Past stations Flashcards
COPD is
A progressive disease characterised by airflow obstruction and airway inflammation , which has little or no reversibility.
Usually related to smoking
COPD is staged using
The GOLD criteria- which stages the disease based on airway obstruction using the FEV1
The GOLD stages are…
GOLD 1 (mild) - FEV1 >80% of predicted but symptomatic
GOLD 2 (moderate)- FEV1 50-79%
GOLD 3 (severe) - FEV1 30-49%
GOLD 4 (very severe) - FEV1 <30%
GOLD stands for
Global Initiative for Obstructive Lung disease
Symptoms of COPD
Breathlessness on exertion (can use MRC)
Wheeze
Frequent infections
Fatigue
Chronic cough
Signs on examination
At bedside:
Sputum pot
Inhalers
Steroids
Hands:
Tar staining
Tremor/ CO2 flap
Bounding pulse
Neck:
Raised JVP if cor pulmonale
Face:
Cushingoid
Cachectic
Pursed lip breathing
Cyanosis
Oral thrush
Chest inspection:
Scars from bullectomy/ lung volume reduction
barrel shaped chest
Palpation:
reduced expansion
hyperresonant
increased vocal fremitus
RV heave
Auscultation
Polyphonic wheeze
Crepitations if infection
Reduced breath sounds over bullae/ bullectomy
prolonged expiratory phase
If signs of COPD in a young patient …
Could be alpha -1 - antitrypsin deficiency
May also be jaundiced (liver involvement)
Presenting the case of COPD
I believe this patient has COPD due to peripheral signs of…
and central signs of…
There were/nt signs of complications such as P HTN/ RVF
infections
or respiratory compromise eg needing O2
or CUSHINGOID ??- steroid use
Differentials for COPD
A1AD
Asthma
Cardiac wheeze
Bronchiectasis
Investigations in COPD
Bedside;
Obs
ABG
Sputum
ECG
Bloods
FBC UE LFTs CRP Bone/ Mg, A1AT
CXR
HRCT
PFTs with transfer factor + test reversibility
echo
Lung function findings in copd
FEV1/FVC <70%
FEV1<80% predicted
Reduced diffusion capacity
Incr TLC/ residual volume
Minimal reversibility
XR findings COPD
hyper expanded lung fields
flattened hemidiaphragm
bullae
HRCT findings in COPD
Emphysema- can grade it
Can grade and localise bullae
Management of COPD
MDT approach
General:
Smoking cessation/ NRT
Optimise nutrition
Pulmonary rehabilitation
Vaccines
Home O2 (PaO2 <7.3 or polycythaemia)
Medical:
SABA/ SAMA
SABA/ LABA
or LAMA/LABA
If asthmatic features- ICS
combination therapy if still bad
Theophylline
Carbocisteine
Exacerbations :
Nebulisers
NIV
Steroids
Surgery in some cases;
Bullectomy
lung reduction
lung transplant
Signs of a failing kidney
-Pain over the graft site
-abdo pain
-Generally unwell/ malaise associated with worsening renal function + increasing urea/ toxic metabolites
-fluid overload
-poor urine output
renal screen
Bedside:
Urine dip/ ACR and MCS
ECG
Bloods
FBC UE LFT Bone profile, vit D
Immunology
ANA ENA anti DS DNA , RF, ANti GBM, p and c anca
immunoglobulins, complement C3 and C4
Serum electrophoresis
Imaging
Renal USS
MRI kidney
Tissue biopsy for histology
What options are available for smoking cessation.
Behavioural treatments
-include motivational interviewing/ counselling
NRT
Drug options including varenicline
SPK ? what bedside tests should you ask for?
URINE DIP FOR GLUCOSE
FUNDOSCOPY FOR RETINOPATHY
How is the pancreas drained in SPK?
drained into the bowel
prep drained into the bladder but this often resulted in UTIs
Complications of post transplant immunosuppression
-infections
-malignancy (PTLD/solid/Skin)
-warts
-skin changes: cushingoid/hirsutism)
-chronic transplant injury (cyclosporin & tac are nephrotoxic)
-metabolic diseaeses , eg DM/anaemia/ hyperlipidaemia, htn
-CVD
Benefits of SPK
-Aims to cure diabetes and nephropathy
-aims to prevent further nephropathy
-improves QOL -> no need for BM monitoring/ insulin injections/ dialysis
-metabolic health improved including lipids and CV risk
complications of SPK
-rejection
-technical graft failure: graft thrombosis
-graft pancreatitis
-infeciton
alternatives to pancreas transplant?
islet cell transplantation
- may not require immunosuppression as may have an infusion of their own islets
-evidence is lacking on which one is better
issues in transplanting organs
consent
compatibility
technical considerations (anatomy)- eg do they need a nephrectomy
fitness for surgery
immunosuppression
rejection
risk of recurrent disease (high in amyloid/IgA)
who makes the decision for a transplant
the patient
an MDT
causes of chronic renal failure
-Diabetic nephropathy
-Glomerulonephritis
-PKD
-Reflux nephropathy
-HTN
-Chronic pyelonephritis
causes of glomerulonephritis
-IgA nephropathy
-Vasculitis associated glomerulonephritis eg panca/ canca
-Nephritis linked to systemic disease eg Lupus nephritis
-infections such as HIV
-Goodpastures syndrome
contra-indications to transplant?
active malignancy
active infection
IV drug abuse or ETOH abuse
Psychiatric disease
Unable to engage in clinics/ immunosuppression / monitoring
types of rejection of transplants:
-Hyperacute rejection (Antibodies against transplant), transplant must be removed
-Acute rejection (may be difficult to distinguish from other issues eg PTLD) - treat with high dose steroids
-Chronic rejection-> gradual graft dysfunction. vascular usually
-Antibody mediated rejection, requires histology to diagnose
donor + recipient work up includes
ABO/ HLA cross matching
screening for transmittable disease and latent viruses
MRA/ isotope scanning to check which is the better kidney
check their renal function + their risk factors
psychology / support
Cardiovascular risk assessment
why is the kidney placed in the pelvis?
-good blood supply
-enough space for it anatomically
-easy location to biopsy if needed
prognostic factors in renal transplantation
-primary renal disease aetiology and risk of recurrence
-live vs deceased donor
-ischaemic time of kidney
-compliance with immunosuppression and monitoring
-episodes of rejection
-cross matching
indications for LTOT in COPD ?
pa O2 <7.3
or paO2< 8 with polycythaemia / or PHTN or nocturnal hypoxamia
