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Medicine - Respiratory Flashcards

1
Q

Why is it important to do an FBC in suspected COPD?

A

Need to investigate for secondary polycythaemia

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2
Q

What is the gold standard test for diagnosing COPD?

A

Spirometry

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3
Q

What are the indications for prescribing azithromycin to copd patients regularly?

A
  • Non-smoker
  • Optomised medical management
  • Referred for pulmonary rehabilitation
  • 4 or more infective exacerbations per year with at least 1 hospitilisation
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4
Q

Recall some conservative measures for managing COPD

A

Smoking cessation
Mucolytics
Vaccines

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5
Q

What is the 1st line for medically managing COPD?

A

SAMA or SABA prn

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6
Q

Give an example of a SAMA

A

Ipratropium

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7
Q

What is the 2nd line for medically managing COPD?

A

It depends if there are asthmatic features:
Asthmatic features: LABA + ICS
No asthmatic features: LABA + LAMA

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8
Q

Give an example of a LAMA

A

Tiotropium

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9
Q

What is Symbicort?

A

LABA + ICS

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10
Q

What would count as ‘asthmatic features’ in a patient with COPD?

A
  • History of asthma/ atopy
  • FEV1 variation over time
  • Eosinophilia
  • Diurnal variation in PEFR (>20%)
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11
Q

Recall some surgical options for managing emphysema

A
  • Bullectomy
  • Lung resection surgery (if emphysema is heterogenous)
  • Endobrachial valve placement
  • Lung transplant
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12
Q

Recall the requirements for long term oxygen therapy in COPD

A

Non smoker plus either:

  • pO2 <7.3
  • pO2 = 7.3-8 and one of secondary polycythaemia/ peripheral oedema/ pulmonary hypertension
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13
Q

Recall some possible local and systemic complications of COPD

A

Local: pneumothorax, lung Ca, bullae formation, lobar collapse
Systemic: pulmonary htn, cor pulmonale, polycythaemia

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14
Q

What are the best investigations for assessing the possibility of asthma in 5-16 year olds?

A

Spirometry with BDR (bronchodilator reversibility) test +/- FeNO test

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15
Q

What are the best investigations for assessing the possibility of asthma in adults?

A

FeNO test followed by spirometry with BDR (bronchodilator reversibility) test +/-:

  • PEFV (peak expiratory flow variation)
  • Bronchial challenge
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16
Q

What is a bronchial challenge?

A

Patient breathes in slowly whilst dose of metacholine/ histamine is increased (airway irritants) to see how high a dose they can tolerate

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17
Q

What is a ‘PC20’ in asthma diagnosis?

A

Measurement taken in bronchial challenge

Provocative concentration causing a 20% fall in FEV1

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18
Q

What is the positive test threshold for diagnosing asthma in a FeNO test?

A

> 40 parts per billion

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19
Q

What is the positive test threshold for diagnosing asthma using FEV1/FVC ratio?

A

<70% (indicative of obstructive picture)

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20
Q

What is the positive test threshold for diagnosing asthma in a BDR test?

A

> 12% variability and >200mL increase in volume after SABA administration

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21
Q

What is the positive test threshold for diagnosing asthma using peak flow variability?

A

> 20% PEFR variability

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22
Q

What is the positive test threshold for diagnosing asthma using a bronchial challenge?

A

PC20 <8mg/mL (with both histamine and metacholine challenge)

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23
Q

Systematically recall some differentials for wheeze

A

Respiratory: obstructive pathologies eg asthma, COPD, inhald foreign body
Rheumatological: granulomatosis with polyangiitis (obliterative bronchiolitis), rheumatoid arthritis
Cardiac: heart failure

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24
Q

At what PEFR should someone definitely be admitted to hospital for an acute asthma attack?

A

<33%

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25
Q

At what SaO2 is an acute asthma attack considered ‘life-threatening?

A

<92%

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26
Q

At what PEFR is an acute asthma attack considered ‘life-threatening?

A

<33%

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27
Q

When would an acute asthma attack be considered ‘near fatal’?

A

When the pCO2 is raised

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28
Q

When can you discharge someone following an acute asthma attack safely?

