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Fire Through Finals > General Medicine: Respiratory > Flashcards

General Medicine: Respiratory Flashcards

1
Q

How can you determine asthma severity (mod, severe, life by…

Speech

PEFR

02

A

Moderate // Severe // Life-threatening

Normal // Incomplete sentences // Reduced consciousness

50-75% // <50% // <33%

NA // >92% // <92%

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2
Q

What RR indicate severe asthma in

>12yrs

5-12yrs

2-5yrs

A

>=25/min

>=30/min

>=40/min

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3
Q

What is the initial management of acute asthma in adults?

A

Oxygen 15L/min

Salbutamol 5mg 6ml/min NEB

IV hydrocortisone 200mg OR PO prednisilone 40mg

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4
Q

What is the initial management of acute asthma in children?

A

Oxygen

Salbutamol 1-2 puffs via spacer (up to 10 puffs)

Oral steroids

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5
Q

If a patient does not improve on initial acute asthma treatment, what add on treatment can you give (adult and children)

A

Nebulised ipratroprium

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6
Q

Following senior input, what further line treatments in asthma are there?

A

IV salbutamol

Aminophylline use

IV MgSO4

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7
Q

What is the discharge criteria for an adult following acute asthma attack?

A

Stable off nebs for 12-24 hours

PEFR >75% of expected

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8
Q

What is the discharge criteria for acute asthma in children?

A

Stable on 3-4 hourly nebs for continuation at home

FEV1 >75% of best

Sats >94%

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9
Q

Apart from wheeze, nocturnal cough and personal history of atopy, what other features suggest asthma?

A

Nothing really

Productive cough, systemic symptoms, persistent cough tend to be caused by other things

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10
Q

What investigations are performed and what are the thresholds for chronic asthma in

Adults

Children

A

Adults: Spirometry with reversibility + FeNO

Children: Spirometry with reversibility +/- FeNO if spirometry not asthmatic in nature

Spirometry: FEV1/FVC <70% + bronchodilator reversibility >=12% in both groups

FeNO: >=40ppb adults, >=35ppb children

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11
Q

What is the treatment ladder for asthma in adults (>=17yrs)

A
  1. Low dose steroid
    • LABA
  3. Increase steroid to medium dose OR + LTRA (remove LABA if no effect)
  4. Refer for specialist
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12
Q

What is the management of chronic asthma management of children (<17yrs)

A
  1. V. low dose steroid
  2. LABA <5yrs < LTRA/LABA
  3. Increase to low dose steroid OR +LTRA/LABA if >5yrs
  4. Specialist management
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13
Q

For management of asthma, what are the conditions for

Stepping up treatment

Stepping down treatment

A

Up: >=3 doses SABA uses/week

Down: Every 3 months if stable

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14
Q

What is the spirometry for COPD

A

FEV1 reduced

FVC normal

–> FEV/FVC low

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15
Q

What is the management of COPD

A
  1. SABA/SAMA PRN

2.

a) Reversibility/IgE: LABA + ICS
b) No reversibility: LAMA* + LABA
3) 1 severe/ 2 mod exacerbations: LABA + LAMA + ICS
4) Specialist input

*Stop SAMA IF GOING ON LAMA*

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16
Q

How do you manage an acute exacerbation of COPD

A

ISOAP

Oxygen

Salbutamol 2.5mg

Ipratroprium bromide 0.5g

Prednisilone 30mg oral

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17
Q

How do ABGs and GCS affect managemnt in COPD?

A

Normal ABGs: O2 + nebs

Worsening hypoxaemia: Increase O2, repeat in 30 mins

Reduced GCS: Get senior help

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18
Q

Patient with a unilateral swollen leg develops SOB, chest pain and low grade fever, what is the main differential?

A

PE

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19
Q

How do you determine whether to perform a CTPA in a PE patient?

A

Well’s Score: >4 is positive

-ve Score but +ve D-dimer: CTPA

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20
Q

When is CTPA not suitable and what do you use instead?

