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Junior Rotation > CardioResp > Flashcards

CardioResp Flashcards

1
Q

Describe the NYHA classification system.

A
  1. No limitation of physical activity
  2. Slight limitation on exertion
  3. Marked limitation but comfortable at rest
  4. Unable to carry out any physical activity without discomfort.
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2
Q

Give the symptoms that may be experienced during an acute myocardial infarction.

A 
Crushing chest pain
Pain the neck, jaw, and/or arm
Sweating
Nausea and vomiting
Abdominal pain (especially if elderly)
Anxiety
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3
Q

What is the acute treatment of an ST-elevated myocardial infarction?

A 
Morphine 5mg
Antiemetic
Oxygen
Nitrates
Aspirin 300mg
Prasugrel (or clopidogrel 300mg)

Admit to cath lab as soon as possible

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4
Q

What long-term medications should a patient be prescribed after an acute myocardial infarction?

A 
Atorvastatin 80mg
Bisoprolol
Prasugrel (clopidogrel if over 80, high bleeding risk, under 60kg)
Aspirin 75mg
Ramipril
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5
Q

What are the potential complications of an acute myocardial infarction?

A

Heart failure
Arrhythmia
Cardiogenic shock
Cardiac arrest

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6
Q

What investigations might you use in a patient with angina?

A

Exercise ECG
Coronary angiogram
Thyroid function test if hyperthyroidism is suspected
FBC to check for anaemia

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7
Q

Give a short-acting nitrate that can be prescribed for the relief of angina pain.

A

Nitroglycerin

Glyceryl trinitrate

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8
Q

Explain how nitrates can relieve the pain in angina

A

They are metabolised to nitrous oxide in the blood, which can cause vasodilation in the coronary vessels. This is done by increasing the levels of cGMP which activates myosin light chain phosphatase, phosphorylating the myosin and causing it to dissociate, allowing relaxation of the muscle.

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9
Q

Give a long-acting nitrate that can be prescribed for the long-term control of angina.

A

Isosorbide mononitrate

Nicorandil

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10
Q

Aside from nitrates, what should be prescribed to patients with angina that reduces their morbidity and mortality?

A

Beta blockers such as atenolol and bisoprolol

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11
Q

Give two procedures which can help patients with angina.

A

Balloon angioplasty

Coronary artery bypass graft

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12
Q

How can angina be prevented?

A

Stop smoking
Lose weight
Improve diabetic and hypertensive control
Increase exercise

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13
Q

What symptoms would you expect in a patient with chronic aortic regurgitation?

A 
Typically asymptomatic
Progressive shortness of breath on exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea
Palpitations
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14
Q

How would you expect a patient with acute aortic regurgitation to present?

A

In heart failure with dyspnoea, fatigue, weakness, and oedema.
They may also have cardiogenic shock with hypotension combined with multisystem organ damage.

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15
Q

A patient in clinic is found to have a loud S2, mid-diastolic murmur, and a wide pulse pressure. What is the most likely cause?

A

Aortic regurgitation

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16
Q

What are the causes of an acute aortic regurgitation?

A

Infective endocarditis

Ascending aortic dissection

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17
Q

What are the causes of a chronic aortic regurgitation?

A 
Rheumatic fever
Infective endocarditis
Trauma
Thoracic aortic aneurysm
Degeneration of the valve or root
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18
Q

What investigations would you use in a suspected aortic regurgitation and why?

A

Echocardiogram with doppler: assess flow across the valve, level of impairment, pulmonary hypertension, vegetations, pericardial effusions
ECG: left ventricular hypertrophy, left atrial enlargement, ST depression, T wave inversion
CXR: cardiomegaly, prominent aortic root

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19
Q

What can be used for symptom control in patients with aortic regurgitation who are not eligible for surgery?

A

Vasodilators
Nitrates
Diuretics

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20
Q

What is the typical triad of symptoms which may occur in aortic stenosis?

A

Syncope
Angina
Breathlessness

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21
Q

A patient in the clinic is found to have a quiet S2, systolic ejection murmur, and a slow rising carotid pulse. What is the most likely cause?

A

Aortic stenosis

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22
Q

What are the most common causes of aortic stenosis?

A

Aortic sclerosis (over 70)
Congenital bicuspid aortic valve (under 70)
Rheumatic heart disease

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23
Q

What investigations would you want for a patient with suspected aortic stenosis, and what would you expect to find?

A

Echocardiogram: assess structural damage or deformity, atrial thrombi
ECG: left ventricular hypertrophy with/without ST/T changes
CXR: check for cardiomegaly and calcification of the valves
Exercise ECG: can show severe LV dysfunction if the patient is asymptomatic.

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24
Q

What is the management for aortic stenosis?

A

Valve replacement via open heart surgery or TAVI
Balloon valvotomy, usually in congenital cases
Diuretics if there is fluid overload
Anti-arrhythmics if necessary

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25
Q

What are the changes seen in the lungs of asthmatics?

A

Bronchoconstriction, airway oedema and inflammation, airway hyper-reactivity, airway remodelling

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26
Q

What can trigger asthma exacerbations?

