General adult internal med

Question 1

bronchodilator responsiveness defn

[NEJM resp medicine today Apr 2024]

Answer 1

10+ % increased FEV1 or FVC
within 10-15 mins rapid acting bronchodilator

Question 2

asthma vs copd for bronchodilator responsiveness

Answer 2

No difference in large cohort study

Short-acting bronchodilator respons does not predict response to LONG-acting B-D

Question 3

resp pathogens causing CAP

name at least 3 in:
gram pos
gram neg
atypical

Answer 3

Gram pos:
- Strep pneumo
- MSSA
- Strep pyogenes
- other strep

Gram neg
- H influenzae
- Moraxella catarrhalis
- ENTERO-bacteriaceae (Klebsiella pneumoniae, E coli)

Atypical
- Legionella pneumophila
- Mycoplasma
- Chlamydophila
- Q fever

Question 4

how to bacteria cause CAP

Answer 4

microaspirations esp during sleep

inhalation (eg of particles)

Question 5

why are ‘typical’ and ‘atypical’ terms not encouraged when describing pneumonia

Answer 5

clinical exam and/or xr are NOT sens or spec for determining cause

…but they say later in article to consider micro testing if clinical features consistent…

Question 6

ddx for non-resolving pneumonia

Answer 6

• complication eg empyema
• underlying bronchogenic carcinoma (with airway obstruction)
• non-covered organism (eg TB)
• inflammatory pneumonia (eg vasculitis, organising pneumonia)

Question 7

amoxy vs macrolide in CAP

Answer 7

strep pneumo - increasingly resistant to macrolides, so use amoxy

for atypicals, macrolide effective, and almost as common as typicals

still just use amoxy

Question 8

CAP in older adults is associated with what

Answer 8

CVD. check lipids, BP, etc

Question 9

which CXR get 6 week follow up in pneumonia

Answer 9

those that had abnormalities. for ?ca.

if abnormal or persisting, refer

Question 10

asthma rx safe to use in pregnancy?

Answer 10

pretty much all of them
salbutamol - A
Ipra - B1
Salmeterol - B3 (but benefits > risks)

risk of not -> preterm, LBW, congenital malformations

Question 11

public health factors that have contributed to reduction in bronchiectasis prevalence

Answer 11

childhood vaccines
improved living conditions
abx

…still common in underserved & migrant communities

Question 12

pathophys of bronchiectasis

Answer 12

infection/inflammation –> neuts, macroph, lymps attacking elastin and lung structures -> dilation of bronchi

mucosa + muscular walls replaced by scarring and oedema, weaker cartilage, and cilial clearance weakened

self perpetuating cycle: recurrent infection, mucus, colonisation airway damage

Question 13

screening tests for cause of non-CF bronchiectasis

Answer 13

FBC, immunoglob levels (M, A, G), Aspergillus serology, Aspergillus specific IgE testing

Consider
- HIV, HTLV1
- Vit D (correlates disease severity)
- alpha-1 anti-trypsin
- autoimmune serology (ACCP, RF, ANA, ENA, ANCA)

If young + upperlobe predominant disease, sweat testing

Question 14

triad sx bronchiectasis

Answer 14

SOB
sputum
cough

also includes: haemoptysis, chest pain, wheeze, indigestions, recurrent chest infx

Question 15

% idiopathic bronchiectasis

Answer 15

~ 50%

but probably they have some underlying immune defect we can’t test

Question 16

why send sputum mcs in bronchiect

Answer 16

check colonisers. includes M avium and M abscessus - need 3 for these.

further ix is fungal + mycobacterial culture

can do yearly

Question 17

most common PFT pattern in bronchiect

Answer 17

obstructive > 50%

can help if concurrent bronchodilator/COPD/asthma present.

do at baseline, don’t need to rpt yrly unless specialist OPD

Question 18

what specialist tests can be considered for bronchiect

Answer 18

bronchscopy - sputum samples, check for tumours/other endobronchial obstruction, opportunisitic infections in a pt who can’t cough up

extended PFTs, other genetic disorder testing (sweat tests, ciliary dyskinesia)