A

When they have been stable for 48 hours - then review 48 hours post-discharge

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29
Q

What is the acronym for things to counsel the patient on before discharge following an acute asthma attack?

A 
TAME
Technique (for inhalers) 
Avoidance (of triggers) 
Monitor (PEFR) 
Educate
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30
Q

What should be the TTA drugs following an acute asthma attack?

A

Either
Prednisolone 40mg OD, PO, 5 days (if they were admitted)
Or
Quadruple ICS dose for 14 days (if they weren’t admitted)

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31
Q

Recall the steps of acute asthma attack management in hospital

A
  1. Oxygen
  2. Nebulised salbutamol (5mg)
  3. Nebulised ipratropium bromide (0.5mg)
  4. Steroid: either PO prednisolone 50mg (to be taken for 5 days) or 100mg IV hydrocortisone
  5. Call for senior support
  6. IV Magnesium sulphate
  7. IV aminophylline
  8. ITU + intubation
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32
Q

When should someone be admitted to hospital because of an acute asthma attack?

A

Always if PEFR <33%

If PEFR is between 33 and 50% and there is no response to medication in A&E

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33
Q

How often can i) salbutamol and ii) ipratropium bromide nebulisers be given?

A

Salbutamol: back to back prn
Ipratropium: 4 hourly

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34
Q

If a patient’s sputum is described as ‘rusty’ in an SBA, what sort of pneumonia is it most likely referring to?

A

Streptococcus pneumoniae

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35
Q

Which type of typical pneumonia is associated with pre-existing lung disease?

A

Haemophilus influenzae

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36
Q

Which type of typical pneumonia is most strongly associated with smoking?

A

Moraxella catarrhalis

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37
Q

If a patient’s sputum is described as ‘red currant jelly’ in an SBA, what sort of pneumonia is it most likely referring to?

A

Klebsiella

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38
Q

Which type of atypical pneumonia is associated with erythema multiforme?

A

Mycobacterium pneumoniae

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39
Q

Which type of atypical pneumonia is associated with steven johnson syndrome?

A

Mycobacterium pneumoniae

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40
Q

Which type of typical pneumonia is most associated with alcoholism?

A

Klebsiella

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41
Q

Which type of typical pneumonia is most associated with diabetes?

A

Klebsiella

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42
Q

Which type of typical pneumonia is most associated with haemoptysis?

A

Klebsiella

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43
Q

What risk factors are C. Psittaci associated with?

A

Birds

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44
Q

Recall one important complication of C. Psittaci pneumonia

A

Haemolytic anaemia

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45
Q

What is the main association with C. burnetti pneumonia in SBAs?

A

Farm animals

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46
Q

Recall the CURB65 score for assessing pneumonia

A 
Confusion (AMTS<8)
Urea >7
Resp rate >30
BP <90/60mmHg
Age >65
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47
Q

What is the most common pathogen implicated in early-onset (<48 hours) vs late-onset (>4 days) hospital-acquired pneumonia?

A

Early-onset: Streptococcus pneumonia

Late-onset: enterobacteria (E coli/ Klebsiella pneumoniae) > MRSA

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48
Q

What is the antibiotic of choice for MRSA pneumonia?

A

Vancomycin

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49
Q

What is the antibiotic of choice according to NICE for non-severe vs severe hospital-acquired pneumonia?

A

Non-severe: co-amoxiclav or doxycycline

Severe: Piptazobactam

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50
Q

Which tests for TB will be positive if the infection has been eliminated by the acquired immune response?

A

Tuberculin skin testing

IGRA (interferon gamma release assay)

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51
Q

Which tests for TB will be positive in latent TB?

A

Tuberculin skin testing

IGRA (interferon gamma release assay)

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52
Q

Which tests for TB will be positive in subclinical TB?

A

Tuberculin skin testing
IGRA (interferon gamma release assay)
(Intermittently a sputum culture)

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53
Q

Recall a possible side effect of each of the drugs used most commonly in multi-drug therapy for TB

A 
Rifampicin: orange secretions
Isoniazid: neuropathy
Pyrizinamide: Liver toxicity
Ethambutol: eye toxicity 
Mnemonic = ONLY
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54
Q

How can histology be obtained when investigating TB (and other lung diseases)?

