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Year 3 > Cough > Flashcards

Cough Flashcards

bronchiectasis, pneumonia, TB, lung cancer, asbestosis

1
Q

What is bronchiectasis?

A

chronic condition that causes increased mucus production and permanent dilation of the bronchi/bronchioles secondary to an underlying cause

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2
Q

Which organisms commonly cause bronchiectasis?

A

H influenzae
S pneumoniae
S aureus
P aeruginosa

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3
Q

What are some common congenital causes of bronchiectasis?

A 
CONGENITAL
Cystic fibrosis
Primary ciliary dyskinesia
Alpha 1 anti-trypsin deficiency
Young's Syndrome
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4
Q

What are the symptoms of bronchiectasis?

A 
Chronic cough (+ copious green sputum)
SOB
Haemoptysis
Fever
Weight loss
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5
Q

What are the signs of bronchiectasis?

A

Basal crepitations on auscultation
Squeaks/pops on inspiration
Clubbing

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6
Q

What investigations would you do on a Pt with bronchiectasis?

A

Imaging:

  • CXR (first line)
  • High res CT (gold standard/most appropriate)

Bloods + cultures

  • ABG
  • FBC (raised WCC
  • Sputum culture
  • Pulmonary function (dec FEV1, inc RV/TLC)

Underlying cause:

  • Serum alpha-1 antitrypsin levels
  • Sweat NaCl concentration and genetic testing for CFTR
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7
Q

What will you see in a CXR and CT in bronchiectasis?

A

CXR- dilated thickened walls

CT- signet ring sign

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8
Q

What is the conservative management of a Pt with bronchiectasis?

A

IRREVERSABLE- SUPPORTIVE MANAGEMENT
Exercise and nutrition
Vaccinations

Airway clearance therapy:

  • Chest physiotherapy (postural drainage/percussion)
  • High frequency oscillation devices
  • Nebulised hypertonic saline (hyperosmolar agent)
  • Inhaled bronchodilator (salbutamol)
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9
Q

What is the prognosis of a Pt with bronchiectasis?

A

Irreversible

Depends on the severity and recurrence of exacerbations

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10
Q

What are the complications of a Pt with bronchiectasis?

A

Haemoptysis
Recurrent infections
Respiratory failure
Cor pulmonale (RHF)

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11
Q

What is pneumonia?

A

Inflammation of the lung parenchyma caused by bacteria, virus, or fungi (LRTI)

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12
Q

What are the three types of pneumonia?

A

Community acquired pneumonia
Hospital acquired pneumonia
Aspiration pneumonia

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13
Q

What are the common causes of CAP?

A

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

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14
Q

What are the common causes of HAP?

A

Pseudomonas aeruginosa
Escherichia coli
Klebsiella pneumoniae
Staph aureus

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15
Q

What are the common causes of atypical pneumonias?

A 
Legionalla pneumophila
Chlamydia psittaci
Mycoplasma pneumoniae
Chlamydia pneumoniae
Coxiella burnetti (Q fever)

‘legions of psittaci MCQ’

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16
Q

What are the mechanisms of entries for pneumonia?

A

Inhalation (viral/atypical)
Aspiration of URT secretions
Haematogenous from local infx (endocarditis)
Direct extension from local foci (TB via lymphatics)

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17
Q

What are the symptoms of pneumonia?

A 
Productive cough with coloured sputum
Fever
SOB (dyspnoea)
Chest pain (pleuritic)
Confusion
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18
Q

What are the signs of pneumonia on inspection

A 
Fever
Confusion
Respiratory distress- use of accessory muscles
Cyanosis (peripheral/central) 
Raised HR/RR
reduced chest expansion
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19
Q

What are the main investigations for pneumonia?

A 
CXR- area of consolidation
FBC- raised WCC
ABG
Sputum MC+S
Pleural fluid MCS (via thoracentesis)
Blood cultures- if severe
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20
Q

What is the scoring system for pneumonias?

A

CURB-65

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21
Q

What is CURB-65?

A 
Confusion
Urea >7
Resp rate >=30
Blood pressure (S<90, D<=60)
Age >=65
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22
Q

What should you do for a Pt with a CURB-65 of 0-1?