A 
Environmental or occupational allergens
Infections
Exercise
Inhaled irritants
Emotion
Aspirin
Gastro-oesophageal reflux disease
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27
Q

What are asthmatics at increased risk of during pregnancy?

A 
Prematurity
Pre-eclampsia
Growth restriction
Maternal morbidity/mortality
Caesarian delivery
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28
Q

What is status asthmaticus?

A

Severe persistent asthma with prolonged bronchospasm

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29
Q

What timing of symptoms in asthma is a red flag?

A

At night

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30
Q

How is asthma diagnosed?

A

Spirometry before and after the use of salbutamol to confirm airway reversibility. More than 20% reduction of symptoms is required.
Methacholine or histamine can be used to trigger symptoms.

Induced sputum with >1% eosinophils can confirm a diagnosis of eosinophilic asthma.

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31
Q

What are the stages in the pharmacological management of asthma?

A

Salbutamol inhaler PRN with low-dose corticosteroid inhaler
ADD salmeterol inhaler BD
ADD moderate-dose corticosteroid inhaler

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32
Q

What are the features of a moderate asthma exacerbation, and how would you manage it?

A

PEF 50-75% of predicted
No features of a severe exacerbation

Manage with nebulised salbutamol and oral steroids
Maintain O2 sats of 94-98%

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33
Q

What are the features of a severe asthma exacerbation, and how would you manage it?

A

PEF 33-50% of predicted
RR >25/min, hr 110/min
Can’t complete sentences in one breath

Manage with nebulised ipratropium bromide and back to back salbutamol. Oxygen to maintain saturations 94-98%.
Take and ABG and inform a senior.

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34
Q

What are the features of a life threatening asthma exacerbation, and how would you manage it?

A

PEF <33% of predicted.
Sat <92%, pO2 <8kPa
Cyanosis, poor respiratory effort, fully silent chest
Exhaustion, confusion, arrhythmia

Manage with nebulised salbutamol and tiotropium bromide, IV aminophylline, and O2 if needed.
ITU and anaesthetics assessment
ICU or anaesthetic assessment
Urgent portable CXR

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35
Q

What is the defining feature of near fatal asthma?

A

CO2 levels normal or high

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36
Q

What symptoms may a patient with atrial fibrillation present with?

A

Palpitations
Heart failure: dizziness, dyspnoea, peripheral oedema
Stroke
Renal failure due to systemic emboli

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37
Q

What signs would you expect to find in a patient with atrial fibrillation?

A

Pulse deficit
Irregularly irregular pulse
Loss of the A wave in the JVP

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38
Q

What are the common causes of atrial fibrillation?

A 
Hypertension
Cardiomyopathy
Mitral or tricuspid valve disorders
Hyperthyroidism
Binge drinking
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39
Q

What investigations would you want in a patient with suspected atrial fibrillation?

A

ECG: irregularly irregular narrow complex tachycardia with no P waves
Echocardiogram: check for structural heart defects and thrombi in the atria
Thyroid function tests

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40
Q

Describe the CHADS VASC scoring system.

A 
Congestive heart failure
Hypertension
Age >75 (2)
Diabetes
Stroke/TIA (2)
Vascular disease
Age >65
Sex Female

A score of 2 or more should have anticoagulation therapy

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41
Q

Describe the HAS BLED scoring system.

A 
Hypertension
Abnormal renal or hepatic function
Stroke
Bleeding
Labile INR
Elderly (>65)
Drugs/alcohol
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42
Q

What is the mechanism of action for rivaroxaban and apixaban?

A

Selective factor Xa inhibitor

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43
Q

What is the mechanism of action of warfarin?

A

Vitamin K antagonist

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44
Q

Why should you be cautious using atenolol in patients with diabetes?

A

It augments the function of metformin and insulin, as well as other anti-hyperglycaemic medications

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45
Q

What is the mechanism of action of diltiazem?

A

Calcium channel blocker

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46
Q

What are the side effects of diltiazem and verapamil?

A

Heart block
Constipation
Symptoms related to bradycardia

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47
Q

What is the mechanism of action of digoxin?

A

Cardiac glycoside which inhibits the sodium/potassium exchange to reduce the rate of contraction but increase the force.

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48
Q

What drug monitoring is required when using digoxin?

A

Serum electrolytes

Renal function

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49
Q

What rate control medications are commonly used in atrial fibrillation?

A

Atenolol/bisoprolol
Diltiazem/verapamil
Digoxin

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50
Q

What rate control medications used in atrial fibrillation should not be used together?

A

Beta blockers and calcium channel blockers

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51
Q

What medications can be used for rhythm control in atrial fibrillation?

A

Amiodarone

Flecainide

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52
Q

In a patient with atrial fibrillation and haemodynamic instability, what should be the first management?

A

Electrical cardioversion

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53
Q

How can patients with atrial fibrillation for less than 24 hours be managed differently than those where it has been present for more than 24 hours?

A

Less: cardiovert immediately
More: anticoagulate for three weeks before cardioversion irrespective of CHADS VASC score

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54
Q

What is the mechanism of action of amiodarone?

A

Class III anti-arrhythmic

Slows the conduction rate and increases the refractory period in the SAN and AVN

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55
Q

What drug monitoring is important with amiodarone?

