Clinical handbook Flashcards
How many lobes does the
a) left lung have?
b) right lung have?
a) two
b) three
What might frothy white pink sputum indicate?
pulmonary oedema
What is the most common bacterial pneumonia?
pneumococcal
Symptoms of pneumococcal pneumonia
fever
pleurisy
herpes labalis
treat pneumococcal pneumonia
amoxicillin
Which type of pneumonia is bilateral cavitating bronchopneumonia?
staphylococcal
Name some complications of pneumonia
type 1 respiratory failure hypotension atrial fibrillation pleural effusion empyema lung abscess
clinical features of a lung abscess
swinging fever cough smelly sputum pleurisy haemoptysis malaise finger clubbing anaemia crepitations
What is the most important distinction between types of bronchial carcinoma?
small cell and non-small cell
Which division of bronchial carcinoma is not resectable and has a poor prognosis?
small cell
How does bronchial carcinoma present?
cough haemoptysis dyspnoea chest pain recurrent pneumonia lethargy weight loss
What are the signs of bronchical carcinoma?
cachexia anaemia clubbing hypertrophic pulmonary osteoarthropathy --> wrist pain supraclavicular or axillary nodes
What signs indicate mets in bronchial carcinoma?
bone tenderness hepatomegaly confusion fits focal CNS signs cerebellar signs proximal myopathy peripheral neuropathy
What is Horner’s syndrome?
when a pancoast tumour blocks the sympathetic chain causing
- Small pupil
- Ptosis (drooping eyelid)
- Enophthalmos (sunken eyes)
- Unilateral loss of sweating
What is Lambert-Eaten myasthenic syndrome?
caused by small cell lung cancer
presents with gait problems then eye symptoms
gait: hyporeflexia + weakness that improve after exercise
What sign of recurrent laryngeal nerve palsy can occur in lung cancer?
hoarse voice
Signs of bronchial carcinoma on CXR
peripheral nodule hilar enlargement consolidation lung collapse pleural effusion bone mets
treat peripheral non-small cell tumour with no mets
excision
treat bronchial obstruction
radiotherapy
What is the prognosis for non-small cell lung cancer?
50% survive 2 years if no spread
What is the prognosis for small cell lung cancer
a) with treatment?
b) without treatment?
a) 1-1.5 years
b) 3 months
Symptoms of asthma
intermittent dyspnoea
wheeze
cough
sputum
Signs of asthma
tachypnoea wheeze hyperinflated chest hyperresonant percussion dec. air entry
Signs of a severe asthma attack
cannot finish sentence
pulse > 110bpm
resp rate>25bpm
low PEF (33-50% predicted)
What 3 factors contribute to airway narrowing in asthma?
bronchial muscle contraction
mucosal inflammation
increased mucus production
What causes mucosal inflammation in asthma?
mast cell and basophil degranulation cause inflammatory mediators to be released
Steps in asthma treatment
- SABA as req.
- SABA + low-dose ICS
- SABA + low-dose ICS + LRTA
- SABA + low-dose ICS + LABA (+/- LRTA if response)
- SABA + MART (ICS + LABA)
What is the most effective preventer drug for adults and older children with asthma?
inhaled corticosteroid
What do B2 adrenoceptor agonists do?
relax bronchial smooth muscle, increase cAMP
Give side effects of B2 adrenoceptor agonists
tachyarrythmia
hypokalaemia
tremor
anxiety
Give an example of
a) SABA
b) LABA
c) ICS
d) anticholinergic
e) leukotriene receptor antagonist
a) salbutamol
b) salmeterol
c) beclometasone
d) ipratropium
e) montelukast
What does theophylline do?
inhibits phosphodiesterase to increase cAMP and reduce bronchoconstriction
SE of theophylline
low therapeutic window so can be toxic
GI upset
arrythmia
Why are anticholinergics used in asthma?
decrease muscle spasm
What characterises COPD?
irreversible airway obstruction
What 2 parts does COPD have?
chronic bronchitis
emphysema
What is chronic bronchitis?
cough, sputum production onmost days for 3 months of 2 years
What is emphysema?
enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls
Describe a pink puffer
increased alveolar ventilation
near normal PaO2
normal/low PaCO2
breathless but not cyanosed
What might a pink puffer progress to?
