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MCCQE1 > Medicine- respiratory > Flashcards

Medicine- respiratory Flashcards

1
Q

Signs and symptoms of lung cancer

A

Shortness of breath

Cough

Haemoptysis

Finger clubbing

Recurrent pneumonia

Weight loss

Lymphadenopathy – often supraclavicular nodes are the first to be found on examination

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2
Q

Signs of lung cancer on CXR

A
  • Hilar enlargement
  • “Peripheral opacity” – a visible lesion in the lung field
  • Pleural effusion – usually unilateral in cancer
  • Collapse
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3
Q

Horner’s syndrome triad

Which lung pathology is it associated with?

A

Partial ptosis, anhidrosis and miosis

Pancoast’s tumour

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4
Q

Classic clinical signs of pneumonia

A

-Bronchial breath sounds. These are harsh breath sounds equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.

  • Focal coarse crackles. These are air passing through sputum in the airways similar to using a straw to blow in to a drink.
  • Dullness to percussion due to lung tissue collapse and/or consolidation.
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5
Q

Legionella pneumophila (Legionnaires’ disease) can sometimes present with what?

A

Hyponatraemia

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6
Q

The rash associated with mycoplasma pneumonia

A

Erythema multiforme

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7
Q

Atypical pneumonia with Chlamydia psittaci is associated with what?

A

Bird keeping

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8
Q

The definition of atypical pneumonia

A

Pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain. They don’t respond to penicillins and can be treated with macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).

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9
Q

Typical asthma triggers

A
  • Infection
  • Night time or early morning
  • Exercise
  • Animals
  • Cold/damp
  • Dust
  • Strong emotions
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10
Q

First line Ix in asthma

A

Fractional exhaled nitric oxide (FeNo test)

Spirometry with bronchodilator reversibility

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11
Q

Monitor serum what for pts on salbutamol?

A

Potassium

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12
Q

Typical sarcoid patient

A

Black Female Young or about 60y old

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13
Q

Blood abnormalities in sarcoid patients

A
  • Raised serum ACE. This is often used as a screening test.
  • Hypercalcaemia (rasied calcium) is a key finding.
  • Raised serum soluble interleukin-2 receptor
  • Raised CRP
  • Raised immunoglobulins
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14
Q

Lung features of sarcoid

A

Lungs (affecting over 90%)

Mediastinal lymphadenopathy

Pulmonary fibrosis

Pulmonary nodules

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15
Q

Diagnosis of sarcoid

A

The gold standard for confirming the diagnosis of sarcoidosis is by histology from a biopsy. This is usually done by doing bronchoscopy with ultrasound guided biopsy of mediastinal lymph nodes.

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16
Q

First line treatment mild sarcoid

A

No treatment is considered as first line in patients with no or mild symptoms as the condition often resolves spontaneously.

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17
Q

The rash associated with sarcoid

A

Erythema nodosum. On the shins usually

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18
Q

Sarcoid histology

A

non-caseating granulomas with epithelioid cells.

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19
Q

Sarcoid treatment

A

Oral steroids are usually first line where treatment is required and are given for between 6 and 24 months.

Patients should be given bisphosphonates to protect against osteoporosis whilst on such long term steroids.

Second line options are methotrexate or azathioprine

Lung transplant is rarely required in severe pulmonary disease

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20
Q

Symptoms + signs of pulmonary hypertension

A

Shortness of breath is the main presenting symptom. Other signs and symptoms are:

Syncope

Tachycardia

Raised JVP

Hepatomegaly

Peripheral oedema.

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21
Q

The causes of pulmonary hypertension

A

The causes of pulmonary hypertension can split into 5 groups:

  • Group 1 – Primary pulmonary hypertension or connective tissue disease such as systemic lupus erythematous (SLE)
  • Group 2 – Left heart failure usually due to myocardial infarction or systemic hypertension
  • Group 3 – Chronic lung disease such as COPD
  • Group 4 – Pulmonary vascular disease such as pulmonary embolism (chronic thromboembolic disease)
  • Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders
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22
Q

ECG changes in pulmonary hypertension

A

-Right ventricular hypertrophy seen as larger R waves on the right sided chest leads (V1-3) and S waves on the left sided chest leads (V4-6) -Right axis deviation -Right bundle branch block

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23
Q

Rx primary pulmonary hypertension

A

IV prostanoids (e.g. epoprostenol)

Endothelin receptor antagonists (e.g. macitentan)

Phosphodiesterase-5 inhibitors (e.g. sildenafil)

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24
Q

Diagnosis of interstitial lung disease

A

Clinical features + high resolution CT scan of the thorax.

HRCT shows a “ground glass” appearance.

When Dx is unclear lung biopsy can be used to confirm with histology.