A

Pregnancy or renal impairment

V/Q scanning

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21
Q

What would allow for a PE to be managed at home?

A

Low PESI score (essentially no comorbities, home support and haem stability)

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22
Q

What should you do if getting a CTPA is going to take a while?

A

Commence anticoagulation anyway

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23
Q

What is the 1st line treatment for PE in most cases?

What circumstances differ from this and what do you give?

A

DOAC (inc active cancer)

Renal impairment: LMWH/UFH or LMWH + VKA

Antiphospholipid syndrome: LMWH + VKA

Massive PE: Thrombolysis

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24
Q

How long is VTE treatment for?

A

3 months initially +/-3 months if unprovoked (ie spontaneous, not provoked by surgery)

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25
Who gets long term oxygen therapy for COPD?
NON SMOKER pO2 \<7.3kpa OR 7.3-8.0 AND one of: - 2ary polycythaemia - peripheral oedema - pulmonary hypertension
26
What are the investigations for acute pneumonia?
1st: Blood culture for sputum GS: CXR within 3-5 days
27
What makes up the CRB65/CURB65 score
Confusion Urea \>7mmol/L Resp rate \>=30 Blood pressure \<90/60 65 years or over
28
What are the 3 most common causes of community acquired pneumonia?
S. pneumoniae H. Influenzae S. Aureus
29
What are the 3 most common atypical causes of pneumonia?
C. Pneumoniae Mycoplasma Legionella
30
What form of lung cancer is most common? Associated with paraneoplastic syndrome?
Adenocarcinoma Small cell
31
What CXR features suggest lung cancer?
Hilar enlargement Lesions Unilateral effusion Collapse
32
What is the order of investigations for lung cancer?
1. CXR 2. CT +/- PET scan 3. Bronchoscopy
33
How does cancer subtype direct treatment for lung cancer?
Small cell: Chemo + radio Non-small cell: Surgery +/- radiotherapy and adjuvant chemo
34
The following signs indicate what extrapulmonary manifestation of lung cancer? Hoarse voice Shortness of breath Facial swelling, SOB and upper body vein distention
Hoarse voice --\> recurrent laryngeal nerve palsy Shortness of breath --\> Phrenic nerve palsy Facial swelling, SOB and upper body vein distention --\> SVC obstruction
35
Name the following paraneoplastic syndromes Eye droop, pupil dilation and lack of sweating Cushingoid features Hypercalcaemia Short term memory difficulties, hallucinations, confusion Proximal limb weakness, double vision, ptosis, slurred speech
Eye droop, pupil dilation and lack of sweating --\> Horner’s syndrome Cushingoid features --\> ACTH from small cell Hypercalcaemia --\> ectopic PTH from squamous cell Short term memory difficulties, hallucinations, confusion --\> small cell limbic encephalitis Proximal limb weakness, double vision, ptosis, slurred speech --\> Lambert Eaton Myasthenic syndrome. Can improve reflexes with sustained muscle contraction
36
Differentiate TB and sarcoidosis based on Cough Systemic symptoms CXR findings Pathogen Histology
TB // Sarcoidosis Productive, haemoptysis // dry Night sweats, +/- spinal pain // facial rash, lymphadenopathy consolidation, cavitation. Ghon focus // bilateral hilar lymphadenopathy Acid fast bacillus (M. tuberculosis) // autoimmune caseating // non-caseating granuloma
37
How do you investigate for tuberculosis?
Active: 1. CXR: Upper lobe cavitation GS: Sputum culture for ZN stain Latent Mantoux \>15 (6-15 may suggest previous TB or BCG)
38
What is the role of NAAT and sputum smear in TB?
Rapid testing for TB but less sensitive than culture
39
What is the treatment for diagnosed tuberculosis?
Primary RIPE 6 months then 2 months RI Reactivation RI 3 months OR I 6 months