A

Chest x-ray
Liver function tests
Urea and electrolytes
Thyroid function tests

Every 6 months

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56
Q

What are the major side effects of amiodarone?

A 
Pulmonary fibrosis
Photosensitivity
Renal impairment
Liver impairment
Thyroid dysfunction
Pneumonitis
Optic neuritis
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57
Q

Why must amiodarone be administered via a central line?

A

It causes severe thrombophlebitis if administered through a peripheral vein

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58
Q

What is the mechanism of action of flecainide?

A

Sodium channel blocker

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59
Q

What are the side effects of flecainide?

A 
Constipation
Faintness
Headache
Nausea
Chest pain
Tachycardia
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60
Q

When should you avoid using flecainide?

A

Heart block

History of severe heart problems

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61
Q

When should you avoid using amiodarone?

A

Thyroid dysfunction

Conduction disturbance

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62
Q

What are the typical symptoms of bronchiectasis?

A

Chronic productive cough
Dyspnoea
Wheezing
Pleuritic chest pain

May cause massive haemoptysis

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63
Q

What would you expect to see on a chest x-ray for someone with bronchiectasis?

A

Thick airway walls
Tram lines
Tubular opacity (mucus plugs)
Ill-defined linear hilar density

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64
Q

What would you expect to see on CT for someone with bronchiectasis?

A

Airway dilation
Signet ring sign
Tram lines

May also have atelectasis, consolidation, and mucus plugs

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65
Q

What would you expect to find on pulmonary function tests in bronchiectasis? Why are they important?

A

Reduced FEV1, FVC, and FEV1:FVC ratio
May have a decreased DLCO

Used to document the baseline and monitor progression of the disease.

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66
Q

Describe the management of chronic bronchiectasis.

A

Respiratory therapy to ensure proper clearing of airway secretions
Salbutamol
Corticosteroids

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67
Q

How should bronchiectasis be managed during an acute exacerbation?

A

Antibiotics
Nebulised saline
Inhaled bronchodilators

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68
Q

What are the predisposing factors for bronchiectasis?

A

Persistent or recurrent infections
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Primary ciliary disorders (Kartageners syndrome)
Primary or secondary immunodeficiency
Connective tissue disorder
Airway obstruction (tumour or foreign body)

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69
Q

What can cause radial-radial delay?

A

Coarctation of the aorta

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70
Q

What can cause a collapsing pulse?

A 
Aortic regurgitation
Fever
Pregnancy
Patent ductus arteriosus
Anaemia
AV fistula
Thyrotoxicosis
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71
Q

What can cause a slow rising carotid pulse?

A

Aortic stenosis

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72
Q

What can cause a narrow pulse pressure?

A

Aortic stenosis

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73
Q

What can cause a wide pulse pressure?

A

Aortic regurgitation

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74
Q

What can cause a raised JVP?

A

Fluid overload
Right ventricular failure
Tricuspid regurgitation

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75
Q

What murmur is heard in mitral regurgitation?

A

Pansystolic murmur

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76
Q

What murmur is heard in aortic stenosis?

A

Mid-systolic ejection murmur

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77
Q

What murmur is heard in mitral stenosis?

A

Early diastolic decrescendo murmur with an opening snap

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78
Q

What murmur is heard in aortic regurgitation?

A

Early diastolic decrescendo murmur

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79
Q

What can cause pathological splitting of the S2 heart sound?

A

Aortic stenosis
Left bundle branch block
Hypertrophic cardiomyopathy

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80
Q

What can cause fixed splitting of the S2 heart sound?

A

Atrial septal defect

Bundle branch block

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81
Q

What can cause a loud S2?

A

Pulmonary hypertension

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82
Q

What changes will be seen on spirometry in a patient with COPD?

A

Low FEV1 and FEV1:FVC ratio

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83
Q

Describe the MRC dyspnoea score.

A
  1. Not troubled by breathlessness except on strenuous exercise
  2. Shortness of breath when hurrying on a level or walking up a slight hill
  3. Walks slower than most people on a level, stop after a mile or so, or stops after 15 minutes of walking at own pace.
  4. Stops for breath walking 100 yards or a few minutes on level ground.
  5. Too breathless to leave the house or breathless when dressing/undressing
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84
Q

Describe the management of COPD.

A

Smoking cessation, pulmonary rehabilitation, and dietetics
Tiotropium bromide inhaler
Combined steroid and bronchodilator inhaler if tiotropium is not sufficient.

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85
Q

Which patients with COPD should be offered long-term oxygen therapy?

A

Persistently low oxygen saturations <7.3kPa if no cor pulmonale, <8kPa with cor pulmonale
Non-smoker
Able to use for at least 16 hours per day
No high CO2 retention

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86
Q

Which patients with COPD can be eligible for lung volume reduction surgery?

A

Localised areas of emphysema

The rest of their lung is healthy

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87
Q

What interventions reduce mortality in COPD?

A

Smoking cessation
Long term oxygen therapy
Lung volume reduction surgery

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88
Q

How can COPD cause right heart failure?

A

It causes chronic hypoxic vasoconstriction which increases the afterload of the right ventricle.

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89
Q

What can be prescribed for COPD patients with right heart failure?

