Interactive Cases in General Internal Medicine (2) NEWLY added

Question 1

60 yr old man • SOB • Sudden onset • PMH: COPD • On symbicort & tiotropium • PR: 110 bpm • JVP:  •  BS, Scattered wheeze & creps (R) • Peripheral oedema • Sats: 80% (air) • FBC: Hb 85, WCC 12, plt: 300

What is the most likely diagnosis?

1. Pneumothorax
2. Pulmonary embolism
3. Airway disease
4. Pneumonia
5. Pulmonary oedema
6. Interstitial lung disease
7. Pleural effusion
8. Anaemia
9. Thyrotoxicosis
10. Nerve/muscle disease

Answer 1

pneumothorax

because sudden

COPD- predisposes you to pneumothorax

Question 2

What are the different differentials of breathlesness based on onset?

Answer 2

Seconds:

• Pneumothorax
• PE
• FB

Min/ Hrs

• Airways (inflammation/obstruction)
• Chest infection (pus)
• Acute heart failure (fluid)

Days/ weeks

• Above (chronic/not resolving)
• Interstitial lung disease
• Malignancy/ Large pleural effusion
• Neuromuscualr
• Anaemia/ Thyrotoxicosis

Question 3

He is started on oxygen.

What is the most appropriate next step in his management?

A. Chest drain insertion

B. Chest ultrasound

C. CPAP

D.Observation

E. Pleural aspiration

Answer 3

A chest drain

Question 4

What is the management of a Pneumothorax

Answer 4

Primary: (no other respiratory conditions)

< 2 cm:

– Discharge, repeat CXR

> 2 cm/SOB:

– Aspiration

– If unsuccessful: chest drain

Secondary (history of COPD)

< 2 cm:

– Aspiration

> 2 cm:

– Chest drain

Question 5

below what number of hb are people breathless?

Answer 5

80

Question 6

Why do you get a raised JVP in this patient

60 yr old man • SOB • Sudden onset • PMH: COPD • On symbicort & tiotropium • PR: 110 bpm • JVP:  •  BS, Scattered wheeze & creps (R) • Peripheral oedema • Sats: 80% (air) • FBC: Hb 85, WCC 12, plt: 300

Answer 6

because there right heart failure due to COPD

Question 7

What are assoicated symptoms with breathlessness?

Answer 7

WBC

Wheeze, breathlessness, Cough

sputum, haemoptisis

Question 8

What are risk factors for PE

Answer 8

Signs of DVT

– Previous DVT/PE

– ? immobility, surgery, malignancy

Question 9

What is the recurrent SOB due to?

This 2 hours afterwards.

Answer 9

too quick ventilation

re-expansion pulmunary oedema

Question 10

47 year old woman • Acute SOB • Pleuritic chest pain • PMHx: DVT • O2 Saturation: 78% (air) • PR: 110 bpm • BP: 120/80 mmHg •raised JVP • Vesicular BS

This is her ECG

What does her ECG show:

A. Atrial fibrillation

B. Normal axis & RBBB

C. Right Axis deviation & RBBB

D. Right Axis deviation & LBBB

E. Left Axis deviation & LBBB

Answer 10

Right Axis deviation & RBBB

Question 11

47 year old woman • Acute SOB • Pleuritic chest pain • PMHx: DVT • O2 Saturation: 78% (air) • PR: 110 bpm • BP: 120/80 mmHg •raised JVP • Vesicular BS

This is her ECG:

What is the most appropriate next step in her management? A.LMWH

B.BiPAP

C.Warfarin

D.Thrombolysis

E.Furosemide

Answer 11

PE

Low molecular weight heparin

Question 12

What does the CXR show?

Answer 12

PE (westermark sign)

Question 13

• 50-year-old female • progressive SOB • dry cough • clubbing • FEV1/FVC ratio > 70%.
What are your differentials?

Answer 13

PULMUNARY FIRBOSIS (reticulaar nodular shadowing)

– Idiopathic fibrosing alveolitis

– Connective tissue disease, RA

– Drugs

– Asbestosis (? ship builder)

Question 14

• 41-year-old man • Smoking history of 30 pack-years • Chronic SOB, chest pain & cough •low BS, Hyper-resonant PN L&R

What does this CXR show?

Answer 14

large bullae

Question 15

50-year-old female Chronic SOB Sputum No clubbing FEV1/FVC ratio < 70%

What does this CXR show?

Answer 15

Hyper expanded lung

Emphysema/ COPD

Question 16

What conditions cause bullae in the lungs?

Answer 16

COPD

Question 17

Cough • sputum • wt loss • Night sweats

What does this CXR show?

Answer 17

TB

Question 18

A 70-year-old man • SOB • Keeps pigeons

Answer 18

fibrosis

Question 19

CXR1

Answer 19

normal

Question 20

CXR 2

Answer 20

COPD/ Emphesema

Question 21

CX3

Answer 21

left pneumothorax

Question 22

What are different types of opacities you can have on a chest X ray and what conditions could it point towards?

Answer 22

Interstitial/alveolar shadowing: fluid (pulmonary oedema), pus (pneumonia), blood ()

Reticulo-nodular shadowing:fibrosis

Homogeneous shadowing: pleural effusion

Masses/cavitations:

Question 23

WHat does this CXR show?

Answer 23

alveolar shadowing

middle lobe pneumonia

Question 24

What does this show

Answer 24

bilateral alveolar shadowing

Pulmonary oedema

Question 25

What does this X ray show

Answer 25

reticular nodular shadowing

FIBROSIS

Question 26

What does this show

Answer 26

pleural effusion

Homogenous shadowing - with miniscus

Question 27

What does this CXR show

Answer 27

homogenous shadowing

could be effusion or collapse

LOOK at trachea

towards is collapse

away is effusion

IN THIS CASE: towards so collapse

Question 28

what does this show

Answer 28

cavitating lesion with an air fluid level

Question 29

What could this be due to ?

Answer 29

infection: klebsiella or staph or TB
inflammation: rheumatoid nodule

malignancy

Question 30

what does this CXR show

Answer 30

enlarged heart-

could be a globular heart- pericardial effusion

Question 31

what does this x ray show

Answer 31

bilateral hilar lymphadenopathy

Question 32

what does a globular heart indicate

Answer 32

pericardial effusion

Question 33

what does this x ray show?

Answer 33

pleural plaques related to asbestos

NOT asbestosis- need fibrosis for this

Question 34

what could cause hilar lymphadenopathy?

Answer 34

infection: tb
inflammation: sarcoidosis
malignancy: lymphoma

Question 35

What does this chest x ray show

Answer 35

mastectomy

Question 36

what does this chest x ray show

Answer 36

pace maker, leads