Interactive cases 2: Respiratory medicine Flashcards
60 yr old man SOB, Sudden onset PMH: COPD On symbicort & tiotropium PR: 110 bpm JVP high decreased BS, Scattered wheeze & creps (R) Peripheral oedema Sats: 80% (air) FBC: Hb 85, WCC 12, plt: 300
PE
What causes bilateral hilar lymphadenopathy
TB, sarcoid, lymphoma
Mass/cavitating lesion
TB, abscess, rheumatoid nodule. Air-fluid level
What is seen with left lower lobe pneumonia?
loss of L hemidiaphragm, normally seen behind the heart
50F, progressive SOB, dry cough, clubbing, FEV1/FVC >70%
Interstitial lung disease e.g. pulmonary fibrosis, reticulonodular shadowing on CXR
3 signs of constrictive pericarditis
high JVP, hepatomegaly, ascites
50F, no clubbing, hyper-expansion on CXR, sputum, chronic SOB, FEV1/FVC 63%
COPD
reticulonodular shadowing
pulmonary fibrosis (idiopathic or extrinsic allergic alveolitis)
homogenous shadowing
pleural effusion (meniscus seen)
Which lobe is affected if CXR consolidatoin obscures the right heart border?
right middle lobe, listen in axilla for pathology
41M SOB, cough, CP, chronic. 30y smoking history, decreased breath sounds, hyper resonant bilaterally
big bullae, vanishing lung syndrome. CT do NOT put achest drain in. Lung volume reduction surgery
What causes a globular heart?
pericarditis with percardial effusion
CXR opacities, fluffy interstial/alveolar shadowing
fluid, pus or blood (pneumonia, HF)
what is symbicort?
long acting beta agonist and steroid (given to COPD pts)
what is tiotropium
anti cholinergic bronchodilator (COPD pts)
Causes of acute breathlessness
pneumothorax (alveoli pop), PE (PA clot), foreign body obstruction (block airway), anxiety
why would there be a raised JVP in COPD pt?
COPD-> chronically hypoxic -> vasoconstriction -> pulmonary HT -> RHF (peripheral oedema)
auscultation of COPD pt
wheeze (airway obstruction) and crepitations
respiratory diseases that are RF for pneumothorax
COPD (bullous burst)
RF for PE
female, middle-aged, smoker, CTD (Marfan’s), immobility, Fx or PMH of DVT
causes of sub-acute breathlessness
(mins/hours) - fluid (HF), pus (pneumonia), blood (in alveoli or interstitium. fluffy air-space shadowing
causes of chronic breathlessness
chronic (infection, PEs, COPD, PF, HF). Basically anything except pneumothorax
Interstitial lung disease
pulmonary fibrosis (idiopathic or extrinsic allergic alveolitis)
scan used to drain fluid
US
What is CPAP?
continuous positive airway pressure. used for Type 1 hypoxic respiratory failure -> improves oxygenation
(both insp and exp positive airway pressure)
Distinguish between primary and secondary pneumothorax
primary has no history of previous lung disease. Secondary has underlying lung disease e.g. COPD
Tx for primary pneumothorax:
<2cm
>2cm
<2cm - leave and observe
>2cm - aspirate (failure -> chest drain)
Tx for secondary pneumothorax:
<2cm
>2cm
<2cm aspirate
>2cm - chest drain
pulmonary oedema cause and CXR findings
LHF or CCF.
CXR bilateral fluffy air space shadowing
What leads determine axis deviation on ECG?
Lead 1 (R or S overall more negative = axis deviation)
avL more +ve - LAD
avL more -ve RAD
S1 Q3 T3
ECG feature of PE
What is BiPAP?
Inspiratory positive airway pressure. Non-invasive ventilation for respiratory acidosis e.g. COPD
What is ePAP?
expiratory positive airway pressure
Why is there a raised JVP in PE pt?
due to clot
could also be RHF/CCF
Mx of PE pt
ABC, give oxygen
LMWH (enoxapaprin, dalteparin)
do CTPA to confirm PE (if not stop LMWH)
Then warfarin when INR high
Why is there a delay in giving warfarin to PE pt?