A

EBUS (endobronchial ultrasound-guided transbronchial needle)

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55
Q

At what CD4 count should someone with HIV be given PCP prophylaxis?

A

<200

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56
Q

What counts as ‘extremely drug-resistant TB’?

A

Resistant to rifampicin, isoniazid, fluoroquinolones and at least 1 injectable

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57
Q

Which lung infection typically gives a history of desaturating on exercise?

A

PCP pneumonia

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58
Q

Recall 3 possible extrapulmonary signs of PCP pneumonia

A

Hepatosplenomegaly
Lymphadenopathy
Choroid lesions (pneumocystis choroiditis)

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59
Q

What stain is the most useful for investigating for PCP pneumonia and what will it show?

A

Silver stain

Cysts

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60
Q

What is the management for i) mild-moderate and ii) severe PCP pneumonia?

A

Mild-moderate: co-trimoxazole

Severe: IV pentamidine

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61
Q

What is the quickest vs the gold standard method for diagnosing active TB from sputum?

A

Quickest: NAAT (takes 24-48 hours, 50-80% sensitive)

Gold-standard: culture (takes 1-3 weeks)

62
Q

Which stain for sputum is used for TB screening vs diagnosis?

A

Screening: auramine
Diagnosis: Ziehl-Neelson

63
Q

Recall some immediate, early and late complications of a chest drain

A

Immediate: pain, failure, haemorrhage, pneumothorax
Early: infection, haematoma, blockage, long thoracic nerve damage (–> winged scapula)
Late: scar formation

64
Q

When is bubbling normal in a chest drain?

A

Pneumothorax
nb: abnormal in pleural effusion
If NO bubbling in pneumothorax then there is likely to be a blockage

65
Q

In what patients would a pneumothorax be counted as secondary?

A

Age >50
Smoking history
Evidence of underlying lung disease on exam or CXR

66
Q

How should secondary pneumothoraces be managed?

A

If >2cm or breathless proceed straight to chest drain
If 1-2cm, try aspiration, and only try chest drain if still >1cm
If <1cm, or successful aspiration –> admit, high flow oxygen and observe for 24 hours

67
Q

How should primary pneumothoraces be managed?

A

If >2cm or breathless –> attempt aspiration
If aspiration unsuccessful (still >1cm) –> chest drain
If aspiration successful –> consider discharge and review in OPC

If <2cm, consider discharge straight away and review in OPC

68
Q

What is a flail chest?

A

3 or more consecutive ribs fracture in 2 or more locations resulting in part of the chest wall moving paradoxically and independently of the rest
This is a life-threatening condition

69
Q

In which direction does the flail segment move during inspiration vs expiration in a flail chest?

A

Inspiration –> inwards

Expiration –> outwards

70
Q

Why is flail chest so dangerous?

A

Increases work of breathing and pulmonary contusions

Free rib can puncture the lung and cause a tension pneumothorax

71
Q

What might be seen on CXR in flail chest?

A

Rib fractures
Subcutaneous emphysema
Pneumothorax
Mediastinal shift if tension

72
Q

What are the principles of management of flail chest?

A

Analgesia and chest physiotherapy for all

Some may also need CPAP and/or surgical fixation

73
Q

Differentiate some causes of exudate vs transudate pleural effusion

A

Exudate (‘eggsudate’) involves protein - causes include: infection, PE, malignancy, trauma and pancreatitis

Transudate is caused by a disturbance of osmotic or colloid pressure - so organ dysfunction is the main cause as organs stop regulating these pressures: liver (cirrhosis), kidney (nephrotic syndrome), heart (CCF). Can also be caused by myxoedema and Meig’s syndrome (nb ascites is a component of this so osmotic pressure must be unbalanced)

74
Q

Recall some important bedside investigations for the cause of a pleural effusion

A

Examination
Basic obs
Urine dip for protein (nephrotic syndrome –> transudate pleural effusion)

75
Q

Recall some useful forms of imaging in investigating a pleural effusion

A
  1. CXR
  2. If confirmed on CXR –> contrast CT (especially if cause is exudative)
  3. If cause is CCF (transudate) do an echo
76
Q

What equipment should be used for a pleural tap?

