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)

Question 19

CPPD stands for?

Answer 19

calcium pyro phosphate disease

Question 20

when to suspect CPPD - over what age?

Answer 20

> 55 yrs PLUS syndromes

Question 21

when to suspect CPPD - what syndromes in > 55 yrs

Answer 21

1. sub/acute arthritis attacks, esp KNEE
2. arthritis like RA or OA, but atypical features
3. CPPD on XR (chondrocalcinosis, etc)
4. severe acute or recurrent axial neck pain, or neck/shoulder girdle stiffness
   hence ddx PMR

Question 22

how to dx CPPD

Answer 22

hard -

the calcium crystals on joint aspirate if you can

DECT = dual energy CT

USS if you can

XR - chrondrocalcinosis.
like to XR both knees, pelvix AP, wrists

Question 23

potential triggers for CPPD

Answer 23

trauma
surgery
severe medical illness

Question 24

how does CPPD differ in CF from gout

Answer 24

tends to affect knees & wrists more

lasts longer if untreated, 1-3 weeks (vs 1-2)

tends to be less fulminant in onset (gout max pain in 12 hrs, vs slower onset)

Question 25

CPPD treatment

Answer 25

hard

similar to gout, but doesn’t respond as well
= colchicine, nsaids, steroids

Question 26

does obesity modify efficacy of DOACs?

Answer 26

pooled analysis -> no

Question 27

natural history of subclinical hypothyroidism in older adults (>65 yrs)

Answer 27

50% resolve spontan in 1-2 yrs of monitoring

Question 28

post-concussion recommendations in children and adolescents

Answer 28

Goldilocks approach - “just right” mod-vig physical activity

> 40 mins too much
15 mins too little

= 30 mins just right