A

Treat at home (GP)

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23
Q

What should you do for a Pt with a CURB-65 of 2?

A

Consider hospital treatment (A+E, short stay)

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24
Q

What should you do for a Pt with a CURB-65 of 3+?

A

Severe pneumonia, admission + consider ITU

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25
Q

What should you after giving a Pt with pneumonia antibiotics?

A

Repeat CXR in 6 weeks

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26
Q

What is the prognosis of a CURB-65 of 0-1?

A

30 day mortality <1%

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27
Q

What is the prognosis of a CURB-65 of 2?

A

30 day mortality 5-15%

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28
Q

What is the prognosis of a CURB-65 of 3+?

A

30 day mortality 20-50%

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29
Q

What are the complications of pneumonia?

A

Septic shock
C difficile from ABx use
HF/resp failure in elderly

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30
Q

How is Legionella transmitted?

A

Via aqueous environments such as air conditioners and contaminated water supplies

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31
Q

What is the difference between Legionnaire’s disease and Pontiac fever?

A

LD- Legionella pneumonia

PF- non-pneumatic Legionella

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32
Q

What are the symptoms of a Legionella pneumonia?

A

Prodromal flu-like symptoms (fever, malaise, myalgia)
Dry cough, can become productive
Nausea, DnV

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33
Q

Why are atypical pneumonias different from typical pneumonias?

A

They cannot be detected by Gram stains and cannot but cultured by standard methods

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34
Q

What additional investigations would you do for a Legionella pneumonia?

A

Urinary antigen detection
U+E- hyponatraemia
LFTs- deranged

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35
Q

What is the treatment for a Legionella pneumonia?

A

IV fluoroquinolones OR macrolides

eg. ciprofloxacin OR clarithromycin

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36
Q

What are the characteristics of a Pneumocystis jirovecii infection?

A

Opportunistic fungal infx

AIDS defining illness

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37
Q

What is the treatment for a Pneumocystis jirovecii infection?

A

high dose Co-trimoxazole

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38
Q

What are the characteristics of a Pseudomonas aeruginosa infection?

A

Seen in Pts with bronchiectasis/CF

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39
Q

What is the treatment for a Pseudomonas aeruginosa infection?

A

Treat with piptazobactam (piperacillin + tazobactam)

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40
Q

What is the presentation of Mycoplasma pneumonia?

A

Insidious onset
Persistent cough
Low grade fever
From a close community setting

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41
Q

What is seen in the blood film of a Mycoplasma pneumonia infection?

A

Red cell/cold agglutinins

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42
Q

What is the treatment for a Mycoplasma pneumonia infection?

A

Erythromycin/clarithromycin

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43
Q

What type of Pt often presents with a Staph aureus infection?

A

IVDU

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44
Q

What is seen in a CXR of a Pt with a Staph aureus infection?

A

Patchy consolidation

Forms abscesses

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45
Q

What is the treatment for a Staph aureus infection?

A

Flucoxacillin

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46
Q

What is the treatment for an MRSA infection?

A

Vancomycin

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47
Q

What is the modality of transport for TB?

A

Aerosol droplets

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48
Q

What are the two conditions required for a Pt to present with TB?

A

Quite hard to catch TB- need prolonged exposure and:

  1. Infection of Mycobacterium tuberculosis
  2. Inadequate immune system
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49
Q

What are the risk factors for TB?

A

Recent travel to South Asians/India/Bangladesh, Latin America, or Africa
Immunosuppression (HIV)
Malnutrition
Alcoholism

50
Q

What is the pathophysiology of TB?

A

Droplets enter the lungs
Macrophages + T lymphocytes contain the infection, forming a granuloma
In weak immune systems, the infection escapes

51
Q

What are the symptoms of TB?

A 
Cough for 2-3 weeks
From dry to wet (green sputum)
FLAWS especially S
Haemoptysis in <10%
SOB
Lymphadenopathy
52
Q

What are the signs of TB?

A

Fever
Crackles
Bronchial breathing
Erythema nodosum

53
Q

What are the investigations you should do for TB?

A
  • Basic obs + bloods
  • CXR
  • Sputum MCS (x3 samples)
  • IGRA = interferon gamma release assay
  • Lymph node biopsy
54
Q

What are the 3 buzzwords for a TB sputum smear?

