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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
Q

Who gets long term oxygen therapy for COPD?

A

NON SMOKER

pO2 <7.3kpa

OR 7.3-8.0 AND one of:

  • 2ary polycythaemia
  • peripheral oedema
  • pulmonary hypertension
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26
Q

What are the investigations for acute pneumonia?

A

1st: Blood culture for sputum

GS: CXR within 3-5 days

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27
Q

What makes up the CRB65/CURB65 score

A

Confusion

Urea >7mmol/L

Resp rate >=30

Blood pressure <90/60

65 years or over

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28
Q

What are the 3 most common causes of community acquired pneumonia?

A

S. pneumoniae

H. Influenzae

S. Aureus

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29
Q

What are the 3 most common atypical causes of pneumonia?

A

C. Pneumoniae

Mycoplasma

Legionella

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30
Q

What form of lung cancer is most

common?

Associated with paraneoplastic syndrome?

A

Adenocarcinoma

Small cell

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31
Q

What CXR features suggest lung cancer?

A

Hilar enlargement

Lesions

Unilateral effusion

Collapse

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32
Q

What is the order of investigations for lung cancer?

A
  1. CXR
  2. CT +/- PET scan
  3. Bronchoscopy
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33
Q

How does cancer subtype direct treatment for lung cancer?

A

Small cell: Chemo + radio

Non-small cell: Surgery +/- radiotherapy and adjuvant chemo

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34
Q

The following signs indicate what extrapulmonary manifestation of lung cancer?

Hoarse voice

Shortness of breath

Facial swelling, SOB and upper body vein distention

A

Hoarse voice –> recurrent laryngeal nerve palsy

Shortness of breath –> Phrenic nerve palsy

Facial swelling, SOB and upper body vein distention –> SVC obstruction

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35
Q

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

A

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
Q

Differentiate TB and sarcoidosis based on

Cough

Systemic symptoms

CXR findings

Pathogen

Histology

A

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
Q

How do you investigate for tuberculosis?

A

Active:

  1. CXR: Upper lobe cavitation

GS: Sputum culture for ZN stain

Latent

Mantoux >15 (6-15 may suggest previous TB or BCG)

38
Q

What is the role of NAAT and sputum smear in TB?

A

Rapid testing for TB but less sensitive than culture

39
Q

What is the treatment for diagnosed tuberculosis?

A

Primary

RIPE 6 months then 2 months RI

Reactivation

RI 3 months OR I 6 months

40
Q

What are the side effects of the RIPE drugs?

A

Rifampicin –> red pee, reduced P450

Isoniazid –> Peripheral neuropathy

Pyrazinamide –> Gout

Ethambutol –> Colour blindness, visual acuity

41
Q

How can you reduce the side effect of pyrazinamide?

A

Co-presribe B6

42
Q

What additional screening test should be done in tuberculosis?

A

HIV test

43
Q

What are the inveestigations for sarcoidosis?

A
  1. CXR shows bilateral hilar lymphadenopathy (as does TB, lymphoma)

Bloods show

Raised ACE and calcium (macrophage activity)

44
Q

What is the management for sarcoidosis?

A

If mild, none

  1. Oral steroids 6-24 months
  2. Methotrexate, azathioprine
45
Q

What symptoms are suggestive of pneumothorax?

A

acute breathlessness +/- pleuritic chest pain and hyperresonance

46
Q

What is the treatment of simple pnemothorax?

A

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
Q

What is the treatment of the following pneumothoraces

Secondary

Iatrogenic

A

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
Q

What advice should be given to pneumothorax patients regarding

Smoking

Flying

Scuba diving

A

Stop

1 week post CXR check

Permanent avoidance unless pleurectomy with clear lung function and CT chest

49
Q

Give the name of a

SABA

SAMA

LAMA

LABA

A

Salbutamol

Ipratrioprium

Tiotropium (lasts for Time-otropium)

-meterols

50
Q

What conditions cause upper zone fibrosis?

A

CHARTS

Coal worker’s pneumoconiosis

Hypersensitivity pneumonitis

Ank spond (rare)

Radiation

TB

Silicosis and sarcodosis

51
Q

How can you differentiate white out lung lesions?

A

See if trachea is central, pulled in or away from the white out

52
Q

What conditions pull the trachea towards the white out?

A

Things reducing pressure on that side

Pneumonectomy

Complete lung collapse

Endobronchial intubation

Pulmonary hypoplasia

53
Q

What white outs push the trachea away from the white out?

A

Things increasing pressure on that side

Pleural effusion

Diaphragmatic hernia

Large thoracic mass

54
Q

What white out lesions keep a central trachea?

A

Consolidation

Pulmonary oedema

Mesothelioma

55
Q

How do exudate and transudate differ in disease process?

