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Respiratory medicine for RACP > Long case > Flashcards

Long case Flashcards

1
Q

Lung disease severity measures - history

A
  • Exercise tolerance, up flights stairs
  • Ability to be comfortable, speaking in sentences
  • Frequency of exacerbations
  • Frequency of hospital admissions
  • Frequency of respiratory infections
  • Frequency of intubations
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2
Q

Lung disease severity measures - exam

A
  • Respiratory rate
  • Acute irritability
  • Low sats and oxygen requirements
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3
Q

Lung disease severity measures - investigations

A
  • FEV1 and FVC
  • DLCO
  • Oxygen saturation and concentration on arterial blood gas
  • Degree of hypercapnoea and compensation for respiratory acidosis
  • Pulmonary pressure on TTE
  • VO2 max on exercise testing
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4
Q

Adherence measures/history - cardiorespiratory

A
  • Regular use of inhalers with correct use of spacer and medications
  • Smoking cessation
  • Peak expiratory flow measures on regular basis
  • Use of action plan
  • Regular GP and specialist appointments
  • Yearly influenza vaccinations, completed pneumococcal vaccinations
  • Avoidance of potential triggers
  • Involvement in rehabilitation and exercise program
  • Involvement of loved ones, community support in care
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5
Q

Bronchiectasis risk factors

A

recurrent childhood infections
immunodeficiency
abnormal mucociliary drainage – CF, kartager’s syndrome

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6
Q

Complications of bronchiectasis

A

o Frequency of pneumonia, courses of antibiotics
o Abscess, empyema and thoracic decortication surgery (time of surgery, management, complications)
o Recurrent pleurisy – severity of symptoms, impact on life, management
o Colonisation with resistant organisms – recent cultures, eradication with Abx
o Pulmonary hypertension and right heart failure
o Bronchial haemorrhage requiring bronchoscopy and cautery
o Amyloidosis
o Other systemic infections (infective endocarditis)

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7
Q

Diagnosis of CF

A

CT, sweat testing, ciliary function testing, bronchoscopy, immunoglobulins, eosinophilia (allergic bronchopulmonary aspergillosis)

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8
Q

Treatment of bronchiectasis

A 
o	Sputum clearance
o	Antibiotics
o	Bronchodilators
o	Inhaled steroids
o	Oral steroids
o	Twice daily postural drainage
o	Vaccination
o	Treatment of HF
o	IV immunoglobulin
o	Bronchoscopy of haemoptysis
o	Lobectomies, wedge resections for localised drainage
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9
Q

Lung carcinoma - local symptoms

A

o Reduced exercise tolerance
o Pleural and thoracic chest pain (pleural and thoracic wall involvement)
o Dysphagia, hoarseness, stridor (tracheal and oesophageal obstruction)
o Headache and dizziness (superior vena caval obstruction)
o Bony pain, abdominal pain (metastasis)

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10
Q

lung carcinoma - systemic symptoms

A 
o	Loss of weight, appetite, night sweats
o	New paraesthesia, weakness unsteadiness (LEMS, peripheral neuropathy, cerebellar degeneration, polymyositis and dermatomyositis, acute transverse myelitis)
o	Limb pain, purpura (DVT, DIC)
o	Polyuria (hypercalcaemia)
o	Acanthosis nigricans, scleroderma
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11
Q

Lung carcinoma - investigations

A

o CT scans, biopsy -bronchoscopy or CT guided, VATS pleural, pleural tap
o Staging -CTCAP, PET scan
o PFTs for fitness for surgery FEV1 >1.5L

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12
Q

Lung carcinoma - treatment

A

o Chemotherapy – weekly/fortnightly course number of courses
 Antiemetic therapy, chemotherapy nursing support
 In hospital, clinic, home
o Radiotherapy
 Brain – prophylactic
 Chest –

