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6th Year Resp MJ > dpd > Flashcards

dpd Flashcards

1
Q

A 60 y/o ma presents w/ sudden onset SOB + no cough, sputum or haemoptysis. PMHx: COPD + DHx: symbicort & tiotropium. HR: 110 bpm. O/E: raised JVP, decreased breath sounds, scattered wheeze & creps (R), peripheral oedema + sats 80% on air. Ix: FBC: Hb 85, WCC 12, Plt 300. What is the most likely diagnosis?

  1. Pneumothorax
  2. PE
  3. Airway disease
  4. Pneumonia
  5. Pulmonary oedema
  6. Interstitial lung disease
  7. Pleural effusion
  8. Anaemia
  9. Thyrotoxicosis
  10. Nerve/muscle disease
A

Pneumothorax

  • sudden onset so you want to exclude PE or pneumothorax
  • no RFs for PE in hx
  • COPD Is a RF for secondary pneumothorax - bullous bursts
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2
Q

What are the risk factors for PE?

A 
Signs of DVT
Previous DVT/PE
Immobility
surgery
malignancy
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3
Q

what framework can you use to classify DDx of SOB

A

Onset: seconds, minutes/hours, days/weeks

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4
Q

Ddx for SOB that comes on in seconds

A

Pneumothorax
PE
Foreign Body
Anxiety

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5
Q

Ddx for SOB that comes on in mins/hours

A 
Airways (inflamm/obstr) eg asthma, COPD
Asthma, COPD
Chest inf (pus)
Acute HF (fluid)
Pulmonary haemorrhage (blood)
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6
Q

Ddx for SOB that comes on in days/weeks

A 
Any of Ddx for s/days if chronic/not resolving 
ILD (Pulm fibrosis)
Malignancy/large pleural effusion
NM
Anaemia/thyrotoxicosis
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7
Q

A 60 y/o ma presents w/ sudden onset SOB + no cough, sputum or haemoptysis. PMHx: COPD + DHx: symbicort & tiotropium. HR: 110 bpm. O/E: raised JVP, decreased breath sounds, scattered wheeze & creps (R), peripheral oedema + sats 80% on air. Ix: FBC: Hb 85, WCC 12, Plt 300. A diagnosis of a R pneumothorax is made and patient is started on oxygen. What is the next most appropriate step in his management?

  1. Chest drain insertion
  2. Chest USS
  3. CPAP
  4. Observation
  5. Pleural aspiration
A

Chest drain insertion

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8
Q

2 types of pneumothorax

A

primary - in pts who do not have lung idsease

secondary - in pts with lung disease eg COPD

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9
Q

what is the tx of primary pneumothorax

A

If < 2 cm, reassure + discharge, repeat CXR

If > 2 cm/SOB, aspiration. If fails: chest drain

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10
Q

what is the tx for a secondary pneumothorax

A

If < 2 cm, aspiration

If > 2 cm, chest drain in 2nd ICS + MCL using a 3-4 cm 16 French gauge needle

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11
Q

A 60 y/o ma presents w/ sudden onset SOB + no cough, sputum or haemoptysis. PMHx: COPD + DHx: symbicort & tiotropium. HR: 110 bpm. O/E: raised JVP, decreased breath sounds, scattered wheeze & creps (R), peripheral oedema + sats 80% on air. Ix: FBC: Hb 85, WCC 12, Plt 300. A diagnosis of a R pneumothorax is made and patient is started on oxygen. A chest drain is performed. What medication should you prescribe?

A

analgesia eg 2% lidocaine

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12
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 120/80 mmHg; raised JVP; vesicular BS. What is the most likely diagnosis?

A

PE

-acute onset + hx of DVT + raised JVP

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13
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 120/80 mmHg; raised JVP; vesicular BS. A diagnosis of PE is made. She is started on high flow oxygen and CXR does not show pneumothorax. What would her ECG show?

A

Sinus Tachy or S1Q3T3

potentially right axis deviation + RBBB (right heart strain)

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14
Q

what is a quick way to determine axis deviation on ECG

A
  1. Is lead I or lead II overall negative? If yes, then there is axis deviation
  2. Is aVL overall positive? If yes, Left axis deviation. If no, right axis deviation
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15
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 120/80 mmHg; raised JVP; vesicular BS. A diagnosis of PE is made. She is started on high flow oxygen and CXR does not show pneumothorax. What is the next most appropriate step of her management?

