PM Quiz Questions Flashcards
Which type hypersensitivity is asthma associated with?
Asthma is associated with type 1 hypersensitivity.
Legionella pneumophilia should be suspected where multiple people contract pneumonia in an air conditioned space.
Legionella pneumophilia should be suspected where multiple people contract pneumonia in an air conditioned space.
What pathogen is responsible for the majority of cases of bronchiolitis?
Respiratory syncytial virus
Emphysema summary:
The residual volume is the volume of air left in the lungs after full expiration (in other words, what is left in the lungs at the end of testing the vital capacity). Emphysema is a form of chronic obstructive airways disease in which damage to the alveolar walls causes many alveoli to fuse forming large air sacks called bullae.
In emphysema there is loss of compliance in the lungs so on breathing out they do not fully spring back to normal and air becomes trapped in the bullae causing an increase in the residual volume. This loss of elasticity means that the total volume that can be blown out becomes reduced and there is a corresponding reduction in vital capacity.
Respiratory centres of the brain:
Medulla
Apneustic
Pneumotaxic
What appears on chest x-ray in someone with COPD?
Patients with COPD typically have a flattened diaphragm on CXR.
Presentation of bronchiolitis:
This is a classic presentation of bronchiolitis: coryzal symptoms and increased work of breathing causing feeding difficulty in a child <1 year. Respiratory syncytial virus is the most common cause of bronchiolitis.
What is the most common cause of croup?
Parainfluenza virus is the most common cause of croup.
Trismus (difficulty opening the mouth) is a feature of peritonsillar abscess (quinsy).
Trismus (difficulty opening the mouth) is a feature of peritonsillar abscess (quinsy).
Sarcoidosis is associated with increased concentrations of what enzyme?
Elevated angiotensin-converting enzyme levels are associated with sarcoidosis.
‘Red-currant jelly’ sputum is a feature of what pathogenic pneumonia?
‘Red-currant jelly’ sputum is a feature of Klebsiella pneumoniae
A 70-year-old man is admitted to the respiratory ward following an infective exacerbation of his chronic obstructive pulmonary disease (COPD). He is being treated with amoxicillin and prednisolone. This is his fourth exacerbation and second hospital admission in the last 12 months. He has previously given up smoking 10 years ago after receiving his diagnosis and has attended pulmonary rehabilitation courses which have offered minimal improvement to his symptoms.
Which antibiotic can be started as prophylaxis for this patient?
Azithromycin prophylaxis is recommended in COPD patients who meet certain criteria and who continue to have exacerbations.
A 45-year-old woman presents to the GP with a new rash on her face. On examination, there is a raised purple lesion covering the nose, cheeks and lips. At first, this was diagnosed as rosacea however it has rapidly progressed. The GP also notes axillary and inguinal lymphadenopathy. On further questioning, she notes some fatigue as well as some dyspnoea over the last 6 months. She has smoked 10 cigarettes a day for the last 8 months and drinks 10 units of alcohol a week.
What is the likely diagnosis?
Sarcoidosis - Facial rash plus lymphadenopathy think sarcoidosis.
Mesothelioma
Mesothelioma is a malignant tumor that is caused by inhaled asbestos fibers and forms in the lining of the lungs, abdomen or heart. Symptoms can include shortness of breath and chest pain. The life expectancy for most mesothelioma patients is approximately 12 months after diagnosis.
Transudate vs Exudate pleural effusions
Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.
Transudate (< 30g/L protein)
- heart failure (most common transudate cause)
- hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
- hypothyroidism
- Meigs’ syndrome
Exudate (> 30g/L protein)
- infection: pneumonia (most common exudate cause), TB, subphrenic abscess
- connective tissue disease: RA, SLE
- neoplasia: lung cancer, mesothelioma, metastases
- pancreatitis
- pulmonary embolism
- Dressler’s syndrome
- yellow nail syndrome
A 64-year-old woman presents to ED with productive cough, haemoptysis, and vague abdominal pain for the past 2 weeks. She has no past medical history of note. Chest X-ray shows multiple large, round, well-circumscribed masses in both lungs.
What is the most likely underlying diagnosis?
Renal cell carcinoma can metastasise to the lungs, causing ‘cannonball metastases’.