Warfarin is initially a pro-coagulant as inhibits protein C and S for first few days
When would you thrombolyse a PE pt?
if haemodynamically unstable (low BP due to e..g MI)
Mx of primary pneumonia >2cm
ABC
aspirate
regular analgesia (especially if chest drain inserted)
what does FEV/FVC ratio tell you?
<70% obstructive lung disease (COPD/asthma) as FEV low
>70% restrictive lung disease (PF) as FVC low
Causes of pulmonary fibrosis
idiopathic
CTD (SLE, scleroderma)
Drugs (Methotrexate, Nitropheratin)
Asbestos (-> asbestosis), not just asbestos plaque
Hyperinflated lung on CXR
see >7 ribs anteriorly and flattened diaphragm
upper lobe shadowing
pulmonary TB
describing CXR
Name, DOB, date+time, PA/AP
Rotation
Inspiration
Penetration (too white=over, too black=under)
Cause of loss of visible l hemidiaphragm (behind heart)
collapse or consolidation
bilateral fluffy shadowing
fluid/blood/pus
most likely pulmonary oedema
CXR total white out
massive effusion or collapse
Differentiate between massive effusion and lung collapse
look at trachea on CXR
effusion pushes trachea away
collapse pulls trachea towards
coin lesion, air fluid level causes
Infection (TB, staph aureus, Klebsiella)
Inflammation (RA or cavitation nodules)
Malignancy (squamous cell carcinoma)
causes bilateral hilar lymphadenopathy
TB, sarcoidosis, lymphoma
signs of asbestos poisoning on CXR
multiple pleural plaques OR
reticular nodular shadowing (asbestosis, type of pulmonary fibrosis)
47W Acute SOB Pleuritic chest pain PMHx: DVT O2 Saturation: 78% (air) PR: 110 bpm BP: 120/80, high JVP, Vesicular BS Most appropriate Mx? 1. LMWH 2. BiPAP 3. Warfarin 4. Thrombolysis 5. Furosemide
LMWH
Vanishing lung syndrome
otherwise known as idiopathic giant bullous emphysema
typically young thin male smokers
radiographic criteria for vanishing lung syndrome
giant bullae in one or both upper lobes occupying at least one third of the hemithorax and compressing surrounding parenchyma
(Air–liquid levels within bullae are uncommon and raise the question of bacterial superinfection)
Mx of vanishing lung syndrome
Lung-volume–reduction surgery after:
assessment of exercise capacity
pulmonary-function testing, smoking cessation
Cough sputum wt loss Night sweats CXR upper lobe shadowing
pulmonary TB
A 70-year-old man
SOB
Keeps pigeons
CXR bilateral reticulonodular shadowing
extrinsic allergic alveolitis
75M 3 day worsening SOB, productive cough, reduced exercise tolerance. 50 pack/year smoking history. Temp 38.5. PR 110 bpm, BP 140/87 mmHg, RR 28 bpm. O2 sats 87% breathing air. He is given oxygen, aiming for 88-92% sats. Next step Mx?
a) IV aminophylline
b) IV MgSO4
c) IV steroids
d) Non invasive ventilation
e) Salbutamol nebuliser
Salbutamol nebuliser
(and ipratropium)
aminophylline if don’t respond to above, MgSO4 for asthmatics, steroids given but don’t work as quickly so not next step. NIV need to see resp acidosis and high CO2.
66M w/metastatic prostate cancer. Has ongoing bony pain which taked paracetomal codeine, and morphine. Pain still not well controlled. Next step Mx?
a) Co-dydramol
b) Finasteride
c) Radiotherapy
d) Tamsulosin
e) Vit D
Radiotherapy
codydramol=paracetomal and codeine, dont want xs. Finasteride and Tamsulosin used for prostate symptoms
