Interactive Cases II

Question 1

COPD is a risk factor for…..?

Answer 1

• COPD is a risk factor for pneumothorax

Question 2

What type of drug is symbicort and what is it used to treat?

Answer 2

• Steroid and LABA (long acting Beta-agonist)
• COPD

Question 3

What type of drug is tiotropium and what is it used to treat?

Answer 3

• Anti-muscarinic
• COPD

Question 4

In a patient with shortness of breath and a raised JVP, assuming these are linked and not due to separate pathologies, give a ddx - 3 causes of the raised JVP and SOB

Answer 4

• Right HF
• COPD → chronic hypoxia → pulmonary HTN - ‘cor pulmonale?’ → Right HF → raised JVP
• PE → right heart strain → pulmonary HTN? ‘Cor pulmonale? → raised JVP

Question 5

What are some risk factors for the development of PE?

Answer 5

• DVT
• Previous DVT / PE
• Immobility
• Surgery
• Malignancy

Question 6

What are the characteristic features of pneumothorax on a CXR?

Answer 6

• No lung markings on the side of the pneumothorax - clear, pure black lung
• Tracheal deviation away from the side of the pneumothorax

Question 7

What are the 2 types of classifications of pneumothorax - each have 2 divisions?

Answer 7

• Simple vs tension
• Primary (spontaneous) vs secondary (secondary to chronic lung disease e.g. COPD)

Question 8

Outline the management plan for primary and secondary pneumothorax

Answer 8

Primary pneumothorax:

• If < 2cm
  
  • Discharge, repeat CXR
• If > 2cm / SOB
  
  • FIRST: Pleural aspiration - insertion of a large bore cannula to remove air from the pleural space
  • IF UNSUCCESSFUL: Chest drain - inserted at 4th ICS MCL

Secondary pneumothorax:

• If < 2cm
  
  • Pleural aspiration
• If > 2cm
  
  • Chest drain

Question 9

What breath sound do you hear in PE?

Answer 9

• Vesicular

Question 10

1) PE can lead to a CVS phenomenon that causes a constellation of CVS signs, what is this and what are the signs?
2) What is a much more common ECG finding than the one mentioned in part 1 (one of the signs)?

Answer 10

1)

• PE → Right Heart Strain
• Signs:
  
  • ↑ JVP
  • RAD (Right Axis Deviation)
  • RBBB (Right Bundle Branch Block) - V2 ‘M’, V6 ‘W’ (WilliaM MarroW)
  • S1Q3T3 on ECG - i.e Deep S-wave on lead I, Deep Q-wave on lead 3 and T-wave inversion on lead 3

2)

• Sinus tachycardia

Question 11

Outline the management plan for PE in order. For haemodynamicall and not haemodynamically stable patients

Answer 11

If haemodynamically stable:

1. LMWH
2. CTPA → if confirmed PE, continue LMWH
3. LMWH + Warfarin
4. Then just take warfarin when INR is optimal

If haemodynamically unstable:

• Thrombolysis

Question 12

What will the FEV1 : FVC ratios show in…

1) Restrictive lung disorders?
2) Obstructive lung disorders?

Answer 12

1)

RESTRICTIVE PATTERN e.g. in fibrosis

• FEV1/FVC ratio > 70%

OBSTRUCTIVE PATTERN e.g. in asthma, COPD

• FEV1/FVC ratio < 70% Obstructivelung disease (Asthma, COPD)

Question 13

Give some respiratory causes of clubbing

Answer 13

• Bronchial carcinoma
• Bronchiectasis
• Empyema
• Fibrosing alveolitis
• Mesothelioma
• Lung abscess

Question 14

Give some causes of restrictive lung diseases (pulmonary fibrosis)

Answer 14

• Idiopathic fibrosing alviolitis
• Connective tissue disorders
  
  • SLE
  • RA
  • Scleroderma
• Drugs
  
  • Methotrexate
  • Amiodarone
  • Nitrofurantoin
• Asbestosis - important to check occupation

Question 15

True or false - COPD has clubbing

Answer 15

• False

Question 16

What are the radiological (CXR) signs of COPD?

Answer 16

• Hyperinflated lungs > 7 ribs
• Flattened diaphragm

Question 17

Identify the different types of opacities on the CXR and what they suggest

Answer 17

• Homogenous shadow → fluid, effusion or collapase
• Reticulo-nodular (lines and dots) → fibrosis
• Fluffy alveolar (interstitial) shadowing → fluid (pulmonary oedema) , pus (pneumonia) or blood
• Masses / cavitations