40
What are the side effects of the RIPE drugs?
Rifampicin --\> red pee, reduced P450 Isoniazid --\> Peripheral neuropathy Pyrazinamide --\> Gout Ethambutol --\> Colour blindness, visual acuity
41
How can you reduce the side effect of pyrazinamide?
Co-presribe B6
42
What additional screening test should be done in tuberculosis?
HIV test
43
What are the inveestigations for sarcoidosis?
1. CXR shows bilateral hilar lymphadenopathy (as does TB, lymphoma) Bloods show Raised ACE and calcium (macrophage activity)
44
What is the management for sarcoidosis?
If mild, none 1. Oral steroids 6-24 months 2. Methotrexate, azathioprine
45
What symptoms are suggestive of pneumothorax?
acute breathlessness +/- pleuritic chest pain and hyperresonance
46
What is the treatment of simple pnemothorax?
Simple primary SOB \<2cm: No treatment, FU in 2-4 weeks SOB \>2cm: Aspirate 2x failed aspirations: Chest drain Tension 1. Large bore cannula 2IC space, mid clavicular 2. Chest drain 5th IC
47
What is the treatment of the following pneumothoraces Secondary Iatrogenic
Secondary \>50 yrs + \>2cm: Chest drain Otherwise aspirate (if \<1cm then give oxygen and admit for 24hrs) Iatrogenic Mostly spontaenous but aspirate if needed
48
What advice should be given to pneumothorax patients regarding Smoking Flying Scuba diving
Stop 1 week post CXR check Permanent avoidance unless pleurectomy with clear lung function and CT chest
49
Give the name of a SABA SAMA LAMA LABA
Salbutamol Ipratrioprium Tiotropium (lasts for Time-otropium) -meterols
50
What conditions cause upper zone fibrosis?
CHARTS Coal worker's pneumoconiosis Hypersensitivity pneumonitis Ank spond (rare) Radiation TB Silicosis and sarcodosis
51
How can you differentiate white out lung lesions?
See if trachea is central, pulled in or away from the white out
52
What conditions pull the trachea towards the white out?
Things reducing pressure on that side Pneumonectomy Complete lung collapse Endobronchial intubation Pulmonary hypoplasia
53
What white outs push the trachea away from the white out?
Things increasing pressure on that side Pleural effusion Diaphragmatic hernia Large thoracic mass
54
What white out lesions keep a central trachea?
Consolidation Pulmonary oedema Mesothelioma
55
How do exudate and transudate differ in disease process?
Transudate: Increased fluid pressure (HF, liver disease, Meig's) Exudate: Increased capillary permeability (Infection, inflammation, cancer)
56
Dull percussion, reduced breath sounds and reduced chest expansion are indicative of what lung pathology?
Pleural effusion
57
How do you determine if an effusion is transudate or exudate?
Transudate \<30gL\< Exudate If between \>25-35g/L, its exudate if one of these is true: - Pleural/serum protein \>0.5 - Pleural LDH/serum LDH \>0.6 - Pleural LDH = normal range x 1.66
58
What do the following features of an effusion suggest? Heavy blood staining Low glucose Raised amylase
Mesothelioma, PE, TB RA, TB (?inflammation using it up) Pnacreatitis, oesophageal perforation
59
How is a pleural effusion investigated and treated?
Investigations 1. CXR GS: Pleural aspirate with US guidance. Use a 21G needle with 50ml syringe Management Treat cause Repeat drainage/pleurodesis/drugs if recurrent
60
When should a chest tube be placed in pleural effusion?
Cloudy Clear but pH \<7.2
61
Regarding asbestos exposure... are pleural plaques pre-malignant? What is the most dangerous form of asbestos? What is the treatment of mesothelioma?
No, plerual plaques are benign Blue (crocodilite) Palliative chemotherapy
62
How do you grade COPD and what are stages 1-4
Post-bronchodilator FEV/FVC \<0.7 AND FEV1 of \>80%: Mild (I) 50-79%: Moderate (II) 30-49%: Severe (III) \<30%: Very severe (IV)
63