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13
Q

Complications of lung carcinoma - disease

A 
o	Progression of local disease, metastasis – liver, abdominal, bony involvement
	Cord compression
ascites
biliary sepsis
obstructive pneumonia
DVT/PE
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14
Q

Complications of prednisolone treatment

A 
	Myopathy
	Opportunistic infections
	Mania/psychosis
	Osteoporotic fractures
	Dysmorphic cushingoid features
	BSL derangements, refractory hypertension
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15
Q

Chemotherapy SEs lung cancer

A 
	Nausea vomiting
	Mucositis
	Typhlitis, neutropaenic sepsis
	Peripheral neuropathy and pain
	Ototoxicity
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16
Q

Complications lung Ca - cancer pain

A 
	Degree of opioid requirement
•	Number of rotations
•	Overdoses
	Local nerve blocks
	Functional loss due to pain
	Degree of sleep loss 
	Degree of emotional distress
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17
Q

Measures of response - lung cancer

A

 Surveillance scans and PET post treatment course
 Blood counts, BMT myeloid/lymphoid malignant cell counts
 Blood tests – CA199, PSA
 Degree of functionality – walking, daily activities, ability to walk, moods
 Level of pain

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18
Q

COPD precipitants

A 
o	Upper and lower respiratory tract infections
o	Omission of medications
o	Heart failure
o	Sleep apnoea
o	Pneumothorax
o	GORD
o	aspiration
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19
Q

COPD diagnosis

A

o Initial symptoms, spirometry – bronchodilator responsiveness, CT, arterial blood gases, FVC, FEV1

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20
Q

Complications of COPD

A

o Number of hospital admissions
o Number of exacerbations
o Number intubations
o Current exercise tolerance, flights of stairs, things unable to do
o FEV1, 6 minute walk test
o Oxygen concentration on arterial blood gas
o Current weight and degree of weight loss
o Pulmonary hypertension and right heart failure
o Lung cancer (separate issue)
o Depression (separate issue)

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21
Q

ECOG

A

0 Acute without restriction of performance
1 Ambulatory and able to attend light work activity, unable to carry out strenuous activity
2 Can manage self-care but unable to attend any form of work activity, ambulatory for more than 50% of the time while awake
3 Can manage one limited self care, bed bound for more than 50% of the time
4 Disabled, completely bed bound

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22
Q

Smoking - history

A

 Amount smoked

 Evidence of nicotine dependence – smokes >10/day, 30mins between smokes, smoking from waking

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23
Q

Smoking - high risk groups

A
  • Pregnancy
  • Parents of young children
  • Aboriginal and torres strait islanders
  • Mental illness
  • Other substance abuse
  • Lung disease
  • CVD risk factors and diabetes
  • Low socio-economic status
24
Q

Smoking - Initial management

A

brief advice, motivational interviewing, quit date
Follow up - Relapses occur in first few weeks of quitting and require follow up
• Associated with weight gain, stress, and withdrawal symptoms

25
Q

Smoking - pharmacological therapy

A

 NRT increases quit rates by 60% from placebo, combination therapy oral and patch more effective than one alone CI – pregnancy, arrhthymias, lactation, CVD, angina, stroke
 Varenicline – most effective, doubling abstinence rates, nausea; CI neuropsychiatric disease; however no increase in SI
 Bupropion – effective with social support- CI in seizures, CNS disease, PD MAOI treatment; caution in DM, CKD, other drugs that may reduce seizure threshold

26
Q

Current COPD treatment

A

o Bronchodilators and spacer
o Domociliary oxygen – ABG, desaturation on 6MWT
o Annual influenza vaccinations
o BiPAP
o Number of prednisolone courses
o Pulmonary rehabilitation attendance, number of times, usefulness
o Lung valves, lobectomies
o Transplantation work up (separate issue)
o Antiprotease therapy for alpha1 antitrypsin
o Frusemide for RHF