A
  1. Acid fast bacilli- property of TB
  2. Ziehl-Neelson staining (type of stain for mycobacterium)
  3. Lowenstein-Jensen agar (used to culture mycobacterium)
55
Q

What are the categories of lung cancer?

A

Small cell (20%)

Non-small cell (80%)

  • Adenocarcinoma (45% of NSCLC, peripheral in lungs)
  • Squamous cell carcinoma (25-30%, later mets)
  • Large cell carcinoma (10%, central)

Metastases

Mesothelioma

56
Q

What are the risk factors for lung cancer?

A

Smoking
Exposure to tobacco smoke, radon gas, asbestos
COPD

57
Q

Facts about lung cancer epidemiology

A

Most common cause of cancer mortality worldwide

3rd most common cancer in Europe

58
Q

What are the characteristics of small cell carcinomas?

A

Strongest association with smoking
Arise in central lung
Rapid growth, highly malignant
May secrete ectopic hormones (ATCH/ADH)

59
Q

What are the characteristics of adenocarcinomas?

A

Most common lung cancer in non-smokers
Most common lung cancer in females
Arise in peripheral lung
Most have pleural involvement

60
Q

What are the characteristics of squamous cell carcinomas?

A

Most common lung cancer in male smokers
Strong association with smoking
Arise in central lung
Can produce PTHrP

61
Q

What are the characteristics of large cell carcinomas?

A

Can arise centrally or peripheral

Poor prognosis

62
Q

What are the symptoms of a Pt with lung cancer?

A

FLAWS
SOB
Cough
Haemoptysis

63
Q

What signs can you find in a Pt with lung cancer?

A 
Horner's syndrome
Cachexia
Anaemia
Clubbing
Paraneoplastic syndromes
Wheeze, crackles, dull percussion, reduced breath sounds
64
Q

What investigations would you do on a Pt with lung cancer?

A 
Obs
CXR
CT
Sputum cytology (assessment of lung secretions)
Bronchoscopy
Biopsy (for definitive diagnosis)
65
Q

What would you see in a CXR of a SCLC?

A

Central mass
Hilar lymphadenopathy
Pleural effusion

66
Q

What would you see in a CXR of a NSCLC?

A

Single/multinodular nodes
Pleural effusion
Lung collapse
Mediastinal/hilar fullness

67
Q

What is a mesothelioma?

A

An aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis

68
Q

Which environmental exposure puts people at risk of developing a mesothelioma?

69
Q

What 2 conditions can be caused by asbestos exposure?

A

Asbestosis

Mesothelioma

70
Q

What is asbestosis?

A

Diffuse interstitial fibrosis

Due to inhalation of asbestos fibres

71
Q

What is the difference between asbestosis and asbestos-induced mesothelioma?

A

Asbestosis- asbestos fibres deposited in the alveoli

Mesothelioma- asbestos fibres deposited in the lining of the lungs

72
Q

Which of the two (asbestosis and asbestos-induced mesothelioma) has a stronger correlation with smoking?

A

Asbestosis

73
Q

What are the risk factors for a mesothelioma?

A

Asbestos exposure (shipyard/construction workers)

74
Q

What are the symptoms and signs for a mesothelioma?

A

Dry cough
SOB
Muffled breath on auscultation (due to pl effusion)

75
Q

What are the investigations for a mesothelioma?

76
Q

What findings would you see in a CXR/CT of a Pt with mesothelioma?

A

Thickened pleural plaques
Fibrosis
Honeycomb appearance

77
Q

25F presents to A&E with 2/7 Hx of productive cough, SOB and fever. The cough is worse at night. She has brought up green mucus 2/7. O/E you hear crackles throughout. Her PMHx is cystic fibrosis at birth and has had similar symptoms in the past.
What is the most likely diagnosis?

A. Asthma
B. Pneumonia
C. Chronic sinusitis
D. Bronchiectasis

A

D. Bronchiectasis

Resp symptoms, mucus, Hx of CF
All leads to bronchiectasis being the most likely.