A

21G needle and 50mL syringe

77
Q

What would a pleural tap show in empyema?

A

pH<7.2
LDH high
Glucose low

78
Q

How are exudate and transudate defined?

A 
Exudate = >30g/L protein
Transudate = <30g/L protein
79
Q

What are Light’s criteria used for and what are the 3 criteria?

A

Light’s Criteria = used in pleural effusion to establish whether fluid is exudate or transudate when protein is 25-35g/L
An exudate is likely if pleural fluid/ serum:
1. Protein >0.5
2. LDH >0.6
Or if pleural fluid LDH >2/3rds upper limit of normal of serum LDH

80
Q

When should a pleural effusion have a chest drain inserted into it?

A

If aspirate is:

  • Turbid/ cloudy
  • tests positive on MC&S
  • Has a pH<7.2
81
Q

What are the general principles of managing pleural effusion?

A
  1. Insert chest drain if indicated

2. Treat cause

82
Q

Recall some options for managing recurrent pleural effusions

A
  1. Could insert an indwelling pleural catheter
  2. Could perform pleurodesis
  3. Could recurrently aspirate
83
Q

What is pleurodesis?

A

“Pleurodesis is a procedure which involves putting a mildly irritant drug into the space between your lung and chest wall (the pleural space), on one side of your chest. This is done to try to ‘stick’ your lung to the wall of your chest and prevent a further collection of fluid or air in this space.”

84
Q

Recall some differentials for the cause of upper lobe vs lower lobe pulmonary fibrosis

A

Upper lobe = TAPE (TB, ABPA, Pneumoconiasis, EAA (hypersensitivity pneumonitis))

Lower lobe = STAIR (sarcoidosis, toxins*, asbestosis, idiopathic pulmonary fibrosis, rheumatological (RhA, SLE, Sjogren’s, scleroderma, CREST)
*toxins = bleomycin, amiodarone, nitrofurantoin, sulfasalazine, methotrexate

85
Q

Recall some signs and symptoms of pulmonary fibrosis on examination

A

Progressive exertional dyspnoea
Dry cough
Clubbing
Bibasal fine inspiratory crepitations

86
Q

What is the gold-standard form of imaging for visualing pulmonary fibrosis?

A

High resolution CT

87
Q

Why would an echocardiogram be useful in a patient with pulmonary fibrosis?

A

May show presence of pulmonary hypertension

88
Q

What are the symptoms of Kartagener’s syndrome (triad)?

A

Situs inversus
Bronchiectasis
Chronic sinusitis

89
Q

What are the symptoms of Young’s syndrome (triad)?

A

Bronchiectasis
Chronic sinusitis
Male infertility

90
Q

Recall 4 causes of pneumonia that are most likely to cause bronchiectasis

A

Streptococcus pneumoniae
Haemophilus influenzae
Klebsiella spp.
Pseudomonas aeruginosa

91
Q

What is the most common cause of bronchiectasis?

A

Idiopathic

92
Q

Which allergic pathology can cause bronchiectasis?

A

ABPA (due to eosinophilia)

93
Q

What is the most useful imaging modality for investigating bronchiectasis?

A

High-resolution CT

94
Q

What is the mainstay of medical management for ABPA?

A

Oral glucocorticoids

95
Q

What are the 2 main medications used in managing acute exacerbations of bronchiectasis?

A

Bronchodilators and antibiotics

96
Q

Recall some possible local and systemic complications of bronchiectasis

A

Local: haemorrhage, lobar collapse, T2 resp failure
Systemic: pulmonary hypertension, cachexia

97
Q

What is the rate of live birth with cystic fibrosis in the UK?

A

1 in 2,500

98
Q

What protein is mutated in cystic fibrosis?