The multiple large, round, well-circumscribed masses in both lungs seen on Chest X-ray here are a characteristic description for ‘cannonball metastases’. Metastases with this appearance are often due to renal cell carcinoma, although they can also be seen with other malignancies such as choriocarcinoma or endometrial cancer.
What is Kartagener’s syndrome?
Kartagener’s syndrome is a rare, autosomal recessive genetic ciliary disorder comprising the triad of situs inversus, chronic sinusitis, and bronchiectasis. The basic problem lies in the defective movement of cilia, leading to recurrent chest infections, ear/nose/throat symptoms, and infertility.
What is the cardinal triad of Meig’s syndrome?
Meig’s syndrome: Benign ovarian tumour, ascites, and pleural effusion.
What is the most common cause of an exudative pleural effusion?
Pneumonia is the most common cause of an exudative pleural effusion.
What is meant by an exudative pleural effusion?
>30g of protein in the pleural effusion
Note: Transudate = <30g of protein
Causes of a transudate pleural effusion:
Transudate (< 30g/L protein)
- heart failure (most common transudate cause)
- hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
- hypothyroidism
- Meigs’ syndrome
Causes of an exudate pleural effusion:
Exudate (> 30g/L protein)
- infection: pneumonia (most common exudate cause), TB, subphrenic abscess
- connective tissue disease: RA, SLE
- neoplasia: lung cancer, mesothelioma, metastases
- pancreatitis
- pulmonary embolism
- Dressler’s syndrome
- yellow nail syndrome
Oscar is a 59-year-old man who presents to his general practitioner with a 4-month history of a persistent cough, dyspnoea, unintentional weight loss of 4kg and anorexia. Oscar has no significant past medical history and has never been admitted to hospital. He is a lifelong non-smoker and works as a receptionist.
On examination, his observations are blood pressure 125/90mmHg, respiratory rate 14/minute, heart rate 85/minute, afebrile and oxygen saturation 94% on room air. There is notable bilateral gynaecomastia with watery nipple discharge, hypertrophic pulmonary osteoarthropathy and supraclavicular lymphadenopathy.
Given the likely diagnosis of lung carcinoma, which is the most likely type given the history and examination findings?
Gynaecomastia - associated with adenocarcinoma of the lung.
In patients suffering with severe asthma what is the order in which you escalate treatment?
The SIGN guidelines give clear instructions on how to escalate care.
- Oxygen
- Salbutamol nebulisers
- Ipratropium bromide nebulisers
- Hydrocortisone IV OR Oral Prednisolone
- Magnesium Sulfate IV
- Aminophylline/ IV salbutamol
In sarcoidosis what are the indications for corticosteroid treatment?
Indications are PUNCH
- Parenchymal Lung Disease
- Uveitis
- Neurological involvement or
- Cardiac involvement
- HyperCa
A 76-year-old man presented with dyspnoea, mild haemoptysis, decreased appetite and his clothing looks loose.
His past medical history includes atrial fibrillation, ischaemic heart disease, hypertension. He used to work as a heating engineer fixing boilers and is a smoker.
What is the likely diagnosis?
The history of dyspnoea with haemoptysis and weight loss suggests the most likely diagnosis is malignancy. Given the history of fixing boilers and the unilateral pleural effusion, a very likely diagnosis is mesothelioma.
What are the features of small cell lung cancer?
Small Cell Lung Cancer
- usually central
- arise from APUD* cells
- associated with ectopic ADH, ACTH secretion
- ADH → hyponatraemia
- ACTH → Cushing’s syndrome
- ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
- Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
Upper zone pulmonary fibrosis is typically caused by what?
Tuberculosis typically causes upper zone pulmonary fibrosis.
Sudden deterioration upon ventilation is suggestive of what?
Tension pneumothorax.
Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome (Kartagener’s syndrome)
Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome (Kartagener’s syndrome)
A 40-year-old female presents with painful, red bumps over her shins. Her GP suspects erythema nodosum. On further questioning she admits to having a non-productive cough and some recent joint pains. The GP requests a chest x-ray, which shows bilateral hilar lymphadenopathy.
What’s the diagnosis?
Sarcoidosis
The likely diagnosis here is sarcoidosis, given by the presence of erythema nodosum, a non-productive cough, arthralgia and bilateral hilar lymphadenopathy on chest x-ray. Sarcoidosis is known to cause hypercalcaemia due to macrophages inside the granulomas causing an increased conversion of vitamin D to its active form.
