AF only)
48
Q

Non-pharmacological management of AF?

A
  • Cease smoking
  • Recommend reduce BMI to 27kg/m^2
  • Reduce alcohol to no more than 3 standard drinks per week
  • Recommend aerobic exercise up to 210 minutes to reduce burden of symptomatic AF
49
Q

Questions to ask to define “issues with performing in the bedroom”?

A
  • Rapid onset? - psychogenic
  • Morning or spontaneous erections?
  • Able to maintain erection sufficient for intercourse?
  • Premature ejaculation?
  • Is he able to ejaculate? - retrograde ejaculation can occur in longterm diabetics or after prostate surgery
  • Any issues with libido?
  • Noticed any changes to the appearance of his penis? - Peyronie’s disease
50
Q

History questions to ask for assessing female factors for infertility/subfertility?

A
  • Any hirsutism / irregular period / acne - PCOS
  • Family history of endometriosis / deep dyspareunia / dysmenorrhoea - symptoms of endometriosis
  • Galactorrhoea / visual changes - symptoms of prolactinoma
  • Weight gain / intolerance to cold - hypothyroidism
  • Abnormal vaginal discharge / past history of sexuall transmitted infections - pelvic inflammatory disease
  • Hot flushes - premature menopause
  • Family history of subfertility
51
Q

Differentials for subfertility/infertility?

A
  • PCOS
  • Endometriosis
  • Pelvic inflammatory disease
  • Hypothyroidism
  • Premature menopause
52
Q

Preliminary investigations for subfertility/infertility?

A

Females:
* Day 3 of cycle FSH, LH, oestradiol
* TSH
* Transvaginal USS - preferably in the first half of the cycle
* Day 21 progesterone (7 days before menses to measure progesterone spike)
* FBC
* Thalassaemia screen
* Rubella and varicella antibodies
* Serology - Hep B, Hep C, HIV, syphilis
* Genetic carrier screening - cystic fibrosis, spinal muscular atrophy, Fragile X
* Blood group and antibody screen
* Anti-Mullerian hormone - usually performed by fertility specialist

Males:
* Sperm analysis - 2-5 days of abstinence before sample

53
Q

List factors that contribute to the discrepancy in health status between patients who live in rural and metropolitan Australia

A
  • Rural areas have less access to GPs/ allied health/medical specialists
  • Higher rates of smoking
  • Lower levels of physical activity
  • Higher rates of alcohol consumption
  • Lower socio-economic status
54
Q

History questions to ask for haemoptysis?

A
  • Unintentional weight loss - lung carcinoma
  • Breathlessness
  • Pleuritic chest pain or calf tenderness - PE
  • Recent travel or contact with someone with tuberculosis - TB
  • History of recurrent chest infections - bronchiectasis
  • Previous asbestos exposure
55
Q

Congenital causes of atlanto-axial subluxation?

A
  • Down syndrome
  • Osteogenesis imperfecta
  • Marfan disease
  • Neurofibromatosis type 1
56
Q

Associations of frozen shoulder?

A
  • Diabetes
  • Thyroid dysfunction
  • Hypercholesterolaemia
  • Hypertension
57
Q
A

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