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1
Q

Pt has a pulmonary arteriovenous malformation (PAVM) - it is 3mm in size. What treatment is required?

A

Consideration of embolisation (no size limit - any visible on radiology should be referred)

Prophylactic abx recommended for dental/endoscopic/surgical procedures due to risk of brain abscesses

Venesection only if features of hyperviscosity

LTOT only in symptoms (often hypoxiaemic due to shunting)

Nb. pt often asymptomatic.
High risk of paradoxical stroke or MI
Pregnancy dangerous

PAVM 0.04% prevalence
Paradoxical embolus (embolus into arterial circulation) - stroke, MI, brain/peripheral abscess, discitis, migraine, frequent nosebleeds
HHT mutation e.g ENG (autosomal dominant)
- Fe def anaemia, frequent nosebleed, VTE risk

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2
Q

What nerves are sensory supply to the mediastinal pleura?

A

Phrenic nerve

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3
Q

How does Midazolam work? What is it’s antidote? And how much can you give? Initial and max dose

A

Increases GABA activity
Flumazenil = antidote
Initial dose: 2-2.5mg (0.5-1if frail/elderly)
Max dose: 7mg (3.5mg if frail/elderly)

Nb.onset approx 2min, max onset 5-10min, duration 30-120min

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4
Q

Pt has INR of 1.6. Is it okay to go ahead with thoracentesis (pleural aspiration)?

A

No absolute contraindication however would suggest correct INR to <1.5 if not urgent procedure

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5
Q

What is dosing of fentanyl for bronch?

A

Initial 25mic to max of 50

Onset almost immediate. Half life 2-7hr

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6
Q

What kind of doses of lidocaine might cause toxicity?

A

≥9.6mg/kg

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7
Q

What is the approx radiation dose equivalent of a CTPA?

A

1.3 years background

Nb. XR 5 days
VQ 7 months

Nb2. VQ gives less radiation to breast tissue but more to baby

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8
Q

What is atopy?

A

Tendency to produce IgE against innocuous antigens

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9
Q

How is IgE produced?

A

By B-cells driven by IL-4

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10
Q

What drives allergic inflammation?

A

Th2 cells + Th2 innate lymphoid cells

IL4/13/5/33/24/RSLP

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11
Q

What is the pathway in acute allergy?

A

IgE –> Mast cell degranulation–> Histamine –> H1 receptor

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12
Q

What is the pathway in chronic allergy?

A

Allergen –> Th2 –> B cells (then degranulate mast cells) + eosinophils

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13
Q

What classifies as anaphylaxis?

A

Compromise of A OR B OR C

nb. 10-20% have no skin involvement
nb2. 30% have no identifiable trigger

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14
Q

What is treatment for anaphylaxis?

A

IM adrenaline 1:1000 0.5ml adult +/- rpt

NOT steroids and anti-histamines

i.e. 0.5mg (1:1000 = 1g:1000ml)
cardiac arrest = 1ml of 1:10000 i.e. 0.1mg

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15
Q

What tests can be done to confirm anaphylaxis?

A

Tryptase
- ASAP + 1-2hrs (<4hrs) + 24hrs
- Relevant level ≥ 1.2xbaseline +2

Nb. not a rule out test

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16
Q

What is diagnosis of rhinitis?

A

2 of: running/blocked/sneezing/itching >1hr day

> 12 weeks = chronic
+ nasal polyps: think Churg Strauss
- nasal polyps: think Ab-def

Nb. unilateral symptoms, absent smell, facial pain, nose bleeds, unpleasant smell, ear symptoms are NOT TYPICAL

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17
Q

What is type 4 allergy?

A

T-cell mediated (occurs over days)
Get skin reactions - most common for drugs or contact hypersensitivity

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18
Q

What is type 3 allergy?

A

Immune complex mediated (hours-days)
Get rash, arthraliga, fever, myalgia, kidney impairment

19
Q

What is type 2 allergy?

A

IgG mediated (hours-days)
Get cytopaenia + haemolytic anaemia

20
Q

What is type 1 allergy?

A

IgE-mediated (<1hr)
Get anaphylaxis, rhinitis, itch, erythema, urticaria, angioedema, bronchospasm

21
Q

How do you treat rhinitis?

A

Nasal steroid +/- nasal antihistamine (dymista = combined)
Consider immunotherapy

Nb. this is for allergy rhinitis (80% of cases)

22
Q

What is considered a positive skin prick or serum IgE?

A

Skin: >3mm (beware cross-reactivity)
Serum: >0.35KU/L

Nb. good negative predictive value but poor positive predictive value

23
Q

Is anaphylaxis always caused by IgE?

A

No - can be aspirin/NSAIDs, exercise, radiological contrast

24
Q

When should Epipen be given for analyphylaxis?

A

If admitted to hospital with anaphylaxis
or known risk

25
Q

What can cause isolated angioedema?

A

ACE-i use - remember can happen many years after starting

26
Q

What are causes of non-allergic rhinitis?