  1. LMWH
  2. BiPAP
  3. Warfarin
  4. Thrombolysis
  5. Furosemide
A

LMWH administered when PE is suspected. CTPA to confirm diagnosis and then warfarin started. However, LMWH must still be continued for a few days as warfarin has a paradoxical procoagulant effect (inhibits protein C&S)

OR DOAC but not an option

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16
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 90/60 mmHg; raised JVP; vesicular BS. A diagnosis of PE is made. She is started on high flow oxygen and CXR does not show pneumothorax. What is the next most appropriate step of her management?
1. LMWH

  1. BiPAP
  2. Warfarin
  3. Thrombolysis
  4. Furosemide
A

Thrombolysis

Patient is not haemodynamically stable

17
Q

what is the CXR sign seen in PE

A

Westermark sign = hypovolaemia leading to vessel collapse distal to PE
CXR shows slightly darker area + CTPA shows clot and no filling after clot

18
Q

what is FEV1

A

forced expiratory volume in 1s

19
Q

what is FVC

A

deep breath in until can’t inhale more + exhale until can’t anymore

20
Q

FEV1:FVC ratio> 70%

A

RESTRICTIVE lung dis eg fibrosis

21
Q

FEV1:FVC ratio< 70%

A

OBSTRUCTIVE lung dis eg COPD or asthma

22
Q

A 50 y/o female presents w/ progressive (chronic) SOB, dry cough, clubbing, FEV1/FVC ratio >70%. CXR shows reticular shadowing. What is the most likely diagnosis?

A

Pulmonary fibrosis due to FEV1/FVC ratio and clubbing w/ dry cough.

23
Q

does COPD cause clubbing

A

Remember COPD does not cause clubbing

24
Q

Ddx of restrictive lung conditions (pulm fibrosis)

A

-Idiopathic fibrosing alveolitis
-Connective tissue disease e.g. SLE, RA, Scleroderma
-Drugs e.g. methotrexate, nitrofurantoin
-Asbestosis (ship builders) = pulmonary fibrosis due to asbestos
N.B. this is different to asbestosis plaques which are due to asbestos exposure

25
Q

A 50y/o female presents w/ chronic SOB, sputum, no clubbing + FEV1/FVC ratio < 70%. Considering the most likely diagnosis, what would her CXR show?

A

Hyperinflated lungs (>7 anterior ribs)
Flattened diaphragm
-copd

26
Q

A pt presents with cough, sputum, weight loss and night sweats. Considering the most likely diagnosis, what would their CXR show?

A

Area of shadowing in L/R upper zone

-tb

27
Q

70 y/o man w/ SOB and keeps pigeons. Considering the most likely diagnosis, what would his CXR show?

A

Bilateral reticulonodular shadowing

-Extrinsic allergic alveolitis

28
Q

What does a homogenous white shadow on a CXR indicate? (CEF)

A

Collapse
Effusion
Fluid
(Look at trachea - Effusion pushes trachea away due to increased pressure; collapse pulls trachea towards)

29
Q

What do reticulonodular shadowing (lines + dots) indicate on a CXR?

A

Fibrosis e.g. allergic alveolitis

30
Q

What does fluffy alveolar shadowing (interstitial) indicate on CXR?

A

FLUID (pulmonary oedema) - bat wing appearance
PUS (pneumonia)
BLOOD (pulmonary haemorrhage)

31
Q

What does a mass/cavitation on a CXR indicate?

A

Infection e.g. TB
Inflammation e.g. sarcoidosis
Malignancy e.g. lymphoma

32
Q

What does a globular heart on CXR indicate?

A

pericardial EFFUSION

33
Q

bronchiectasis causes classify (5)

A

IDIOPATHIC
POST-INF: viral inf, mycobacterium or severe pneumonai
IMMUNE: primary immuen def, HIV
GENETIC: alpha 1 anti-trypsin, CF, PCD, CTD
POST-OBSTRUCTIVE: asthma, COPD, Cancer, FB

34
Q

pleural effusion examination findings

A

Stony dull to percussion
VR is reduced
Breath sounds are reduced
(sound travels poorly through fluids)

35
Q

in consolidation what happens to VR +. BS

A

sound travels WELL through SOLIDS

so in conSOLIDation - both VR+ BS are INCREASED

6th Year Resp MJ (2 decks)

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