Chest medicine Flashcards
Commonest cause of pneumonia?
Steptococcus pneumoniae
Chlamidophila psittaci, how would you contract this bacteria?
Birds, this is a zoonosis
CURB-65 breakdown?
C - confusion U - urea >7mmol/L R - resp rate >30/min B - BP (sys <60) Age - greater than 65
SARS - what type of pathogen is it?
Coronavirus
Atypical cause of pneumonia in HIV +ve patients with CD4 less than 200/mm3?
Pneumocystis pneumonia caused by Pneumocystis jiroveci
Common causes of HAP?
G-ve bacteria (E coli & P aerunginosa) 50%
Staph aureus 20%
Strep pneumoniae 15%
Typical features?
Cough, purulent sputum, fever with pleuritic chest pain and breathlessness
Localised chest signs: crackles, dullness, bronchial breathing
Resp failure indicated by cyanosis and tachypnoea
Investigations?
CXR - consolodation
Haematology and biochem tests
Pulse oximetry & ABG
Sputum gram stain
Sputum culture
Blood culture
Pleural fluid aspiration
Antibiotics in CAP and HAP?
CAP - amoxicillin (plus clarithromycin if atypical)
HAP - aminoglycacide and 3rd gen cephlasporin
What is ARDS?
a form of acute respiratory failure by PULMONARY OEDEMA
resulting from ENDOTHELIAL DAMAGE
due to a cascade of INFLAMATORY EVENTS
developing in responce to an INTIATING INJURY/ILLNESS
ARDS - pathogensis?
Usually pulmonary oedema results from increased hydrostatic pulmonary capillary pressure (e.g. left ventricular failure), but in ARDS it is a result of increased alveolar capillary PERMIABILITY
Prognosis of ARDS?
50% mortality
Survivors often left with fibrosis
ARDS - clinical features?
Occurs in response to:
DIRECT injury - aspiration, severe pneumonia
INDIRECT injury - sepsis, major trauma, pancreatitis
12 - 24hrs after precipitating events. First signs are of dyspnoea and tachypnoea
How to differentiate causes of pulmonary oedema?
Pulmonary capillary wedge pressure is typically <18mmHg in ARDS.
In cadiogenic pulm oedema, the pulmonary artery pressure increases above 18mmHg
What are the two disease of large airways?
Asthma and COPD
What are the three RCP question regarding asthma?
- Have you had trouble sleeping?
- Have you had any symptoms during the day time?
- Has your asthma interfered with your usual activities?
Finding of asthma o/e?
Freq normal
Hyperinflation
Wheeze: exp., diffuse and polyphonic (‘musical’)
Signs of atopy: exzema, conjunctivitis
Differential of asthma?
COPD Heart Failure Bronchiectasis GORD Pulm fibrosis
What findings would lead you away from asthma?
cough no wheeze
no variation of symtpoms
no relief with B2 agonist
voice disturbances
Two key investigations?
PEFR
Spirometry
(Also, cultures, bloods, imaging)
Steps in the management of asthma?
Step 1 - B2 agonist
Step 2 - add steroid
Step 3 - add LABA
Step 4 - trial of increased steroid dose. Leukotriene antagonist. Theophiline.
Step 5 - daily steroid tablet and specialist care referal.
Acutely unwell patients can be managed with MOVE acronym- standing for…?
M - monitor (cardiac, BP, pulse ox, ect.)
O - oxygen
V - venous access
E - ECG
Specifically for asthma, the OSHIT acronym can be used, it stands for:
O - oxygen S - salbutamol H - hydrocortisone I - Ipratropium bromide T - theophiline/magnesium
& MONITOR
Severity scale for asthma:
Moderate:
worsening symptoms
PEFR 50-75% best
Acute severe: PEFR 33-50% RR >25 HR >110 Unabble to speak in sentences
Life threatening: PEFR <92% silent chest cyanosis poor resp effort arrythmia exhaustion
Near fatal:
increased PaCO2 requiring ventilaiton
In a suspected chest infection what does a swinging fever suggest?
Indicative of a collection of pus outside of the pneumonia
I.e. empyema or para-pneumonic infection
CXR findings in pneumonia?
Walled off cavity lesion with fluid level
With every admission of asthma,what should be done?
Follow up within 30 days
Review of self-medication skills and inhaler programme
In an admission of asthma, if a severely unwell patient recovers to >75% PEFR what should you do?
Send patient home
What might you see in a person who is losing control of their asthma management?
Waking at night with wheeze, cough, chest pain
Increase use of bronchodilator therapy
Decreased effectiveness of bronchodilators
Missing work days
Change in exercise tolerance
If a patient comes in with an acute asthma attack, when can you discharge them home?
When they have been stable of their regular medication for 24hrs, prior to discharge
or if PEFR is >75% best
What advice should you give to a patient about how they should act if they suffer an asthma attack?
- Take inhaler (B2) immediately
- Sit down loosen clothing
- Take the inhaler every minute for 5 minutes.
- No improvement call 999
- Continue step 3 until ambulance arrives.
What is the pathological process that occurs in CF that allows for easy infection of the lungs?
CF results in permanent dilatation of the bronchioles, allowing for repeated infections of the airways
What signs would you find in a young adult with CF?
and in a neonate?
Finger clubbing; bilateral coarse crackles; cyanosis
Failure to thrive; meconium ileus; rectal prolapse.
Patients with COPD are prone to developing hypercapnia when they are on oxygen therapy, how would this present and how would you treat it?
Increasing confusion and tiredness/lethargy after being on oxygen therapy
Trial NIV (BiPAP) in these patients
A patient with lung tumours can secrete PTH, leading to hypercalaemia. What are the symptoms of primary hyperthyroidism?
‘Bones’ - pain and sometimes pathological # (ostitis fibrosa cystica)
‘Stones’ - renal stones
‘Groans’ - abdo pain from ulcers, nausea, indigestion and constipation
‘Psychic moans’ - lethagy, fatigue, depression
A patient presents with a likely lung cancer but she is hyponatraemic, what is going on?
The lung cancer is a small cell cancer which can cause SIADH leading to low sodium levels.