27
Q

COPD - asthma ddx

A 
Non smoker
Childhood onset
Allergy
Nocturnal symptoms
Rapid response to treatment
Eosinophila in sputum
Bronchodilator reversibility
Atopy
28
Q

COPD - bronchiectasis ddx

A

Daily sputum expectoration
Childhood recurrent chest infections, pertussis
Clubbing

29
Q

COPD examination

A
  • Pursed lip breathin
  • Cyanosis/polycythaemia
  • Intercostal recession
  • Prolonged forced expiration
  • Tracheal tug
  • Reduced diaphragmatic movements
  • Reduced chest wall expansion
  • Hoover’s sign
  • Reduced breath sounds w/ wheeze
  • Sputum
  • RHF – parasternal heave, cv JVP, palpable P2, pulsatile liver
  • Cachexia
30
Q

Sleep apnoea - history

A
  • History – symptoms/concern leading to sleep study
  • Use of hypnotics
  • Evidence of paroxysmal nocturnal dyspnoa, orthopnoea, sensation of choking
  • Driving – heavy machinery licence, adherence to driving restrictions
31
Q

Risk factors OSA

A 
obesity
daytime sleepiness
alcohol
hypertension
atrial fibrillation
GORD, COPD
systolic heart failure
deviated nasal septum
nasopharyngeal deformity or tonsillar enlargement (if no obvious obesity)
32
Q

Epworth sleepiness scale

A 
o	Reading 
o	TV
o	Theatre or meeting
o	Driving as a passenger > 1hr
o	Lying in afternoon
o	Sitting and talking
o	Sitting after lunch
o	Dozing at traffic lights
33
Q

Components of sleep study

A 
o	Electroencephalogram
o	Apnoea/hypoapnoea index
o	Chin myogram
o	Electro-occular monitoring REM sleep
o	Sats probe
o	ECG overnight
34
Q

Managment OSA

A 
o	Use of CPAP
	Adherence, nose bridge ulcers, uncomfortable mask, dyspnoea/anxiety in mask
	Improvement in sleepiness
o	Weightloss
o	Surgical correction of upper airway
35
Q

OSA exam

A
  • Malampatti score
  • Neck circumference
  • BMI
  • Hip/waist ratio
  • Acanthosis nigricans
  • Evidence of nasal bridge ulcers
36
Q

Interstitial lung disease - symptom history

A

o Dry cough, worsening dysponea
o History of pneumothorax, young woman
o Systemic/rheumatic symptoms
o History of asthma -> Churg-Strauss syndrome
o Haemoptysis/renal disease – Goodpastures/SLE

37
Q

Interstitial lung disease - drug/RTx history

A

 Cardiac/anti-arrhythmic – amiodarone, procainamide
 Hydralazine
 Rheumatologic – MTX, penicillamine
 Chemotherapeutics – bleomycin, bisulphin
o Prior radiotherapy

38
Q

Interstitial lung disease - rheumatic symptoms

A 
Raynauds
Polyarthritis
Rashes
Morning stiffness
Generalised malaise, LOW, LOA, sweats
Pleural lung disease, pericarditis
39
Q

Interstitial lung disease - occupational history

A

 Silica, asbestos, coal
 Nitrogen, chloride gas, ammonia gas
 Brake fluid, vinyl chloride

40
Q

Interstitial lung disease - Hypersensitivity exposure

A

 Bird, farmers – mouldy hay/grain
 Cotton (byssinosis), flax/hemp dust
o History of tuberculosis exposure

41
Q

Interstitial lung disease - investigations

A

o CT chest – fibrosis, usual interstitial pneumonia (honey combing, subpleural basal predominance, traction bronchiectasis), Non-specific interstitial fibrosis
o Brochoscopy and lavage w/ biopsy
o ESR, CRP, ANA/ENA ABG

42
Q

Interstitial lung disease - treatment

A

o Remove exposure, steroids – hypersensitivity, COP, sarcoidosis, CTD, histiocytosis X
o Nifedipine
o Lung Tx
o Home O2