A

Hormones, medications, irritants, NARES (ass with eosinphils –> responds to steroids)

27
Q

What is treatment for allergy?

A

Allergen avoidance

Desensitisation - only temporary tolerance due to recent/ongoing exposure. Therefore might do to aspirin/NSAIDs/penicilln/peanut/chemo

Tolerance - persistant tolerance
–> allergen immunotherapy
- gradually increase exposures to allergy
- indications: bad rhinitis +/- mild asthma OR systemic reaction to wasp/bee
- need to known allergen, inadequate/intolerant to drugs
- CANT do if mod/severe/uncontrolled asthma or multiple allergies/pregnancy/autoimmune disease

28
Q

How might OHS and OSA look different on sleep study?

A

OHS w/o OSA –> don’t get repetitive drop in SATS, get prolonged low SATS during REM sleep with slow return to baseline

29
Q

What might you see on chest/abdomen movement and nasal flow with OSA?

A

Rib cage and abdomen should move together but not getting nasal flow

30
Q

What is treatment for central sleep apnoea?

A

Autoset CPAP

BUT IF EF<45% then fixed level CPAP as autoset increases mortality

Nb. do MRI brain in central sleep apnoea to look for brainstem or cerebellapontine angle tumours

31
Q

When should COPD pt be referred for pulmonary rehab?

A

<4 weeks hospital admission for COPD
COPD + exercise limitation due to SOB

32
Q

What are causes of anterior mediastinal mass?

Anterior also called pre-vascular compartment

A

Thymoma
- smooth border, soft tissue attenuation
- may have cystic component +/- calcium
- metastasizes to pleura = may get plerual effusion
- usually >50, ass with hypogammaglobulinaemia

Teratoma - multiple densities visible
- soft tissue attenuation with fat within
- ring calcification, solid enhancing septa
- may have fluid inside

Thyroid mass lesion
- Contiguous with neck

Lymphoma (Hodgkin & large B cell)
- Multiple lesions
- Unilateral pleural/pericardial effusion

33
Q

What does anterior mediastinal mass look like on CXR?

A

Obtuse angle with mediastinum
Loss of R heart border
Hilar vessels visible through
Will not be visible above clavicle

34
Q

What are borders on CT for anterior mediastinum?

A

Sternum (know mediastinal window)

Axial: draw line around anterior pericardium/ascending aorta/aortic arch - infront = anterior (nb. lateral border = parietal pleura)

Lateral: anterior to trachea or posterior to IVC

35
Q

What is treatment for periodic limb movement disorder?

A

Ropinorole (non-ergot dopamine agonist) +/- clonazepam (if concurrent insomonia but not routine)

  • repetitive movements (usually legs) mainly in REM >15/hr + sleep disturbance
  • idiopathic or ass with restless legs, OSA, REM sleep behaviour disorder, narcolepsy, CCF, HTN, ESRF, Parkinson etc
36
Q

Disease+ Disease-
Test + A B
Test - C D

How calculate sens, spec, NPV, PPV?

A

Sens = A/(A+C)
Spec = D/(B+D)
PPV = A/(A+B)
NPV = D/(D+C)

37
Q

What test compares means from two independent groups?

A

Unpaired t-test
If small sample (n<30) then non-parametric test Mann-Whitney U

Categorical data in contingency tables: Chi squared or Fischer exact

Nb. paired t-test = compare repeat measurement from same individual

38
Q

Pt with heart disease has slate grey discolouration of skin. What is most likely medication causing this and what is the pathophysiology?

A

Amiodarone - photosensitivity leading to blue-grey discolouration

Foamy macrophage highly characteristic

39
Q

When should oxygen be given in bronchoscopy?

A

> 4% change or <90% for >1min

40
Q

What are clotting/anticoag requirements for bronchoscopy?

Plt count
Clopidogrel
Warfarin
DOAC

A

Plt >20
Clopidogrel 7d (nb aspirin can continue) - liaise with cardiologist if >12months after insertion of drug eluding stent or >1 after bare metal stent

Warfarin
- high risk (metallic mitral valve, prosthetic heart valve + AF, AF + mitral stenosis, <3months after VTE, thrombophilia syndrome) = stop five days before, start LMWH two days after stopping, but omit on day of procedure, restart warfarin on evening of procedure and continue LMWH until INR adequate
- Low risk (metal aortic valve, xenograft, heart valve, AF without valve disease,> three months after VTE) = stop warfarin, five days before, check INR, less than 1.5, restart on an evening of procedure, check iron or one week later.

DOAC not in guideline

41
Q

Patient needs bronchoscopy, had MI 4 weeks ago. What should you do?

A

Ideally wait 4 weeks. If needed consider consult with cardiologist.

42
Q

What is reversal dose for Midazolam?

A

Flumezanil 200 micro grams IV over 15mins

43
Q

What is the risk of bleed in bronchoscopy?

A

Severe: 0.26%
Minor: 0.19%

Doubles if taking transbronchial biopsy

44
Q

By how much is cardiovascular risk increased in pt with untreated OSA?

A

2-3 fold

Revision (17 decks)

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