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25
Q

Two medications that can slow the progression of Idiopathic Pulmonary Fibrosis

A

Pirfenidone is an antifibrotic and anti-inflammatory

Nintedanib is a monoclonal antibody targeting tyrosine kinase

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26
Q

Drug Induced Pulmonary Fibrosis (8)

A
  • Amiodarone
  • Cyclophosphamide
  • Methotrexate
  • Nitrofurantoin
  • Bleomycin
  • Amphoteracin B
  • Carbamazepine
  • Acebutolol
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27
Q

Secondary Pulmonary Fibrosis

A
  • Alpha-1 antitripsin deficiency
  • Rheumatoid arthritis
  • Systemic lupus erythematosus (SLE)
  • Systemic sclerosis
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28
Q

Primary spontaneous pneumothorax - associated conditions (4)

A
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Alpha-1-antitrypsin deficiency
  • Homocystinuria
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29
Q

Management of primary spontaneous pneumothorax

A
  • stable, small (<3 cm), minimal symptoms: observation + O2
  • symptomatic or large (>3 cm): aspiration
  • unstable/tension pneumothorax: needle decompression then chest tube, and VATS if unsuccessful (25-50%) Video-assisted thoracoscopic surgery
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30
Q

Management of tension pneumothorax

A
  • Needle thoracostomy – large bore needle, 2nd ICS mid clavicular line, followed by
  • Chest tube in 5th ICS, anterior axillary line
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31
Q

What is the target INR for warfarin post PE?

A

2-3

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32
Q

CXR signs of pleural effusion

A

Blunting of costophrenic angle

Fluid in lung fissures

Tracheal + mediastinal deviation

Large effusions might have a meniscus

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33
Q

Signs of tension pneumothorax

A
  • Chest pain
  • Tracheal deviation
  • Absent breath sounds/ decreased air entry
  • Hypotension
  • Hypoxia
  • Jugular vein distension
  • Possibly hyperresonance
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34
Q

Characteristics of Lofgren’s Syndrome

A
  • Bilateral hilar lymphadenopathy
  • Erythema nodosum
  • Arthralgia 95% diagnostic specificity for sarcoidosis (nb treated with NSAIDs rather than steroids)
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35
Q

Which drugs should not be used alone in the Rx of asthma?

A

Long acting beta2 agonists

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36
Q

First line investigations in asbestosis

A

Pulmonary function studies - restrictive picture seen

CXR- pleural plaques in the diaphragmatic pleura

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37
Q

Pulmonary function test typical of fibrosis

A

FEV1 decreased FEV1/ FVC normal or increased

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38
Q

Clinical signs of pleural effusion

A
  • Decreased breath sounds
  • Decreased fremitus
  • DTP on the effusion side
  • Deviation of the trachea to the opposite side
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39
Q

CXR signs of pleural effusion

A
  • Blunting of the costophrenic angle
  • Fluid in the lung fissures
  • Larger effusions will have a meniscus.
  • Tracheal and mediastinal deviation if it is a massive effusion
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40
Q

Characteristics of empyema aspirate

A

Low pH (<7.2) Low glucose Raised LDH

41
Q

Severity of COPD

A

Stage 1: FEV1 >80% of predicted Stage 2: FEV1 50-79% of predicted Stage 3: FEV1 30-49% of predicted Stage 4: FEV1 <30% of predicted

42
Q

Diagnosis of COPD

A

spirometry required for diagnosis (post-bronchodilator FEV1/FVC <0.70)

43
Q

Airway changes in COPD

A

Airway changes include

  • increased goblet cells
  • fibrosis of bronchioles
  • loss of tethering due to destruction of alveolar walls
44
Q

Complications of COPD

A
  • Hypercapnic respiratory failure
  • Polycythaemia 2° to hypoxemia
  • Chronic hypoxemia
  • Pulmonary HTN from vasoconstriction
  • Cor pulmonale
  • Pneumothorax dt rupture of emphysematous bullae
  • Depression
  • Bacterial infections- leading to bronchiectasis
45
Q

Management of stable COPD

A

PROLONG SURVIVAL

  • Smoking Cessation
  • Vaccination Annual influenza + pneumococcal vax
  • Home Oxygen Prevents cor pulmonale and decreases mortality if used >15h/d; indicated if: (1) PaO2 <55 mmHg or (2) PaO2 <60 mmHg with cor pulmonale or polycythemia
46
Q

First line Abc in COPD exacerbations

A

1st line: Amoxicillin-Clavulanic Acid

47
Q

Diagnostic criteria for pleural effusion (Transudate vs exudate)

A

Transudate Protein <30 g/L (in patients with a normal serum protein level) Exudate Protein >30 g/L (in patients with a normal serum protein level)

48
Q

High pleural fluid LDH is associated with what?

A

Levels greater than 1000 IU/L are suggestive of empyema, malignancy or rheumatoid effusion.

