Gen Med 2 Resp

Question 1

60 yr old man
• SOB
• Sudden onset
• PMH: COPD
• On symbicort & tiotropium
• PR: 110 bpm
• JVP: increased
• decreased BS, Scattered wheeze & creps (R)
• Peripheral oedema
• Sats: 80% (air)
• FBC: Hb 85, WCC 12, plt: 300

What is the likely diagnosis?

Answer 1

Pneumothorax

Sudden onset SOB with unilateral wheeze and reduced breath sounds

No cough

Hx of DVT (?)

Question 2

What is tiotropium and symbicort?

Answer 2

Tiotropium = M3 blocker
Symbicort = budesonide (glucocorticoid) and formoterol (beta 2 adrenergic agonist)

Question 3

How do you classify breathlessness?

Answer 3

Seconds
Mins/ Hrs
Days/ weeks

Question 4

What respiratory condition will occur in seconds?

Answer 4

• Pneumothorax
• PE
• FB (foreign body)

Question 5

What respiratory conditions occur in mins or hours?

Answer 5

• Airways (inflammation/obstruction)
• Chest infection (pus)
• Acute heart failure (fluid)

Question 6

What respiratory conditions occur in days or weeks?

Answer 6

• Above (chronic/not resolving)
• Interstitial lung disease
• Malignancy/ Large pleural effusion
• Neuromuscular
• Anaemia/ Thyrotoxicosis

Question 7

What is in the management plan for a large secondary (>2cm) pneumothorax?

Answer 7

Chest drain

LA and Analgesia

Question 8

How would you treat a small (<2cm) secondary pneumothorax?

Answer 8

Pleural Aspiration

LA and Analgesia

Question 9

How would you treat a primary pneumothorax?

Answer 9

<2cm Discharge w/ repeat CXR

>2cm Aspiration, chest drain if unsuccessful
LA and Analgesia

Question 10

What is a complication of a chest drain?

Answer 10

Re-expansion pulmonary oedema

Question 11

• 47 year old woman
• Acute SOB
• Pleuritic chest pain
• PMHx: DVT
• O2 Saturation: 78% (air)
• PR: 110 bpm
• BP: 120/80 mmHg
• increased JVP
• Vesicular BS

Answer 11

PE

ECG shows Right deviation with RBBB

Question 12

How do you find axis deviation?

Answer 12

Look at I, II, III
If one is overall more negative then there is an axis deviation

Look at aVL
If it is overall more positive then there is left axis deviation (neg is right axis deviation)

Question 13

What is the most appropriate first step in management of suspected PE?

Answer 13

LMWH
Warfarin when confirmed

Haemodynamically compromised- thrombolysis

Question 14

What might a CXR show in a PE?

Answer 14

Dark area of collapsed vessels (Westermarks sign)

Question 15

What is bullous lung disease?

Answer 15

Bullous lung disease is an entity characterized by the presence of bullae in one or both the lung fields, with normal intervening lung.

You see air fluid levels on the CXR

Clinical picture
COPD with chronic SOB, chest pain and cough
Reduced BS, hyper resonant

Question 16

• 50‐year‐old female
• progressive SOB
• dry cough
• clubbing
• FEV1/FVC ratio > 70%.

What is seen on the X ray with fibrosis?

Answer 16

Reticular shadowing (not fluffy like pulmonary oedema)

Question 17

What might cause fibrosis in the lungs?

Answer 17

– Idiopathic fibrosing alveolitis
– Connective tissue disease, RA
– Drugs
– Asbestosis (? ship builder)

Question 18

Night sweats, upper zone shadowing (nodes), weight loss with sputum and cough

Diagnosis?

Answer 18

Infection (TB)

Question 19

How do you present an CXR?

Answer 19

• This is a PA/AP CXR of
–Name & DOB
– Taken on (date)
– At (time)

With regards to the quality of the film:
• Rotation
• Inspiration
• Penetration

Question 20

How do you describe shadowing?

Answer 20

• Interstitial/alveolar shadowing (fluid, pus, blood)
• Reticulo‐nodular shadowing (fibrosis)
• Homogeneous shadowing (effusion)
• Masses/cavitations (infection, inflammation, malignancy)

Question 21

How do you look at lung fields?

Answer 21

• Compare L vs R upper/mid/lower zones
– alveolar/interstitial shadowing
– reticulonodular shadowing
– homogeneous shadowing

• Follow the periphery
– pneumothorax
– pleural thickness
– costophrenic angles
– diaphragm
– heart
– mediastinum