type 1 resp failure
Describe a blue bloater
decreased alveolar ventilation
low PaO2
high PaCO2
cyanosed but not breathless
What might a blue bloater progress to?
cor pulmonale
Symptoms of COPD
cough
sputum
dyspnoea
wheeze
Signs of COPD
tachypnoea accessory muscle use hyperinflated reduced cricosternal distance reduced expansion resonant or hyperresonant percussion quiet breath sounds cyanosis
Signs of COPD on CXR
hyperinflation
flat hemidiaphragm
large central pulmonary artery
decreased peripheral vascular markings
What might an ECG of someone with COPD show?
right atrial and ventricular hypertrophy –> cor pulmonale
What PaO2 level indicates respiratory failure?
less than 8kPa
What differentiates between the two types of respiratory failure?
PaCO2 level
What is the PaCO2 in type 1 respiratory failure?
normal or low
What causes type 1 respiratory failure?
V/Q mismatvh
eg pnuemonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, ARDS
What is the PaCO2 in type 2 respiratory failure?
high (>6 kPa)
What causes type 2 respiratory failure?
alveolar hypoventilation
due to resp disease (asthma, COPD, fibrosis, obstructive sleep apnoea), reduced respiratory drive, neuromuscular disease, thoracic wall disease
clinical features of hypoxia
dyspnoea restlessness agitation confusion central cyanosis
clinical features of hypercapnia
headache peripheral vasodilation tachycardia bounding pulse tremor papilloedema confusion drowsiness coma
In which type of resp failure does oxygen need to be given with care?
type 2
Where do pulmonary embolisms usually arise from?
venous thrombosis in the pelvis or legs
Symptoms of PE
acute breathlessness pleuritic chest pain haemoptysis dizziness syncope
Signs of PE
pyrexia cyanosis tachypnoea tachycardia hypotension raised JVP pleural rub pleural effusion
In which patients should D-dimer test be carried out?
patient doesnt have high probability of PE
Symptoms of pneumothorax
suddent onset dyspnoea and pleuritic chest pain
Signs of pneumothorax
reduced expansion
hyperresonant
red breath sounds
What sign shows a tension pneumothorax?
trachea deviates away from affected side
Why might a spontaneous pneumothorax occur in a young, thin man?
rupture of subpleural bulla
manage tension pneumothorax
insert large bore needle with syringe with 0.9% saline into 2nd intercostal space midclavicular line
How can pleural effusions be divided?
by protein content
low = transudates
high = exudates
What can cause a transudate pleural effusion?
- increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
- hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
What can cause an exudative pleural effusion?
increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy
Signs of a pleural effusion
decreased expansion
stony dull percussion
diminished breath sounds
What is sarcoidosis?
a multisystem granulomatoud disorder of unknown cause
How does acute sarcoidosis present?
erythema nodosum +/- polyarthralgia
What sign is seen on CXR in patients with sarcoidosis?
bilateral hilar lymphadenopathy
+/- infiltrates, fibrosis
Give some pulmonary symptoms of sarcoidosis
dry cough
progressive dyspnoea
reduced exercise tolerance
chest pain
Give some non-pulmonary signs of sarcoidosis
lymphadenopathy
hepatomegaly
splenomegaly
uveitis
What does tissue biopsy of sarcoidosis show?
non-caseating granuloma
How is sarcoidosis treated?
acute: rest + NSAIDs
mild: leave alone
mod: steroid therapy
What is interstitial lung disease?
number of conditions characterised by chronic inflammation and/or progressive interstitial fibrosis of lung parenchyma
give some clinical features of interstitial lung disease
dyspnoea on exertion
non-productive paroxysmal cough
abnormal breath sounds
restrictive spirometry
give pathological features of interstitial lung disease
fibrosis
remodelling of interstitium
chronic inflammation
hyperplasia of type 2 pneumocytes
How is interstitial lung disease categorised?