A

Furosemide

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90
Q

What are some of the side effects for patients using long-term steroids?

A 
Weight gain
Osteoporosis
Mood changes and psychosis
Bruising 
GI symptoms
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91
Q

How should COPD exacerbations be managed?

A

Controlled oxygen therapy (Venturi masks)
Nebulised tiotropium bromide
Oral steroids
IV aminophylline

Antibiotics if there is a raised CRP or WCC

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92
Q

If a patient with a COPD exacerbation has been treated but their ABG does not improve, how should they be managed?

A

BIPAP (non-invasive ventilation)

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93
Q

Who is BIPAP (non-invasive ventilation) contraindicated in?

A 
Untreated pneumothorax
GCS <8
Facial injury
Life-threatening hypoxia
Vomiting
Agitation
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94
Q

Why is therapeutic drug monitoring required for aminophylline?

A

It has a narrow therapeutic index

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95
Q

What are the side effects of aminophylline?

A

Palpitations
Gastric irritation
Hypotension
Convulsions

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96
Q

Describe the main presentation of cystic fibrosis.

A

Newborn screening
Meconium ileus
Chest infections
Intestinal malabsorption

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97
Q

What are the typical respiratory effects of cystic fibrosis?

A

Recurrent or chronic infections
Pneumothorax
Haemoptysis
Cor pulmonale

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98
Q

What are the typical gastrointestinal effects of cystic fibrosis?

A

Meconium ileus (abdominal distention, vomiting, failure to pass meconium)
GORD
Malnourised
Constipation or bowel obstruction
Bulky and offensive stools (pancreatic insufficiency)
Features of vitamin ADEK deficiency

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99
Q

Why do cystic fibrosis patients often have reduced fertility?

A

In men, the failure of the vas deferens to develop is the most common cause. There may also be obstruction of the ducts that semen passes through.

In women, there are often viscous cervical secretions which reduce the passage of sperm through the cervix.

100
Q

What investigations are required to diagnose cystic fibrosis?

A

Chloride sweat testing

Genetic testing for CFTR mutations

101
Q

What would you expect to find on pulmonary function tests in a patient with cystic fibrosis?

A

Reduced FVC and FEV1

Increased residual volume

102
Q

What lifestyle advice should be given to patients with cystic fibrosis?

A

Diet therapy
No smoking
Avoid contact with other cystic fibrosis patients and people ill with respiratory infections
Regular exercise and airway clearance
Clean and dry nebulisers properly
NaCl tablets in hot weather, be careful of dehydration

103
Q

What are common complications of cystic fibrosis?

A

Diabetes
Malabsorption
Distal intestinal obstruction syndrome
Right heart failure

104
Q

What are some genetic conditions which cause dyslipidaemia?

A

Familial hypercholesterolaemia: LDL receptor defect reducing clearance
Familial defective ApoB: reduces LDL clearance
PCSK9 GoF mutation: increased degradation of LDL receptors
Lipoprotein lipase deficiency: reduced chylomicron clearance from blood vessels
ApoC-II deficiency: functional LPL deficiency

105
Q

What are the causes of secondary dyslipidaemia?

A

Sedentary lifestyle with an excessive intake of saturated fats, cholesterol, and trans fats
Diabetes mellitus
Alcohol overuse
Chronic kidney disease
Hypothyroidism
Cholestatic liver disease
Drugs: thiazides, beta blockers, oestrogen, progestins, glucocorticoids, antiretrovirals

106
Q

What investigations are important when diagnosing dyslipidaemia

A 
Serum lipid profile
Fasting glucose
Liver enzymes
Creatinine
TSH
Urinary protein
107
Q

What is the non-pharmacological management of dyslipidaemia?

A

Dietary modification and regular exercise

108
Q

What is the pharmacological management of dyslipidaemia?

A

Atorvastatin/simvastatin (first line)
Benzafibrate
Ezetimibe

109
Q

What is the mechanism of action of atorvastatin and simvastatin?

A

HMG-CoA reductase inhibitor, reducing cholesterol synthesis in the liver

110
Q

What are the common side effects of atorvastatin and simvastatin?

A

Myalgia
Abdominal pain
Raised LFTs

111
Q

What is the mechanism of action of benzafibrate?

A

Stimulates endothelial lipoprotein lipase to increase fatty acid oxidation in the liver and muscle, as well as decreasing LDL synthesis in the liver.

112
Q

Why should statins and fibrates not be used together?

A

It increases the risk of rhabdomyolysis

113
Q

What are the common side effects of benzafibrate?

A

Dyspepsia
Abdominal pain
Raised LFTs

114
Q

What is the mechanism of action of ezetimibe?

A

Reduces cholesterol absorption in the small intestine

115
Q

What are the common causes of acute heart failure?

A 
Infection
Allergic reactions
Pulmonary emboli
Cardiopulmonary bypass surgery
Severe arrhythmias
Heart attack
116
Q

What are the common causes of chronic heart failure?

A 
Coronary artery disease
Hypertension
Myocardial infarction
Arrhythmia
Diabetes medication
Heart defect
Alcohol overuse
Kidney problems
Sleep apnoea
117
Q

What are the symptoms of heart failure?

