Investigations + treatments

Question 1

Bloods FBC?

Answer 1

Anaemia

Question 2

Bloods Blood cholesterol, glucose and HbA1c?

Answer 2

abnormal cholesterol and glucose are risk factors for ischaemic heart disease.

Question 3

Bloods TFTs?

Answer 3

hyperthyroidism can cause tachycardia and high-output cardiac failure.

Question 4

Bloods U&Es?

Answer 4

if you think the patient is fluid overloaded, need to give diuretics

Question 5

Bloods BNP?

Answer 5

hormone that is released by ventricular cells in heart failure, has high negative predictive value (tells if you don’t have heart failure).

Question 6

CXR?

Answer 6

signs of heart failure,

pneumonia,

pleural effusion,

bronchiectasis,

or fibrosis.

image shows pulmonary fibrosis

Question 7

ECG?

Answer 7

normally abnormal in patients with heart failure, an important cause of heart failure is necrosis to areas of the heart by previous MI.

Question 8

Peak expiratory flow rate?

Answer 8

stratify the severity of an asthma attack in chronic asthma.

Question 9

Spirometry?

Answer 9

used to distinguish between restrictive (FVC <70% and FEV1 >70%) and obstructive (FEV1<70% and FVC >70%)lung diseases.

Question 10

how does heart failure explain SOB?

Answer 10

not pumping enough blood, back pressure forces fluid out from the pulmonary vasculature into the alveoli so decreased lung compliance, decreased gas exchange and airway obstruction

Question 11

How does heart failure explain orthopnoea?

Answer 11

lying down increases venous return to the heart making congestion of blood in the pulmonary vessels worse forcing more fluid into the lungs

Question 12

How does heart failure explain displaced apex beat?

Answer 12

doesn’t pump out all the blood, so dilates displacing apex beat. This is a volume overloaded heart, not hypertrophic (which is caused by hypertension and aortic stenosis and is a pressure overloaded heart).

Question 13

How does heart failure explain crackles in lungs?

Answer 13

fluid in alveoli collapses them, as patient breathes in deeply, they pop back open

Question 14

How does heart failure explain peripheral oedema?

Answer 14

heart cant cope with venous return, leading to back pressure in venous system, can manifest as raised JVP and hepatomegaly + tender, and fluid is forced out into surrounding tissue.

Question 15

Treatment for congestive heart failure secondary to ischaemic heart disease. Symptomatic relief?

Answer 15

left ventricular failure leads to pulmonary oedema. Sit them upright, give O2, reduce cardiac preload with vasodilators and morphine to reduce sensation of SOB.

Question 16

Treatment for congestive heart failure secondary to ischaemic heart disease. Pathophysiological mechanism?

Answer 16

reduce the O2 demand of the heart with Beta blockers which slow heartbeat.

Inhibit the renin-angiotensin-aldosterone system with ACE inhibitors, this reduces reabsorption of Na and water from the kidneys

Question 17

Treatment for congestive heart failure secondary to ischaemic heart disease. Treat underlying cause?

Answer 17

the most common cause of heart failure atherosclerosis of the coronary arteries.

To prevent it getting worse, give statin to reduce cholesterol, aspirin to reduce risk of thrombosis

Question 18

Reasons for postoperative SOB (5)?

Answer 18

Atelectasis; (alveolar collapse), pain stops patients breathing properly and mucus eventually plugs the bronchioles preventing air entry, the areas of lung collapse as air is absorbed into surrounding tissue.

Pneumonia; poor clearance of mucus and weakened immune response.

Pulmonary oedema; due to heart failure or excessive fluids.

PE; DVT isn’t uncommon after surgery due trauma and immobilisation.

Anaemia; if there’s blood loss.

Question 19

Management of asthma?

Answer 19

Avoidance of triggers; smoke, pets, any allergens, exercising…

Bronchodilation; Beta agonists increase sympathetic stimulation to the heart.

Reduction of immune response in lungs; inhaled corticosteroids

Question 20

Chronic bronchitis?

Answer 20

productive cough every day for >3 consecutive months a year for at least 2 years.

Question 21

COPD management?

Answer 21

Stop smoking, inhaled therapy (Beta2 agonists, inhaled corticosteroids should be added to long acting bronchodilators in patients with exacerbations), pulmonary rehab (physio, exercise), vaccination, non-invasive ventilation (NIV), long term O2 to hypoxic patients

Question 22

Restrive lung pathology?

Answer 22

FEV1 >70% but FVC <70%. Interstitial lung disease is restrictive and fits with fine crackles in all lung fields.

Question 23

Difference between asthma and COPD?

Answer 23

Asthma is a reversible and transient obstruction of the airways caused by excessive mucus production, airway inflammation and constriction of the bronchi.

COPD is irreversible and progressive obstruction of the airways with a history of chronic bronchitis and emphysema.

Question 24

Short-acting bronchodilators?

Answer 24

Salbutamol; Beta2 agonist. Ipratropium; antimuscarinic/cholinergic, often used in COPD, but less in asthma

Question 25

Inhaled steroids?

Answer 25

beclomatasone, reduces inflammation, used in both asthma and COPD as second-line treatment.

Question 26

Long-acting bronchodilators?

Answer 26

Salmeterol; LABA. Tiotropium; long-acting muscarinic agents (LAMA), used in COPD but asthma

Question 27

Respiratory failure?

Answer 27

impairment of pulmonary gas exchange sufficient to result in hypoxaemia and/or hypercapnia

Question 28

Type I respiratory failure?

Answer 28

or hypoxaemic respiratory failure, caused by disease pathology affecting how much oxygen can get into the pulmonary blood due to problems with gas exchange or ventilation.

Question 29

Type I respiratory failure causes?

Answer 29

any lung disease, e.g. asthma, COPD, pneumonia, pulmonary fibrosis

Question 30

Type II respiratory failure?

Answer 30

or hypercapnic respiratory failure, caused by ventilator failure resulting in alveolar hyperventilation so CO2 builds up and isn’t being shifted

Question 31

Type II respiratory failure causes?

Answer 31

decreased respiratory drive (opiates, stroke), impaired lung movements like reduced compliance and hyperinflated lungs with increased dead space in COPD.

Question 32

Differential diagnosis for bibasal crepitations?

Answer 32

Question 33

Differential diagnosis for SOB in post operative patient?

Answer 33