78
Q

25F presents to A&E with 2/7 Hx of productive cough, SOB and fever. The cough is worse at night. She has brought up green mucus 2/7. O/E you hear crackles throughout. Her PMHx is cystic fibrosis at birth and has had similar symptoms in the past.
What is the first line investigation for this patient?

A. Bloods (FBC, CRP)
B. CXR
C. CT
D. Pulmonary function

A

B. CXR

Everyone with these symptoms should get a CXR as a first line investigation. CT is the gold standard but only used when you have a high suspicion of bronchiectasis.

79
Q

50M smoker with diabetes + HTN presents to A&E with 1/7 confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHg, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base. His urea is 5 mmol/L.
What is the most likely causative organism in this case?

A. Staphylococcus aureus
B. Mycoplasma pneumoniae
C. Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Legionella pneumophila
A

C. Streptococcus pneumoniae

80
Q

50M smoker with diabetes + HTN presents to A&E with 1/7 confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHg, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base. His urea is 5 mmol/L.
How should we treat this patient?

A. Admit and give IV co-amoxiclav + macrolide
B. Admit and give oral amoxicillin
C. Admit for observations
D. Give him a smoke cessation leaflet
E. Send home with oral amoxicillin and advise to return if he becomes severely unwell

A

E. Send home with oral amoxicillin and advise to return if he becomes severely unwell

His CURB-65 score is only 1, due to the confusion.

81
Q

General differentials for a productive cough

A

ACUTE

  • pneumonia
  • TB

CHRONIC

  • Lung cancer
  • Bronchiectasis
  • Cystic fibrosis

MIXED

  • Heart failure
  • COPD
82
Q

What is the most common bacterial cause of community-acquired pneumonia (CAP)?

A

Streptococcus pneumoniae

83
Q

Which atypical organism is associated with faulty air conditioning systems?

A

Legionella

84
Q

What scoring system is used to assess CAP severity?

85
Q

What non-invasive test(s) can be used to identify the causative organism

A

Sputum culture

also urinary antigen testing – atypicals

86
Q

What organisms are found in aspiration pneumonia?

A

anaerobes from gut flora

87
Q

Which pathogen causes atypical pneumonia in bird owners?

A

Chlamydia psittaci

88
Q

Which pneumonia may be present in alcoholics?

A

Klebsiella

89
Q

Which pneumonia causes hyponatraemia + abnormal LFTs?

A

Legionella pneumophilia

90
Q

Which HAP causes cavitating lesions on CXR?

A

S. Aureus

Klebsiella

91
Q

Which pneumonia is associated with transverse myelitis?

A

Mycoplasma pneumonia

Causes inflammation of spinal cord

92
Q

green sputum is a sign of what?

A

bacterial pneumonia

93
Q

What are the signs of pneumonia on percussion/auscultation?

A

Dull to percussion over area of consolidation
Basal coarse crepitations
Bronchial breathing (harsh, loud, high pitched)
Increased vocal resonance

94
Q

Signs/symptoms of atypical pneumonia

A
  • Dry cough
  • Headache
  • Diarrhoea
  • Myalgia
  • Hepatitis
95
Q

A 35 year old man presents to his GP with shortness of breath and a dry cough. Upon further questioning, he admits to generalised muscle aches and a fever. He suffers from eczema and takes potent steroid medications. The patient lives at home with his dog and pet parrots.

What is the most likely causative organism?

A Streptococcus pneumoniae
B Chlamydia psittaci
C Mycobacterium tuberculosis
D Haemophilus influenzae
E Legionella pneumophila
A

Chlamydia psittaci

Dry cough and muscle aches suggest atypical organism

Parrots are a risk factor for chlamydia psittaci (usually doesn’t cause infection but this patient is immunocompromised due to the steroids)

96
Q

what would an ABG show in pneumonia?

A

Type 1 respiratory failure

low oxygen, normal CO2

97
Q

2 types of pneumonia on CXR

A
  1. lobar pneumonia (strep pneumoniae)

2. bronchopneumonia (patchy, heterogenous consolidation in numerous zones)

98
Q

What causes air bronchograms?

A

BRONCHOPNEUMONIA

bronchi filled with air, and surrounded by alveoli that are filled with pus (i.e. consolidation)

99
Q

Which antibiotics would you use to treat pseudomonas?