A 
Exertional dyspnoea
Orthopnoea
Fatigue and weakness
Tachycardia/arrhythmia
Reduced exercise tolerance
118
Q

What investigations are important in patients with heart failure?

A 
Chest x-ray
Blood tests
Electrocardiogram
Serum BNP
Transthoracic doppler echocardiogram

TFT, LFT, eGFR, fasting lipids/glucose, urinalysis, and peak flow/spirometry may also be useful in chronic heart failure to assess the impact on other organs systems and rule out other disorders.

119
Q

What would you expect to see on a chest x-ray of a patient with heart failure?

A 
Cardiomegaly
Kerley B-lines
Upper zone vessel enlargement
Batwing alveolar oedema
Blunt costophrenic angles
120
Q

What drugs improve prognosis in heart failure?

A 
Angiotensin receptor blockers
ACE inhibitors
Beta blockers
Spironolactone
Aldosterone inhibitors
121
Q

Describe the management of heart failure.

A

Beta blockers (ACEi or ARB if reduced LVEF)
Diuretics to relieve congestive symptoms
Amlodipine for comorbid treatment of hypertension

122
Q

How can heart failure cause renal dysfunction?

A

Reduced cardiac output causes reduced perfusion of the kidney, which is exacerbated by the activation of RAAS. This causes vasoconstriction of the renal arterioles as well as increasing ADH production.

123
Q

What drugs commonly used in heart failure can contribute to renal dysfunction?

A

Diuretics
ACE inhibitors
ARBs

124
Q

What blood pressure indicates mild hypertension?

A

> 140/90

125
Q

What blood pressure indicates moderate hypertension?

A

> 160/100

126
Q

What blood pressure indicates severe hypertension?

A

> 180/110

127
Q

What are some of the causes of secondary hypertension?

A 
Primary aldosteronism
Phaeochromocytoma
Cushing syndrome
Renal parenchymal disease
Renovascular disease
Congenital adrenal hyperplasia
Hyperthyroidism
Myxoedema
Coarctation of the aorta
128
Q

Describe the non-pharmacological management of hypertension.

A

Weight loss
Reduced salt intake
Stop smoking
Reduced alcohol intake

129
Q

What is the first-line therapy for a 45 year old patient with hypertension?

A

Ramipril

130
Q

What is the first-line therapy for a 76 year old patient with hypertension?

A

Amlodipine

131
Q

What investigations should be conducted in a patient with hypertension?

A

Multiple blood pressure measurements
Urinalysis and urea:creatinine to measure renal function
Fasting lipids
TSH measurement if thyroid abnormalities

132
Q

What are the overarching features of interstitial lung disease?

A

Chronic inflammation

Progressive interstitial fibrosis

133
Q

What are the risk factors for interstitial lung disease?

A

Age and gender
Past medical history (radiotherapy-induced)
Drug history (amiodarone, methotrexate, bleomycin)

134
Q

What is the typical presentation of interstitial lung disease?

A

Dyspnoea on exertion

Non-productive paroxysmal cough

135
Q

What are the typical changes on CT in interstitial lung disease?

A

Honeycombing
Traction bronchiectasis
Mosaicism
Hilar lymphadenopathy

136
Q

What are the typical examination findings in a patient with interstitial lung disease?

A

Clubbing
Reduced chest expansion
Fine end-inspiratory crepitations
Cor pulmonale

137
Q

What investigations are important in patients with interstitial lung disease?

A 
FBC, CRP, ESR
LFT for drug monitoring
Calcium levels
anti-GBM if haemoptysis is present
ACE if sarcoid
IgG for specific precipitation
RhF in rheumatoid arthritis
HIV if relevant
Oxygen levels
Urinalysis
ECG
Imaging
Pulmonary function tests
138
Q

What are the typical changes in pulmonary function tests in interstitial lung disease?

A 
Reduced:
TLCO
DLCO
FVC
TLC
Restrictive pattern
139
Q

Describe the management of interstitial lung disease.

A 
Remove the cause if there is one
Prednisolone/methotrexate
Transplantation if young and fit
Treat infections early (may be atypical)
Oxygen therapy
Stop smoking
140
Q

Give some of the more common interstitial lung diseases.

A 
Idiopathic pulmonary fibrosis
SLE
Rheumatoid arthritis
Sarcoidosis
Asbestosis
141
Q

What are the most common causative organisms in community acquired pneumonia?

A

Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumonia

142
Q

What are the most common causative organisms in hospital acquired pneumonia?

A

Enterobacteria
Staphylococcus aureus
Pseudomonas

143
Q

Who is at increased risk of aspiration pneumonia?

A 
Stroke
Dementia
Myasthenia gravis
Reduced conciousness
GERD
Achalasia
Poor dental hygeine
144
Q

What are the most common causative organisms in patients who are immunocompromised?

A 
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Moraxella catarrhalis
Mycobacteria pneumoniae
Gram negative bacilli
145
Q

What are the most common causes of viral pneumonia?

A

Influenza
Measles
CMV
Varicella zoster

146
Q

What are the symptoms of pneumonia?

A 
Fever, rigors, malaise, anorexia
Dyspnoea
Cough
Sputum
Haemoptysis
Pleuritic chest pain
Confusion (may be only sign in elderly)
147
Q

What are the common signs found on examination of. someone with pneumonia?