Obstructive vs Restrictive Lung Conditions
HIGH YIELD
Ø Obstructive
→ Causes
• Asthma, COPD, bronchiectasis, cystic fibrosis
→ Results
• ↓↓↓↓↓ FEV1, ↓ FVC, ↓ FEV1/FVC ratio of<70%
• Reversibility after bronchodilators is seen in asthma
Ø Restrictive
→ Causes
• Idiopathic pulmonary fibrosis, pneumoconiosis
• Extrinsic restrictive (restrictive due to out of lung) - anka sp, scoliosis
→ Results
• ↓ FEV1, ↓↓↓↓↓ FVC, ↑ FEV1/FVC ratio of>70%
Small cell lung carcinoma secreting ACTH can cause Cushing’s syndrome
Small cell lung carcinoma secreting ACTH can cause Cushing’s syndrome
Adult with asthma not controlled by a SABA - add a low-dose ICS
(then you add LABA)
Adult with asthma not controlled by a SABA - add a low-dose ICS
(then you add LABA)
Connective tissue disorders e.g. systemic lupus erythematosus can cause exudative pleural effusion
Connective tissue disorders e.g. systemic lupus erythematosus can cause exudative pleural effusion
What is the treatment for patients having a severe asthma attack?
Nebulised salbutamol, nebulised ipatropium bromide, oral prednisolone.
According to the British Thoracic Society (BTS), as a baseline all patients presenting with severe or life-threatening asthma should be given a nebulised short acting β2 agonist (e.g. salbutamol), a corticosteroid - either oral or IV, and nebulised ipratropium bromide. For milder exacerbations ipratropium bromide is not required as a first line agent but may be considered if the patient does not respond to initial therapy.
ABG interpretation ROME
Respiratory = Opposite
low pH + high PaCO2 i.e. acidosis, or
high pH + low PaCO2 i.e. alkalosis
Metabolic = Equal
low pH + low bicarbonate i.e. acidosis, or
high pH + high bicarbonate i.e. akalosis
What is the CURB65 score and what is it used for?
The CURB-65 calculator can be used in the emergency department setting to risk stratify a patient’s community acquired pneumonia.
A 55-year-old man is seen in the respiratory clinic. He describes progressively worse shortness of breath, that is worse when walking, and a dry cough. On examination he has bibasal crackles and there is evidence of finger clubbing. Spirometry is done, which shows a clearly restrictive pattern. He is previously fit and well, and has worked as a gardener all his life.
What is the diagnosis and what is best investigation for your most likely diagnosis?
Idiopathic pulmonary fibrosis - high resolution CT is the investigation of choice.
This is a typical history of idiopathic pulmonary fibrosis- a man 50-70, progressive exertional dyspnoea, dry cough, finger clubbing, bilateral basal crackles, and a restrictive lung pattern. A chest x-ray will show interstitial shadowing, and a high resolution CT will show ‘honeycomb’ lungs.
What are the landmarks for a chest drain insertion?
The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi.
RISK FACTORS: SOME OCCUPATIONAL CAUSES OF LUNG DISEASE
WHatis the next important investigation following this chest x-ray?
CT Abdomen
The chest x-ray shows cannonball metastases which are most commonly caused by renal cell cancer. A CT abdomen is the most appropriate test to investigate this possibility.
Other tests should of course be considered including a prostate specific antigen.
79yr old with a history of recent weight loss what does this xray show?
Lung cancer - The x-ray shows a large right sided hilar mass with resultant collapse of the right upper lobe. As a consequence the hyperexpanded right middle and lower lobes are hyperlucent (‘blacker’).
What are the general signs of lobar collapse on x-ray?
The general signs of lobar collapse on a chest x-ray are as follows:
Tracheal deviation towards the side of the collapse
Mediastinal shift towards the side of the collapse
Elevation of the hemidiaphragm
CURB-65 - what is it used for and what’s it’s criteria.
CURB-65, also known as the CURB criteria, is a clinical prediction rule that has been validated for predicting mortality in community-acquired pneumonia and infection of any site.
NICE recommend, in conjunction with clinical judgement:
Consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk)
Consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk)
Consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)