- known cause eg occupational
- part of systemic disease eg. sarcoidosis
- idiopathic
What is extrinsic allergic alveolitis?
a type of interstitial lung disease caused by inhalation of allergens causes a hypersensitivity reaction
What characterises
a) the acute stage
b) the chronic stage
of extrinsic allergic alveolitis?
a) infiltration of acute inflammatory cells
b) granulomas form and obliterative bronchiolitis occurs
Give some causes of allergic alveolitis & the relevant name
bird dropping proteins –> bird fancier’s lung
aspergillus –> malt worker’s lung
fungal spores –> farmer’s lung
Symptoms of acute extrinsic allergic alveolitis
fever rigors myalgia dry cough dyspnoea crackles
Symptoms of chronic extrinsic allergic alveolitis
increasing dyspnoea weight loss exertional dyspnoea type 1 resp failure cor pulmonale
What blood cell characterises acute extrinsic allergic alveolitis
neutrophils
manage acute extrinsic allergic alveolitis
remove cause
give o2
PO prednisolone
What causes fibrotic shadowing on a CXR in the
a) upper lung?
b) mid lung?
c) lower lung?
a) TB, extrinsic allergicalveolitis, ank spond, radio
b) sarcoidosis
c) idiopathic pulmonary fibrosis, asbestosis
What is the most common cause of interstitial lung disease?
idiopathic pulmonary fibrosis
Symptoms of idiopathic pulmonary fibrosis
dry cough exertional dyspnoea malaise weight loss arthralgia
Signs of idiopathic pulmonary fibrosis
cyanosis
finger clubbing
fine-end inspiratory creps
What does CXR show in idiopathic pulmonary fibrosis?
dec lung volume bilateral lower zone shadows honeycomb lung (advanced disease)
In idiopathic pulmonary fibrosis is
a) increased lymphocytes
b) increased eosinophils
indicative of a good or poor prognosis?
a) good
b) poor
What is the prognosis of idiopathic pulmonary fibrosis?
50% 5 year survival
Describe coal worker’s pneumoconiosis
inhaled coal dust is ingested by macrophages which die and release their enzymes causing fibrosis
What are the symptoms of coal worker’s pneumoconiosis?
asymptomatic
What does coal worker’s pneumoconiosis progress to?
progressive massive fibrosis
What characterises progressive massive fibrosis?
dyspnoea
fibrosis
cor pulmonale
What can exposure to asbestos cause?
pleural plaques
risk of bronchial adenocarcinoma and mesothelioma
Clinical features of mesothelioma
chest pain dyspnoea weight loss finger clubbing recurrent pleural effusion
What does mesothelioma look like on CXR?
thickened pleura pleural effusion (bloody)
Manage mesothelioma
pemetrexed and cisplatin
What is obstructive sleep apnoea?
intermittent closure/collapse of the pharyngeal airways during sleep
Describe the typical sleep apnoea patient
obese middle aged man presenting with snoring or daytime somnolence
What are the complications of sleep apnoea?
hypertension
pulmonary hypertension
type 2 respiratory failure
What can diagnose sleep apnoea?
polysomnography
Management of sleep apnoea
weight loss
reduce alcohol and caffeine
CPAP
surgery to relieve pharyngeal obstruction
What is cor pulmonale?
right heart failure caused by chronic pulmonary arterial hypertension
Name some causes of cor pulmonale
- chronic lung disease eg COPD, fibrosis
- pulmonary vascular disorders eg pulmonary emboli, sickle cell
- thoracic cage abnormality
- neuromuscular disease eg myasthenia gravis, MND
- hypoventilation
clinical features of cor pulmonale
dyspnoea
fatigue
syncope
signs of cor pulmonale
cyanosis
tachycardia
raised JVP
pan-systolic murmur
What does cor pulmonale show on a CXR?
enlarged right heart
prominent pulmonary arteries
Manage cor pulmonale
treat cause
treat resp failure with low O2
treat cardiac failure with diuretics eg furosemide
venesect if high haematocrit
What is the prognosis for cor pulmonale?
poor
50% die in 5 years
How is TB treated?
2 months of 4: isoniazid, rifampicin, ethambutol, pyrazinamide
4 months of 2: isoniazid and rifampicin
Which TB drug causes optic neuritis?
ethambutol
Which TB drug causes peripheral neuropathy?
isoniazide
Which TB drug causes body fluids to turn orange?
rifampicin