A

Transudate: Increased fluid pressure (HF, liver disease, Meig’s)

Exudate: Increased capillary permeability (Infection, inflammation, cancer)

56
Q

Dull percussion, reduced breath sounds and reduced chest expansion are indicative of what lung pathology?

A

Pleural effusion

57
Q

How do you determine if an effusion is transudate or exudate?

A

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
Q

What do the following features of an effusion suggest?

Heavy blood staining

Low glucose

Raised amylase

A

Mesothelioma, PE, TB

RA, TB (?inflammation using it up)

Pnacreatitis, oesophageal perforation

59
Q

How is a pleural effusion investigated and treated?

A

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
Q

When should a chest tube be placed in pleural effusion?

A

Cloudy

Clear but pH <7.2

61
Q

Regarding asbestos exposure…

are pleural plaques pre-malignant?

What is the most dangerous form of asbestos?

What is the treatment of mesothelioma?

A

No, plerual plaques are benign

Blue (crocodilite)

Palliative chemotherapy

62
Q

How do you grade COPD and what are stages 1-4

A

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
Q

What does a Hx of bronchiectasis and allergy/raised eosinophils suggest and how is it treated?

A

Aspergillosis

  1. Oral glucocorticoids
  2. Itraconazole
64
Q

Which COPD patients are eligible for daily oral azithromycin therapy?

A

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
Q

Whats wrong with this CXR?

A

NG tube in right lower lobe of lung

Should be sub-diaphramatic

66
Q

What are the 4 common causes of an anterior mediastinal mass?

A

Thyroid mass

Thymic mass

Terrible lymphadenopathy

Teratoma

67
Q

How can small cell cancer and cushing’s disease be diferentiated?

A

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
Q

What should a pneumonia patient with COPD be presribed in addition to antibiotics?

A

Prednisilone

69
Q

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?

A

NRT, varenicicline (nicotinic partial agonist), buproprion (NA + DA agonist, nicotinic antagonist)

Until 2 weeks post target quit date

Wait 6 months

70
Q

Which smoking cessation drugs cause…

Nausea + headache

insomnia, weird dreams

seizzure risk

A

NRT + varencicline

varencicline

buproprion

71
Q

What smoking cessation agents are contraindicated in…

Epilepsy

Pregnancy

Breastfeeding

Depression

Eating disorders

A

Bupriprion as increased seizure risk

Buproprion, varencicline in pregnancy and breastfeeding

varencicline as partial psych effects

buproprion in eating disorders

72
Q

Which pregnant women get smoking cessation

What is the management plan

A

Current smokers, quit <2 weeks ago, CO >7ppm

  1. Behaviorual intervention
  2. Nicotine replacement therapy
73
Q

What 3 pathogens are the most common exacerbants of COPD?

A

H. Influenzae

S. Pneumoniae

M. Catarrhalis

74
Q

Can asthmatics taking prednisilone breastfeed?

A

Yes

75
Q

Muscle tenderness in a suspected lung cancer patient is indicative of what?

A

LEMS

Autoimmunity against Ca2+ channels instead of the cancer

76
Q

What drug should be avoided in pneumonia patients with long QT?

A

Clarithromycin

77
Q

What features suggest acute bronchitis?

What lab finding indicates treatment and what is it?

A

Cough +/- white or discoloured sputum. CXR rules out pneumonia

If CRP >100, give doxycycline (Amox in children or pregnants)

78
Q

How would you confirm occupational asthma?

A

Serial peak flow measurements in and out of work

79
Q

How can you differentiate facial rashes in sarcoidosis and SLE?

A

Lupus: Photosensitive, ‘butterfly’ rash

Sarcoidosis: non-painful, indurated, affects nose, cheeks, ears and lips

80
Q

How does restrictive lung disease present in terms of

FEV1

FVC

FEV1/FVC

A

FEV1: Reduced

FVC: Very reduced

FEV/FVC: Normal or increased

81
Q

What does this CXR show?

A

Right upper lobe consolidation

Opacity abutting the horizontal fissure

82
Q

What conditions cause finger clubbing?

A

CLUBBING

Cyanotic, cystic defects

Lung abscess

Ulcerative colitis

Bronchiectasis

Benign mesothelioma

Iinfective endocarditis

NOT COPD

GI stuff

83
Q

If COPD symptoms present in a young person, what should you suspect?

A

a1-antitrypsin deficiency

84
Q

red jelly sputum indicates what?

A

Klebsiella pneumoniae

85
Q

When do you initiate management for sarcoidosis?

A

Evidence of worsening CXR or spirometry

Involvement of systems outside resp or joints

hypercalcaemia

Lupus pernio

86
Q

What blood gas result is worrying in an asthma attack?

A

normal pCO2, shows no longer blowing off CO2 via hyperventilation because theyre tiring

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