43
Q

Investigations for pulmonary HTN

A

TTE, cardiac catheterisation, PFT, CT chest, V/Q, CTPA, HRCT, 6 minute walk test

44
Q

Risk factors for Pul HTN

A

o Prior PE, COPD, heart failure, family history, gene testing (BMPR2), HIV, interstitial lung disease, sleep apnoea, scleroderma/MCTD

45
Q

Medications for pul HTN

A

warfarin, bosentin, sildenafil, prostacyclin (SE: flushing)

46
Q

History for sarcoidosis

A 
o	Systemic symptoms
o	Joint symptoms and rash
o	Eye involvement – uveitis
o	Sinusitis, parotiditis
o	Renal stones
o	Nerve palsies
47
Q

Differentials for sarcoidosis

A

o Connective tissue disease -SLE – joint/rashes, mucosal involvements, RA, seronegative arthritis, sjogrens
o Bechet’s disease – genital and mucosal ulcers, family history
o Vasculitis – Granulomatous polyangiitis, eosinophilic polyangiitis, polyarteritis nodosa, GCA/PMR +/- glomerulonephritis
o Antiphospholipid syndrome
o Lymphoma, paraproteinaemia, POEMS, castleman’s
o Subacute infective endocarditis
o Atrial myxoma
o Cholesterol emboli – recent angiography
o Tick disease
o Hypothyroidism/hyperthyroidism

48
Q

Symptoms of hypercalcaemia in sarcoid

A

o Polyuria, polydipsia, confusion

49
Q

Investigations for sarcoidosis

A

o ESR, CRP, ANA/ENA/ANCA, dsDNA, SPEP, immunoglobulins, TFTs, FBE, CMP, Vitamin D, CT chest, TTE, blood cultures bone marrow biopsy

50
Q

Cystic fibrosis - systemic involvement

A 
o	Recurrent pneumonia, pleurisy, effusion, empyema and abscess
o	Bronchiectasis
o	Nasal polyps
o	Pancreatic failure - malabsorption,
o	small bowel obstruction
o	Focal biliary cirrhosis
o	Exocrine diabetes mellitus
51
Q

Cystic fibrosis - investigations

A

o Sweat/chloride testing
o PCR/DNA gene marker
o Spirometry FEV1, CT scans
o Sputum cultures, colonisation
o FBE for anaemia of chronic disease, IDA, and B12 deficiency
o LFTs, INR, abdominal USS, AFP, gastroscopy for varices

52
Q

Cystic fibrosis - complications

A 
o	Haemoptysis
o	Pneumonia
o	Empyema
o	Pleurisy
o	Pneumothorax
53
Q

Management of cystic fibrosis

A 
o	Physiotherapy
o	Exercise tolerance
o	Pancreatic enzyme supplementation
o	High fat diet
o	Recombinant DNAase
-	Transplantation work up
o	Regular appointments
o	Fertility, consideration of IVF
54
Q

Indications for lung transplant

A 
COPD FER <25%, 
cystic fibrosis PaCO2 > 55, FER < 30%,
ILD DLCO <20%, symptoms, 
eisenmengers, 
pulHTN – PAP >55, cardiac index <2L/min?
55
Q

Contra-indications for lung transplant

A

Relative - T2DM ,osteoporosis, etOH, smoking, MAC/tuberculosis abscesus colonisation, wt >130% ideal <70% ideal, compliance
Absolute HIV, HBV, HCV, malignancy <5yrs

56
Q

Transplant history

A
  • Rejection -HLA matching
  • Infections – influenza, aspergillosis, CMV, myxomavirus, aspergillosis
  • Immunosuppression – renal transplant, hyperlipidaemia, post transplant lymphoproliferative disorders
  • Brochiolitis oliterans – chronic rejection,

Respiratory medicine for RACP (6 decks)

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