49
Q

A 52-year-old male presents with a cough, shortness of breath and fever. CXR shows a right-sided pleural effusion. A thoracentesis is performed and the results of the pleural fluid analysis are as follows: Colour: purulent Pleural/serum total protein ratio: >0.5 pH: 7.1 WBC count: 67,000 cells/µL Glucose: 1.5 mmol/l LDH: 1430 IU/L What is the most likely cause?

A

The most likely diagnosis is empyema. This gentleman has presented with, fever, shortness of breath and cough. The pleural fluid is purulent on inspection, the white cell count is significantly raised and glucose levels are low. The history and pleural fluid results are strongly suggestive of empyema and he should be treated empirically while culture results are awaited

50
Q

A 56 -year-old, previously well woman was admitted with a 4-week history of a cough, night sweats and 1-week history of progressive breathlessness. She had never smoked and has no history of heart disease or rheumatological disease. Pleural fluid results are as follows: Colour: milky-white, odourless Triglyceride: 0.5 mmol/l Cholesterol: 12.4 mmol/l What is the most likely diagnosis?

A

The most likely diagnosis is pseudochylothorax. This woman has presented with a cough, night sweats and progressive breathlessness. A triglyceride level of less than 0.56 mmol/l and a cholesterol level of more than 5.18 mmol/l is indicative of pseudochylothorax. A pleural biopsy revealed chronic inflammation, and mycobacterium tuberculosis was isolated on a pleural fluid culture.

51
Q

Potential ECG finding in COPD

A

ECG: cor pulmonale (peaked p waves and right axis deviation)

52
Q

ABG evidence of CO2 retention in COPD

A

During stable disease: PaCO2 >6.0 and bicarbonate >30 indicates that the patient is a “CO2-retainer”

53
Q

CXR findings in COPD

A

Chest X-ray: hyperinflation >6 anterior ribs or >10 posterior ribs visible in the mid-clavicular line Flattened diaphragm Hyperlucent lungs

54
Q

COPD KEY POINTS

A
  • COPD is a triad of emphysema, chronic bronchitis and small airway fibrosis.
  • The main risk factors are tobacco smoking and inhaled pollutants. -COPD presents with progressive dyspnoea and productive cough. -Diagnosis is based on clinical features + spirometry (FEV1/FVC <70%).
  • Management consists of conservative measures (such as smoking cessation) and inhaled bronchodilators.
  • Complications include respiratory failure and cor pulmonale.
55
Q

Winnipeg Criteria for antibiotics in COPD

A

Two of the following

  • Dyspnoea
  • Sputum production
  • Sputum purulence
56
Q

Hypoxaemia on ABG

A

If PaO2 is <10 kPa on air, a patient is considered hypoxaemic. If PaO2 is <8 kPa on air, a patient is considered severely hypoxaemic and in respiratory failure.

57
Q

Type 1 Respiratory failure

A

Type 1 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with normocapnia (PaCO2 <6.0 kPa). It occurs as a result of ventilation/perfusion (V/Q) mismatch; the volume of air flowing in and out of the lungs is not matched with the flow of blood to the lung tissue. As a result of the VQ mismatch, PaO2 falls and PaCO2 rises. The rise in PaCO2 rapidly triggers an increase in a patient’s overall alveolar ventilation, which corrects the PaCO2 but not the PaO2 due to the different shape of the CO2 and O2 dissociation curves. The end result is hypoxaemia (PaO2 < 8 kPa) with normocapnia (PaCO2 < 6.0 kPa). Examples of VQ mismatch include: Reduced ventilation and normal perfusion (e.g. pulmonary oedema, bronchoconstriction) Reduced perfusion with normal ventilation (e.g. pulmonary embolism)

58
Q

Type 2 respiratory failure

A

Type 2 respiratory failure involves hypoxaemia (PaO2 is <8 kPa) with hypercapnia (PaCO2 >6.0 kPa). It occurs as a result of alveolar hypoventilation, which prevents the patient from being able to adequately oxygenate and eliminate CO2 from their blood. Hypoventilation can occur for a number of reasons including: Increased resistance as a result of airway obstruction (e.g. COPD). Reduced compliance of the lung tissue/chest wall (e.g. pneumonia, rib fractures, obesity). Reduced strength of the respiratory muscles (e.g. Guillain-Barré, motor neurone disease). Drugs acting on the respiratory centre reducing overall ventilation (e.g. opiates).