What does a Hx of bronchiectasis and allergy/raised eosinophils suggest and how is it treated?
Aspergillosis 1. Oral glucocorticoids 2. Itraconazole
64
Which COPD patients are eligible for daily oral azithromycin therapy?
Those who have - Stopped smoking + have optimal medical management but keep having exacerbations - Exclusion of the following \> Bronchiectasis (CT thorax) and atypical, TB (sputum culture) \> QT prolongation via LFTs and ECG
65
Whats wrong with this CXR?
NG tube in right lower lobe of lung Should be sub-diaphramatic
66
What are the 4 common causes of an anterior mediastinal mass?
Thyroid mass Thymic mass Terrible lymphadenopathy Teratoma
67
How can small cell cancer and cushing's disease be diferentiated?
High dose dexamethasone will suppress cushing's disease (due to -ve feedback) Since SCLC is ectopic, it is unaffected by the normal ACTH system .'. no suppression
68
What should a pneumonia patient with COPD be presribed in addition to antibiotics?
Prednisilone
69
Regarding smoking cessation... What 3 agents are available? How long should presription last for? How long should you wait before a repeat prescription if the cessation was unsuccessful?
NRT, varenicicline (nicotinic partial agonist), buproprion (NA + DA agonist, nicotinic antagonist) Until 2 weeks post target quit date Wait 6 months
70
Which smoking cessation drugs cause... Nausea + headache insomnia, weird dreams seizzure risk
NRT + varencicline varencicline buproprion
71
What smoking cessation agents are contraindicated in... Epilepsy Pregnancy Breastfeeding Depression Eating disorders
Bupriprion as increased seizure risk Buproprion, varencicline in pregnancy and breastfeeding varencicline as partial psych effects buproprion in eating disorders
72
Which pregnant women get smoking cessation What is the management plan
Current smokers, quit \<2 weeks ago, CO \>7ppm 1. Behaviorual intervention 2. Nicotine replacement therapy
73
What 3 pathogens are the most common exacerbants of COPD?
H. Influenzae S. Pneumoniae M. Catarrhalis
74
Can asthmatics taking prednisilone breastfeed?
Yes
75
Muscle tenderness in a suspected lung cancer patient is indicative of what?
LEMS Autoimmunity against Ca2+ channels instead of the cancer
76
What drug should be avoided in pneumonia patients with long QT?
Clarithromycin
77
What features suggest acute bronchitis? What lab finding indicates treatment and what is it?
Cough +/- white or discoloured sputum. CXR rules out pneumonia If CRP \>100, give doxycycline (Amox in children or pregnants)
78
How would you confirm occupational asthma?
Serial peak flow measurements in and out of work
79
How can you differentiate facial rashes in sarcoidosis and SLE?
Lupus: Photosensitive, 'butterfly' rash Sarcoidosis: non-painful, indurated, affects nose, cheeks, ears and lips
80
How does restrictive lung disease present in terms of FEV1 FVC FEV1/FVC
FEV1: Reduced FVC: Very reduced FEV/FVC: Normal or increased
81
What does this CXR show?
Right upper lobe consolidation Opacity abutting the horizontal fissure
82
What conditions cause finger clubbing?
CLUBBING Cyanotic, cystic defects Lung abscess Ulcerative colitis Bronchiectasis Benign mesothelioma Iinfective endocarditis **NOT COPD** GI stuff
83
If COPD symptoms present in a young person, what should you suspect?
a1-antitrypsin deficiency
84
red jelly sputum indicates what?
Klebsiella pneumoniae
85
When do you initiate management for sarcoidosis?
Evidence of worsening CXR or spirometry Involvement of systems outside resp or joints hypercalcaemia Lupus pernio
86
What blood gas result is worrying in an asthma attack?
normal pCO2, shows no longer blowing off CO2 via hyperventilation because theyre tiring

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