*Mechanics of Breathing, Infections & Chest Pain

Question 1

Discuss the presentation & initial investigation of chest pain and pain on inspiration

Answer 1

• ECG: signs of arrhythmia, PE, angina, acute coronary syndrome
• Bloods
  1. FBC: check for anaemia which may be exacerbating stable angina
  2. Troponin: takes 3-4 hours to increase but can stay high for 14 days. High troponin indicates damage to myocardium
  3. D-dimer
  4. Blood glucose: to review person’s CV risk
  5. U&E: to review person’s CV risk
  6. LFT: check for cholecystitis and pancreatitis
  7. CRP/ESR: pneumonia
• Chest x-ray
• CT
• CTPA – pulmonary embolism
• Echocardiogram

CV - cardiovascular

Question 2

Discuss the key differential diagnosis of chest pain and pain on inspiration

Answer 2

Cardiac
- Myocardial ischaemia/infarction
- Pericarditis
- Aortic dissection
Respiratory
- Pulmonary embolism
- Pneumothorax
- Pneumonia
- Pleural inflammation
- Lung cancer
Gastrointestinal
- Oesophageal spasm
- Dysmotility/reflux
- Oesophageal rupture
Musculoskeletal
- Rib fracture
- Metastases
- Muscle spasm/strain
- Costochondritis
Other systems
- Skin (herpes zoster/shingles)
- Upper abdomen radiated to chest – e.g. stone in the gall bladder, cholecystitis
- Psychological states – panic attack, hyperventilation

Question 3

Describe the main defence mechanisms of the respiratory tract against inhaled pathogens and the mucociliary system function

Answer 3

• Mechanical - Nasal Hair & Mucocillary system
• Chemical - Lysozymes, Lactoferrin, Defensins & Surfactant
• Cellular - Phagocytes (alveolar macrophages) & Dendritic cells
• Normal flora

Question 4

Explain the physiology of ventilation including the role of the muscles of ventilation and surfactant

Question 5

Explain the transport of oxygen and carbon dioxide in the body, including the control of acid-base balance

Question 6

Explain the role of the autonomic nervous system in the lung

Question 7

Discuss the microbiology of respiratory pathogens

Question 8

Discuss common and important parasite and vector borne diseases

Question 9

Describe the nature of microbial commensals and distinguish them from pathogens causing sore throat

Question 10

Discuss the basic epidemiology, pathophysiology, presentation, investigation, management and prognosis of upper respiratory tract infections

Question 11

Discuss the basic epidemiology & pathophysiology of Influenza

Question 12

Discuss the basic presentation & investigation of Influenza

Question 13

Discuss the basic management & prognosis of Influenza

Question 14

Discuss the basic epidemiology & pathophysiology of Lower respiratory tract infections & pneumonia

Question 15

Discuss the basic presentation & investigation of Lower respiratory tract infections & pneumonia

Question 16

Discuss the basic management & prognosis of Lower respiratory tract infections & pneumonia

Question 17

Describe the relationship between ventilation and perfusion of the lung

Question 18

5 Life threatening causes of chest pain & How to rule each out

Answer 18

1. Myocardial Infarction - ECG & Trop
2. Aortic Dissection - Echo
3. Tension Pneumothorax - CXR & absent breath sounds
4. Pulmonary embolism - ddimer & CTPA
5. Oesophageal rupture - haematemsis

Question 19

Discuss the management of Chest Pain

Answer 19

Analgesia

Admit people with:
- Respiratory rate >30 breaths per minute
- Tachycardia >130 beats per minute
- Systolic blood pressure <90mmHg or diastolic <60mmHg
- Oxygen saturation less than 92%, or central cyanosis
- Altered level of consciousness
- Raised temperature

Do not routinely administer oxygen, only if:
- Oxygen saturations <94% who are not at risk of hypercapnic respiratory failure
- Use simple face mask to achieve target of 94-98%
- Use a 28% venturi and keep flow rate to 4L/min to achieve target 88-92%