A

cAMP-dependent chloride channel on chromosome 7

99
Q

Recall some signs and symptoms of cystic fibrosis

A 
CLUBBING FINGERS
Meconium ileus 
Recurrent chest infections, wheeze, coughing
ABPA, sinusitis, nasal polyps
Male sterility
Growth faltering
Bronchiectasis due to airway damage
Jaundice (cirrhosis, portal hypertension) 
Diabetes mellitus
100
Q

What result would be positive for cystic fibrosis in a sweat test?

A

Abnormally HIGH NaCL

101
Q

What abnormalities due to cystic fibrosis might be seen on a chest x ray?

A

Hyperinflation
Peri-bronchial shadowing
Bronchial wall thickening
Ring shadows (bronchi seen end-on)

102
Q

What are the 1st and 2nd line options for mucolytic therapy in cystic fibrosis?

A

1st line: Dornase alfa

2nd line: rhDNase + hypertonic saline, mannitol dry powder (INH)

103
Q

Which prophylactic oral antibiotics are given to patients with cystic fibrosis to prevent chance of exacerbation?

A

Flucloxacillin and azithromycin

104
Q

What adjustments to diet should be made for patients with cystic fibrosis?

A

High calorie and high fat (150% of normal)
Fat soluble vitamin supplements
CREON pancreatic enzyme replacement with every meal

105
Q

How can liver problems in cystic fibrosis be medically managed?

A

Ursodeoxycholic acid

106
Q

What sort of bowel obstruction can people with cystic fibrosis develop?

A

Distal intestinal obstruction syndrome (DIOS)

Viscous muco-faeculent material obstructs the bowel

107
Q

How can distal intestinal obstruction syndrome be managed?

A

Usually can be cleared with oral laxatives

108
Q

Recall 5 subtypes of non small cell lung cancer

A 
Adenocarcinoma 
Squamous cell carcinoma
Large cell carcinoma
Alveolar cell carcinoma
Bronchial adenoma
109
Q

What % of all lung cancers are small cell?

A

15%

110
Q

What is hypertrophic osteoarthropathy (HPOA)?

A

Painful proliferative periostitis affecting long bones - commonly affecting the wrists and ankles - a cause of clubbing

111
Q

Which types of lung cancer are associated with HPOA?

A

Adenocarcinoma

Squamous cell carcinoma

112
Q

Which type of lung cancer is associated with gynaecomastia?

A

Adenocarcinoma

113
Q

Which type of lung cancer is associated with PTHrP?

A

Squamous cell carcinoma

114
Q

Which type of lung cancer is associated with ectopic TSH?

A

Squamous cell carcinoma

115
Q

Which type of lung cancer is associated with beta HCG?

A

Large cell carcinoma

116
Q

For the following lung cancers, say whether they are typically central or peripheral:

  • Small cell
  • Adenocarcinoma
  • Squamous cell
  • Large cell
A
  • Small cell: central
  • Adenocarcinoma: peripheral
  • Squamous cell: central
  • Large cell: peripheral
117
Q

Which type of lung cancer is associated with Lambert-Eaton Myasthaenic syndrome?

A

Small cell carcinoma

118
Q

Which type of lung cancer is associated with SIADH?

A

Small cell carcinoma

119
Q

Which type of lung cancer is associated with production of ectopic ACTH?

A

Small cell carcinoma

120
Q

Which lung cancer is more common in non-smokers?

A

Adenocarcinoma

121
Q

Which type of lung cancer can present with hoarseness?

A

Pancoast tumours (apical)

122
Q

What is the most common initial symptom of SVC obstruction?

A

Feeling full in the face when leaning forwards

123
Q

Recall some signs and symptoms of lung cancer

A

Classically: Cough, haemoptysis, weight loss
Also: SOB, chest pain, anorexia, SVCO

124
Q

In what order should imaging be requested for suspected lung cancer?

A

CXR
Volumentric CT
FDG-PET-CT

125
Q

What is the use of spirometry in lung cancer patients?

A

Determining fitness for surgery

126
Q

How can a biopsy be obtained in lung cancer?

A

Bronchoscopy and EBUS

127
Q

What are the 2 week wait guidelines for lung cancer for under 40s?

