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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
Smoking - pharmacological therapy
 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
Current COPD treatment
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
COPD - asthma ddx
``` Non smoker Childhood onset Allergy Nocturnal symptoms Rapid response to treatment Eosinophila in sputum Bronchodilator reversibility Atopy ```
28
COPD - bronchiectasis ddx
Daily sputum expectoration Childhood recurrent chest infections, pertussis Clubbing
29
COPD examination
- 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
Sleep apnoea - history
- 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
Risk factors OSA
``` 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
Epworth sleepiness scale
``` 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
Components of sleep study
``` o Electroencephalogram o Apnoea/hypoapnoea index o Chin myogram o Electro-occular monitoring REM sleep o Sats probe o ECG overnight ```
34
Managment OSA
``` 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
OSA exam
- Malampatti score - Neck circumference - BMI - Hip/waist ratio - Acanthosis nigricans - Evidence of nasal bridge ulcers
36
Interstitial lung disease - symptom history
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
Interstitial lung disease - drug/RTx history
 Cardiac/anti-arrhythmic – amiodarone, procainamide  Hydralazine  Rheumatologic – MTX, penicillamine  Chemotherapeutics – bleomycin, bisulphin o Prior radiotherapy
38
Interstitial lung disease - rheumatic symptoms
``` Raynauds Polyarthritis Rashes Morning stiffness Generalised malaise, LOW, LOA, sweats Pleural lung disease, pericarditis ```
39
Interstitial lung disease - occupational history
 Silica, asbestos, coal  Nitrogen, chloride gas, ammonia gas  Brake fluid, vinyl chloride
40
Interstitial lung disease - Hypersensitivity exposure
 Bird, farmers – mouldy hay/grain  Cotton (byssinosis), flax/hemp dust o History of tuberculosis exposure
41
Interstitial lung disease - investigations
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
Interstitial lung disease - treatment
o Remove exposure, steroids – hypersensitivity, COP, sarcoidosis, CTD, histiocytosis X o Nifedipine o Lung Tx o Home O2
43
Investigations for pulmonary HTN
TTE, cardiac catheterisation, PFT, CT chest, V/Q, CTPA, HRCT, 6 minute walk test
44
Risk factors for Pul HTN
o Prior PE, COPD, heart failure, family history, gene testing (BMPR2), HIV, interstitial lung disease, sleep apnoea, scleroderma/MCTD
45
Medications for pul HTN
warfarin, bosentin, sildenafil, prostacyclin (SE: flushing)
46
History for sarcoidosis
``` o Systemic symptoms o Joint symptoms and rash o Eye involvement – uveitis o Sinusitis, parotiditis o Renal stones o Nerve palsies ```
47
Differentials for sarcoidosis
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
Symptoms of hypercalcaemia in sarcoid
o Polyuria, polydipsia, confusion
49
Investigations for sarcoidosis
o ESR, CRP, ANA/ENA/ANCA, dsDNA, SPEP, immunoglobulins, TFTs, FBE, CMP, Vitamin D, CT chest, TTE, blood cultures bone marrow biopsy
50
Cystic fibrosis - systemic involvement
``` 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
Cystic fibrosis - investigations
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
Cystic fibrosis - complications
``` o Haemoptysis o Pneumonia o Empyema o Pleurisy o Pneumothorax ```
53
Management of cystic fibrosis
``` 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
Indications for lung transplant
``` COPD FER <25%, cystic fibrosis PaCO2 > 55, FER < 30%, ILD DLCO <20%, symptoms, eisenmengers, pulHTN – PAP >55, cardiac index <2L/min? ```
55
Contra-indications for lung transplant
Relative - T2DM ,osteoporosis, etOH, smoking, MAC/tuberculosis abscesus colonisation, wt >130% ideal <70% ideal, compliance Absolute HIV, HBV, HCV, malignancy <5yrs
56
Transplant history
- 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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