A

Tazocin + gentamicin

100
Q

Which antibiotics would you use to treat CAP?

A

amoxicillin (co-amoxiclav if sevre)

101
Q

Which antibiotics would you use to treat atypical pneumonia infections?

A

Clarithromycin

102
Q

Which antibiotics would you use to treat aspiration pneumonia?

A

Metronidazole

103
Q

Pneumonia is most commonly treated with which to Abx?

A

Amoxicillin + clarithromycin

104
Q

symptoms of lung abscess as complication of pneumonia

A

Swinging fevers
Persistent pneumonia
Foul-smelling sputum

105
Q

Complications of pneumonia

A

Pleural effusion
Lung abscess (often Staph aureus)
Empyema (puss in pleural cavity)
Sepsis

106
Q

Define TB

A

Infection by Mycobacterium tuberculosis, which causes multi-systemic disease

107
Q

Explain the progression of TB disease

A

Primary: initial infection (often asymptomatic, can be pulmonary)

Latent: asymptomatic infection

Post-primary: reactivation usually when immunocompromised (severe symptoms)- may present decades after primary infection

If severe disease –> miliary = lymphohaematogenous dissemination of TB

108
Q

State some extra-pulmonary manifestations of TB

A
  • meningitis
  • Erythema nodosum
  • clubbing
  • peritonitis, ascites
  • constrictive pericarditis, effusion
  • normocytic anaemia
  • Pott’s disease
  • epidydimo-orchitis, infertility
  • renal failure
  • Addison’s disease
109
Q

What would you see on lymph node biopsy in TB

A

caseating granulomas

110
Q

What is the Mantoux test?

A

TST injects purified protein derivative intradermally into skin.
If you have TB, you will form a larger radius of induration due to T-cell activity

Can’t distinguish between active and latent TB

111
Q

What would you see on CXR in a person with TB?

A
  • Consolidation (patchy/heterogenous)
  • Bi-hilar lymphadenopathy
  • Upper lobe scarring- typically affects upper lobes
  • Cavitating lesions
  • Pleural effusions- like any pneumonia
  • Nodular shadowing in miliary (severe) TB
112
Q

A 42 year old woman presents to A&E with cough, haemoptysis and a fever. She has had worsening shortness of breath and has been losing weight unintentionally after returning from her holiday to Bangladesh.
SaO2 = 91%
RR = 22
HR = 99

What is the next best step in her management?

A Oxygen, 2L via nasal cannula
B Rifampicin, isoniazid, pyrazinamide and ethambutol
C Amoxicillin and clarithromycin
D Oxygen, 15L via non-rebreather mask

A

Oxygen, 15L via non-rebreather mask

Sats are low so treat her low oxygen first before treating the TB itself

Best way to reach target sats of 94-98% is with high flow oxygen (when she has reached her target sats, she can use a nasal cannula to keep her topped up on oxygen)

This is the ABCDE approach for acute conditions

113
Q

acquired causes of bronchiectasis

A

Childhood/recurrent/persistent viral infx:

  • Pneumonia
  • TB
  • Measles
  • Pertussis
  • Aspergillus fumigatus

Lung cancer

114
Q

triad of Primary ciliary dyskinesia

A

Bronchiectasis
Sinusitis
Situs inversus (organs on wrong side)

115
Q

What might discern pneumonia from bronchiectasis?

A

bronchiectasis = copious, large volumes of sputum

116
Q

4 causes of respiratory clubbing (BILT)

A

Bronchiectasis
IPF
Lung cancer
TB

117
Q

Gold standard test for bronchiectasis. What does this show?

A

HR-CT

classic feature = signet ring sign

118
Q

What is the pharmacological management of a Pt with bronchiectasis?

A 
IV ABx (if acute infection)
Oral ABx (prophylactic)(e.g. azithromycin)
119
Q

What might differentiate bronchiectasis from COPD?

A

presence of clubbing

120
Q

most common lung cancer in non-smokers + females

A

adenocarcinoma

121
Q

which lung cancer has the strongest association with smoking?

A

small cell/ non-small cell squamous

Year 3 (38 decks)

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