A 
Diminished expansion
Dull percussion
Increased vocal fremitus
Bronchial breathing
Tachycardia, tachypnoea, hypotension, pyrexia
May have cyanosis
148
Q

What investigations should be done in pneumonia?

A

Oxygen saturation
FBC, U+E, LFT, CRP
Blood/sputum culture and microscopy
Sample and culture pleural fluid if present
Bronchoscopy and/or bronchoalveolar lavage if immunocompromised or ITU

149
Q

Describe the CURB-65 scoring system.

A 
Confusion
Urea >7mmol/L
Respiratory rate >30/min
BP <90/60
Age >65
150
Q

Describe the management of pneumonia.

A

Oral antibiotics (amoxicillin/doxycycline/..)
Oxygen to maintain O2 sats >94%
IV fluids to combat anorexia, dehydration, shock
Analgesia if they have pleurisy

151
Q

What is the mechanism of action of doxycycline?

A

Inhibits protein synthesis

152
Q

What are the side effects of doxycycline?

A

Blood disorders
GI disturbance
Tinnitus

153
Q

What is the mechanism of action of gentamicin?

A

Inhibits the 30S ribosome to reduce protein synthesis

154
Q

What are the serious side effects of gentamicin?

A

Ototoxic
Nephrotoxic
Peripheral neuropathy

155
Q

What is the mechanism of action of ceftriaxone?

A

Inhibits bacterial wall synthesis

156
Q

What are the side effects of ceftriaxone?

A 
Dizziness
Diarrhoea
Superinfection
Anaemia
Increased bleeding with anticoagulants
157
Q

What is the mechanism of action of metronidazole?

A

Inhibits nucleic acid synthesis by disrupting DNA

158
Q

What are the serious side effects of metronidazole?

A

Hepatotoxic

Peripheral neuropathy

159
Q

What is the most likely type of respiratory failure in pneumonia?

A

Type 1 respiratory failure

160
Q

What are the common complications in pneumonia?

A 
Hypotension
Respiratory failure
Atrial fibrillation
Pleural effusion
Empyema
Lung abscess
Sepsis
161
Q

In pneumonia patients, what are the potential reasons for a chest x-ray that isn’t clear 6 weeks after discharge?

A

Complications (empyema/abscess)
Host (immunocompromised)
Antibiotics (inadequate or inappropriate)
Organism (resistant or unexpected)
Second diagnosis (pulmonary embolism, cancer, organising pneumonia)

162
Q

When might a tuberculin skin test give a false negative?

A

Immunosuppression
Miliary TB
Sarcoidosis
Lymphoma

163
Q

What are the common chest x-ray changes in tuberculosis?

A

Upper lobe consolidation
May have cavitation
Areas of fibrosis and calcification

164
Q

How is tuberculosis diagnosed?

A

Sputum ZN staining

165
Q

Why is tuberculosis culture important even though it can take up to 12 weeks?

A

Identification of rifampicin or multidrug resistance

166
Q

What is seen on histology in a tuberculosis infection?

A

Caseating granuloma
Epithelioid cells
Langhans giant cells

167
Q

What is the typical antibiotic regime in tuberculosis?

A

Rifampicin and isoniazid for 6 months

Pyrazinamide and ethambutol for 2 months

168
Q

What are the side effects of rifampicin?

A

Hepatoxic
Thrombocytopaenia
Orange secretion

169
Q

What are the side effects of isoniazid?

A

Hepatotoxic
Leukopaenia
Neuropathy

170
Q

What are the side effects of pyrazinamide?

A

Hepatitis
Arthralgia
Precipitate acute gout

171
Q

What are the side effects of ethambutol?

A

Optic neuritis

172
Q

What should be tested during drug therapy for tuberculosis?

A

Colour vision
FBC
U+E
LFT

173
Q

What is the most common presentation of tuberculosis?

A 
Cough
Sputum
Malaise
Weight loss
Night sweats
Pleurisy
Haemoptysis
Pleural effusion
174
Q

What are the risk factors for peripheral vascular disease?

A 
Age 
Hypertension
Diabetes
Dyslipidaemia
Smoking
Obesity
Male
175
Q

What is the most common presentation for peripheral vascular disease?

A

Intermittent claudication - pain, aching, cramping in the legs during walking which is relieved at rest

176
Q

What is commonly found on examination in peripheral vascular disease?

A 
Peripheral pulses diminished or absent
Atrophic skin
Non-healing wounds
Gangrene
Ulceration
177
Q

What is LeRiche syndrome?

A

Buttock, thigh, calf claudication with erectile dysfunction due to aortoiliac peripheral arterial disease

178
Q

What investigations can be useful in peripheral vascular disease?

A 
Doppler ultrasound
MRI angiography (if surgery considered)
179
Q

Describe the management of peripheral vascular disease

A 
Reduce modifiable risk factors
Supervised exercise programmes
Angioplasty
Bypass surgery
Major amputation
180
Q

What investigations are useful in a patient with a pleural effusion?

A

Chest x-ray

Thoracentesis (colour, biochemistry, cytology, microbiology)

181
Q

What are some causes of a transudate pleural effusion?