A 
At least 2 symptoms in non-smokers, or at least 1 symptom in ex/current-smokers: 
Cough
Chest pain
Fatigue
Unintedned weight loss 
SOB
Appetite loss
128
Q

What are the 2 week wait guidelines for lung cancer for over 40s?

A

At least one of the following symptoms:
mnemonic = INTEL
Infection (chest, recurrent)
Nail clubbing
Thrombocytosis
Examination signs consistent with lung Ca
Lymphadenopathy (supraclavicular/ persistent cervical)

129
Q

What minimum result on spirometry is necessary for a lung cancer patient to be considered fit for surgery?

A

FEV1>1.5L on spirometry

130
Q

What 2 tests are used to detemine whether a lung cancer patient is fit for surgery?

A

Spirometry and mediastinoscopy

131
Q

Which stages of small cell lung cancer might be suitable for surgery?

A

T1-2a, N0 M0

132
Q

How would late stage small cell lung cancer be managed?

A

If limited disease: combination chemoradiotherapy

If extensive disease: palliative chemotherapy

133
Q

How is non-small cell lung cancer that is not suitable for surgery managed?

A

Palliative/ curative radiotherapy (poor response to chemo)

134
Q

What sort of nerve palsy can be a local complication of lung cancer?

A

Phrenic nerve palsy or recurrent laryngeal nerve palsy

135
Q

Recall some possible systemic complications of lung cancer

A

Depending on type of tumour, may get:

  • Gynaecomastia
  • Ectopic hormone production (LEMS, SIADH, ACTH, PTHrP)
  • Dermatomyositis
136
Q

How would FEV1 and FVC be affected by obstructive vs restrictive lung pathologies?

A

Obstructive: FEV1 very reduced; FVC reduced or normal
Restrictive: FEV1 reduced; FVC very reduced

137
Q

Why would the TLCO be reduced in obstructive and restrictive lung disease?

A

TLCO = overall measure of gas transfer
Obstructive disease: O2 can’t get in –> reduced TLCO
Restrictive disease: fewer capillaries to access –> reduced TLCO

138
Q

What do TLCO and DLCO stand for?

A

TLCO = transfer factor of CO
DLCO = diffusion capacity of CO
Who knows where the Ls come from??

139
Q

How should the TLCO be managed?

A

Inhale and hold breath for 10 seconds then exhale. There shouldn’t be any CO in the exhalation

140
Q

How does the TLCO relate to the amount of CO being exhaled

A

Raised TLCO = less CO being exhaled than normal

Caused of increased perfusion: diastolic CHF, exercise, alveolar haemorrhage, polycythaemia, asthma

141
Q

What sign on chest x ray is produced by left lower lobe collapse?

A

Sail sign

142
Q

What sign on chest x ray is produced by left upper lobe collapse?

A

Veil sign

143
Q

When prescribing macrolides for CAP, recall one common drug that has a significant drug interaction with it

A

Statins

144
Q

What are the indications for corticosteroid treatment in sarcoidosis?

A

Parenchymal lung disease
Uveitis
Hypercalcaemia
Neurological or cardiac involvement

145
Q

If a patient has well-controlled asthma, how much is it reasonable to reduce their steroid dose by?

A

25-50%

146
Q

What are the borders of the area in which a chest drain can be inserted?

A

Base of the axilla
Lateral edge pectoralis major
5th intercostal space
Anterior border of latissimus dorsi

147
Q

How do emphysematous bullae appear on CXR?

A

Lucency without a visible wall

148
Q

Recall one rheumatoid arthritis drug that can cause pulmonary fibrosis

A

Methotrexate

149
Q

How should pulmonary fibrosis affect FEV1:FVC ratio and TLCO?

A

FEV1:FVC ratio should be normal (>70%)

TLCO should be decreased

150
Q

In what lung pathology might you get raised platelets on an FBC?

A

Lung malignancy

151
Q

What is re-expansion pulmonary oedema?

A

If a pleural effusion is drained too quickly, re-expansion pulmonary oedema is a rare but important complication that can develop

152
Q

Recall 4 drugs that can cause pulmonary fibrosis

A

Amiodarone
Nitrofurantoin
Sulfasalazine
Methotrexate

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