59
Q

Antibodies assoc with Wegener’s Granulomatosis (Granulomatosis with polyangiitis)

A

anti-neutrophil cytoplasmic antibodies (ANCAs) - but not exclusively

60
Q

Diagnosis of Wegener’s Granulomatosis (Granulomatosis with polyangiitis)

A

Tissue biopsy from affected area

61
Q

The only treatment for COPD that prolongs life (2)

A
  1. Smoking cessation 2. O2 therapy in chronic hypoxaemia
62
Q

Indications for home oxygen in COPD

A

Pa02 <55mmHg Sp02 <88%

63
Q

First line therapies for an acute exacerbation of COPD

A
  • Supplemental 02 (88-92%)
  • Short acting bronchodilators SABA (albuterol) and anticholinergics (Ipratropium)
  • Systemic corticosteroids (prednisone)
  • Abx if increased dyspnoea, cough or sputum
64
Q

Antibodies which are pathognomic for Goodpasture Syndrome

A

Anti-glomerular basement membrane

65
Q

Lung nodules- suspicious features

A
  • >8mm
  • Irregular borders
  • Ground glass opacity
  • Doubling in size in one month to one year
  • Hx smoking
  • Old age
  • Extra-pulmonary malignancy
66
Q

Signs of acute respiratory distress syndrome

A
  • Typical CXR appearance of widespread bilateral pulmonary infiltrates
  • Acute onset
  • PCWP <18 or no evidence of increased left atrial pressure - Pa02/ Fi02 <200
67
Q

Acute glomerulonephritis and pulmonary haemorrhage

A

Goodpasture syndrome

68
Q

Respiratory side effect of ACE inhibitors

A

Dry cough

69
Q

Coarse crackles are associated with what? And fine crackles?

A

Coarse- bronchiectasis Fine- interstitial lung disease + fibrosis

70
Q

What is the most serious complication of systemic sclerosis?

A

Pulmonary hypertension

71
Q

Causes of bronchiectasis

A
  • Cystic fibrosis
  • Pneumonia
  • Respiratory infections
  • TB
  • Rheumatoid arthritis
  • Sjogren’’s syndrome
  • Inflammatory bowel disease
  • Marfan’s
  • Alpha-1 antitrypsin
  • Allergic bronchopulmonary aspergillosis
72
Q

Bronchiectasis presentation

A

Productive cough + foul green sputum - lasting months to years Rarely- clubbing

73
Q

Bronchiectasis diagnosis

A

High resolution CT Radiographic findings include airway dilation, bronchial wall thickening, and atelectasis

74
Q

FEV1/FVC ratio > 70% suggests what?

A

Restrictive ventilatory defect

75
Q

Typical ABG pictures in an asthma attack (early and late)

A

Early: respiratory alkalosis caused be hyperventilation (PaC02 decreased, pH increased, mild hypoxaemia) Late: Respiratory muscle fatigue results in respiratory acidosis caused by inability to ventilate (normalizing PaC02, normalizing pH, reduced Pa02)

76
Q

Consider what in a patient who is < 60 with COPD and no smoking history?

A

Alpha-1 antitrypsin deficiency

77
Q

The most common malignancy associated with asbestos exposure

A

Bronchogenic carcinoma

78
Q

Complications of silicosis (2)

A

1) Increased risk of TB (screen annually)
2) Progressive massive fibrosis

79
Q

With what are ferruginous bodies in the alveolar septum associated?

A

Asbestosis

80
Q

What does acute respiratory distress syndrome most commonly follow?

A

Sepsis

81
Q

What is the classical CXR appearance of ARDS?

A

Ground glass appearance due to bilateral alveolar infiltrate consistent with pulmonary oedema

82
Q

Best investigations to diagnose pulmonary hypertension

A

Echo can estimate pulmonary artery pressure + assess RV function = best initial Ix

Most accurate test is right heart catheterization showing mean arterial pulmonary pressure over 25mmHg

83
Q

Best investigation if a patient with suspected PE has a modified Wells score <4

A

D-Dimers- normal dimers exclude PE

84
Q

Best investigation if a patient with suspected PE has a modified Wells score >4

A

CTPA

85
Q

Which anticoagulant is contraindicated in pregnancy?

A

Warfarin

86
Q

Which lung cancer is most strongly associated with smoking?

A

Small cell

87
Q

Management of small cell cancer ie surgery/chemo or radio?

A

Unresectable. Sometimes respond to chemo + radio then recur. Poor prognosis.

88
Q

Pleural effusions: best first Ix and then best next step

A

First Ix CXR Then thoracentesis

89
Q

Obstructive sleep apnea- best initial test

A

Polysomnography

90
Q
A

Pleural effusion

91
Q
A

Sarcoidosis

92
Q
A

Erythema nodosum

93
Q
A
94
Q
A

Horner’s syndrome

95
Q
A

Bronchiectasis

96
Q

Virchow’s triad

A

Stasis

Endothelial injury

Hypercoagulability

97
Q

Do what to loculated pleural effusions before thoracentesis?

A

Localise by US or CT prior to drainage

98
Q

In thoracentesis where is the needle passed in relation to the rib and why?

A

Over the top to avoid the neurovascular bundle

MCCQE1 (20 decks)

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