A

Liver failure, nephrotic syndrome, malabsorption, chronic infection (hypoalbuminaemia)
Constructive pericarditis, heart failure, fluid overload
Meig’s syndrome
Hypothyroidism

182
Q

What are some causes of an exudate pleural effusion?

A

Rheumatoid arthritis, granulomatous disorders, SLE, pulmonary infarction
Bronchial carcinoma, metastases
Empyema, TB

183
Q

Describe the management options for a pleural effusion.

A

If a clear transudative cause, treat this then wait for the effusion to resolve itself.
With exudative causes, insert a chest drain to gradually remove the fluid.
Permanent chest drain or pleurodesis if malignant cause.

184
Q

What is the problem with draining pleural effusions too quickly?

A

It causes pulmonary oedema

185
Q

Who is most at risk of a primary spontaneous pneumothorax?

A

Tall
Male
Smoker (especially cannabis or heroin)

186
Q

What are the causes of. a secondary spontaneous pneumothorax?

A 
Cystic fibrosis
COPD
Pneumonia
Diving
Trauma
Ehlers-Danlos
Marfans
187
Q

Describe the intervention in a primary pneumothorax.

A

If >2cm, aspirate and discharge

If <2cm, insert a chest drain

188
Q

Describe the intervention in a secondary pneumothorax.

A

If >2cm, insert a chest drain and admit. Give oxygen therapy.

189
Q

If a patient has a narrow-complex tachycardia and is haemodynamically unstable, what is the management?

A

Electrical cardioversion immediately

190
Q

If a patient has narrow-comlex tachycardia and is haemodynamically stable, what is the management?

A

Valsava manoeuvre
Carotid sinus massage
Adenosine

191
Q

What broad-complex tachycardias can be terminated with adenosine?

A

Supraventricular tachycardia with abberancy
Wolff-Parkinson-White syndrome (antidromic)
Supraventricular tachycardia with bundle branch block

192
Q

What is the long term management of a narrow-complex tachycardia?

A

Bisoprolol
Flecainide (pill in pocket or regular)
Verapamil
Amiodarone (rarely)

Ablation if medical therapy is insufficient.

193
Q

What should you treat any regular broad-complex tachycardia as?

A

Ventricular tachycardia

194
Q

What are the risk factors for venous thromboembolism?

A 
Immobility
Recent surgery
Flight more than 4 hours
Pregnancy
Combined oral contraceptive pill
Cancer
Obesity
Fracture
History of VTE
195
Q

How can a deep vein thrombosis be confirmed?

A

Doppler ultrasound

D-dimer testing

196
Q

What are the Well’s criteria for pulmonary embolism?

A 
Clinical signs and symptoms of DVT
PE is number 1 diagnosis or equal
HR over 100bpm
Immobilised >3 days or surgery within 4 weeks
Previous DVT/PE
Haemoptysis
Malignancy <6 months or palliative
197
Q

What are the symptoms of pulmonary embolism?

A 
Acute onset shortness of. breath
Pleuritic chest pain
Haemoptysis
Syncope
Sense of impending doom, anxiety
Tachypnoea
Tachycardia
Accentuated second heart sound
Fever 
Cyanosis
198
Q

What investigations are important with a suspected pulmonary embolism?

A 
CT pulmonary angiogram
D-dimer
Acid-base status
ECG to rule out MI
Chest radiography (can be suggestive and rule out cause
199
Q

What are some differential diagnoses for unilateral leg swelling?

A 
Deep vein thrombosis
Lymphoedema
Varicosities
Lymphoedema
Cellulitis
Baker's cyst
200
Q

What is the acute management of a pulmonary embolism if there is haemodynamic stability?

A

Dalteparin

201
Q

What is the long-term prevention of a pulmonary embolsim

A

Warfarin
Rivaroxaban
Apixaban

202
Q

What is the acute management of a pulmonary embolism if there is haemodynamic instability?

A

Alteplase
Reteplase
Streptokinase
Urokinase

203
Q

What are the options for the management of a pulmonary embolism where thrombolysis is contraindicated or treatment has failed?

A

Embolectomy

IVC filter

204
Q

What can be used for thromboprophylaxis in pregnant women?

A

Heparin

warfarin crosses the placenta

205
Q

What type of lung cancer typically causes obstruction and is detected before metastasis?

A

Squamous cell carcinoma

206
Q

What type of lung cancer is most likely to cause excessive mucus secretion?

A

Adenocarcinoma

207
Q

Where do adenocarcinomas arise from?

A

Mucus cells of the bronchial epithelium

208
Q

Why are small cell carcinomas able to present in a wide variety of ways?

A

They arise from enterochromaffin cells which are able to produce a range of polypeptides

209
Q

What is the most common presentation of lung cancer?

A

A persistent cough

210
Q

How does a pancoast tumour typically present?

A

With severe pain and weakness in the shoulder, inner surface of the arm, and weakness in the hand due to compression of C8, T1, and T2

211
Q

Explain how a lung cancer can cause Horner’s syndrome

A

A central posterior tumour can compress the sympathetic chain at or above the stellate ganglia

212
Q

What is the presentation of Horner’s syndrome?

A

Ptosis, miosis, dilation lag

Also have anhydrosis in half of the face but this is hard to detect

213
Q

What is the presentation of superior vena cava syndrome?

A

Early morning headache
Oedema of the upper limb
Distention of the veins in the neck and chest
Facial congestion

214
Q

How do liver metastases typically present?

A

Painless jaundice

Pruritis

215
Q

How do bone metastases typically present?

A

Severe bone pain
Pathological fractures
Compression of the spinal cord

216
Q

If a patient with lung cancer had metastases to their spine, what symptoms would you expect them to develop?

A

Back pain
Urinary retention
Saddle-pattern sensory loss

217
Q

What type of lung cancer is most likely to cause endocrine complications?

A

Small cell lung cancer

218
Q

What are the ymptoms or signs of hyponatraemia?

A 
Nausea
Malaised
Reduced conciousness
Seizure
Coma
219
Q

Describe SIADH seen in lung cancer.

A

The ectopic production of ADH by the tumour increases water retention by the kidneys and can cause hyponatraemia. The fluid overload can be negated by limiting the water intake.

220
Q

How can lung cancer cause Cushing’s syndrome?

A

The tumour can produce ACTH ectopically which increases the amount of corticosteroids produced by the adrenal glands.

221
Q

Describe the typical presentation of a patient with lung cancer causing Cushing’s syndrome.

A

Weight gain
Acne
Thin skin
Increased pigmentation

222
Q

How can lung cancer cause hypercalcaemia?

A

Ectopic production of PTHrP (parathyroid hormone related peptide) which stimulates the parathyroid glands, increasing the release of calcium from bones as well as calcium retention in the kidneys.

223
Q

What type of lung cancer is most likely to cause hypercalcaemia?

A

Squamous cell carcinomas

224
Q

What is the likely presentation of a lung cancer patient with PTHrP secretion?

A 
Renal stones
Constipation
Depression
Polyuria
Psychosis
225
Q

What are paraneoplastic syndromes?

A

Conditions which are non-neoplastic and non-endocrine that occur alongside malignancy

226
Q

Give some examples of paraneoplastic syndromes seen in patients with lung cancer.

A 
Polyneuritis
Cerebellar degeneration
Lambert-Eaton syndrome
Hypertrophic pulmonary osteoarthropathy
Clubbing
Carcinoid syndrome
227
Q

What is polyneuritis?

A

Inflammation of the myelin sheath which is caused by autoantibodies. It can present with any neurological symptom and is irreversible.

228
Q

What is the presentation of cerebellar degeneration?

A

Cerebellar ataxia with a typical gait, clumsy movement of the arms and legs, slurred speech, nystagmus

229
Q

What is Lambert-Eaton syndrome?

A

Myasthenia gravis-like symptoms caused by autoantibodies that are triggered by the lung cancer

230
Q

What is hypertrophic pulmonary osteoarthropathy?

A

Joint stiffness with pain in the wrists and ankles which may be accompanied by gynaecomastia, caused by lung cancer. It is associated by clubbing of the fingers.

231
Q

What is carcinoid syndrome?

A

Hepatomegaly, flushing, and diarrhoea caused by the secretion of serotonin and kallikreine.

232
Q

What might be found on examination in a patient with lung cancer?

A 
Nothing
Pleural rub
Stony dull percussion (pleural effusion)
Axillary lymph node enlargement
Absent breath sounds and dull percussion at the lung bases if there is phrenic involvement
233
Q

What should be covered by a staging CT for lung cancer?

A

Liver
Adrenal glands
Brain

234
Q

What is the most accurate scan for staging lung cancer?

A

PET scan

235
Q

When should a bronchoscopy done in lung cancer?

A

Tumours which are 10cm around the hilum

Biopsy of mediastinal lymph nodes

236
Q

What blood-related investigations would you want to do in lung cancer and why?

A

FBC - anaemia is common
LFT - check for liver involvement
Blood biochemistry - hyponatraemia indicates adrenal involvement, hypercalcaemia indicates bone involvement

237
Q

What staging system is used for lung cancer?

A

TNM

238
Q

Describe the WHO performance status.

A
  1. Fit and active
  2. Fit but unable to work
  3. Up for more than 50% of the day, able to self care
  4. Up for less than 50% of the day, able to self care
  5. Bed bound, unable to self care
  6. Dead
239
Q

What are the treatment options for a patient with stage 1 lung cancer?

A

Surgical resection

240
Q

What are the treatment options for a patient with stage 2 lung cancer?

A

Surgical resection (although likely to have metastases)

241
Q

What are the treatment options for a patient with stage 2a lung cancer?

A

Surgical resection with adjuvant chemotherapy

242
Q

What are the treatment options for a patient with stage 4 lung cancer

A

Chemotherapy

243
Q

What are the categories of small cell lung cancer, and why are they different to non-small cell lung cancer?

A

Limited -. confined to one lung or hemithorax, may have spread to unilateral lymph nodes
Extensive -. distant metastases

It is very aggressive so metastasises early.

244
Q

What is the mainstay of treatment for small cell carcinoma?

A

Chemotherapy

245
Q

What limits patients having surgery for lung cancer?

A

Maximum T2N1M0

Must have a WHO performance status between 0 and 2

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