Pneumonia, PE, oedema, pneumothorax

Question 1

S+S PE

Answer 1

SOB, pleuritic CP, syncope, tachycardic, potentially have fever, low sats

Question 2

1st line investigations for PE

Answer 2

CXR
Wells score:over 4 = PE likely, under 4 = unlikely
If over 4 = LMWH + CTPA
Under 4 = D dimer.
If positive, CTPA
If they have an allergy to contrast, do V/Q perfusion ABG (mildly alkalotic)

Question 3

Acute management of PE

Answer 3

O2, vascular access, NSAIDs or weak opioid
LMWH unless massive thrombolysis (then fluid challenge first)
Warfarin within 24hrs
LMWH for 5 days until INR over 2

Question 4

Long term management of PE

Answer 4

3 month warfarin then assess

Continue if unprovoked PE

Question 5

1st line investigations + results for pneumonia

Answer 5

CXR (consolidation), ECG, bloods (raised CRP, WCC, urea)
Culture bloods + sputum
ABG
CURB65 = ICU >3
Pneumococcal + legionella urinary testing
Pneumonia = S+S of LRTI + radiological signs

Question 6

What is CURB65?

Answer 6

Confusion <8 AMTS
Urea >7
RR >30
BP <90/<60
Age >65

30 day mortality

Question 7

1st line management for low severity CAP

Answer 7

Amoxicillin
Allergic: clindamycin or tetracycline
5 days

Question 8

1st line management for moderate-high severity CAP (Curb >2)

Answer 8

Amox + macrolide (clarithromycin) 7-10 days - ADMIT

High severity: clarithromycin + cefotaxime IV - ADMIT

Question 9

1st line management for HAP

Answer 9

Ceftriaxone + metronidazole

Question 10

What are the organisms that cause CAP?

Answer 10

Gram positive:
Strep pneumoniae
H influenza - commonly COPD
Staph
Mycoplasma

Question 11

What are the organisms that cause HAP?

Answer 11

Gram negative:
Pseudomonas
Mycoplasma
Legionella
Chlamydia pneum
Staph aureus
Pneumonia developing >48hrs after admission

Question 12

What are the S+S of legionella?

Answer 12

Flu, dry cough, bradycardic

Question 13

How to manage legionella?

Answer 13

Clarithromycin or erythromycin for 14 days

Report to PHE

Question 14

How to distinguish aspiration pnemumonia

Answer 14

Sudden onset in someone with hx of vomiting or swallowing problems
May look like pulmonary oedema on CXR
Distinguish by fever, bloods

Question 15

Management of severe croup

Answer 15

Nebulised adrenaline 1:1000

Dex or pred

Question 16

Investigations for ?asthma

Answer 16

ABCDE
ABG - high CO2 + low O2 (when breathing slows)
CXR, ECG, bloods
Fractioned exhaled nitric oxide for diagnosis

Question 17

Pneumothorax S+S

Answer 17

Abrupt SOB
Dull heavy chest pain
Hyperresonant
Reduced air entry (absent breath sounds)

Question 18

Management of tension pneumothorax

Answer 18

Needle decompression (large bore cannula 2nd ICS mid clav) - then CXR + chest drain (5th IC space, mid axillary line)

Question 19

Presentation of HF with pulmonary oedema, and what heart sounds are produced?

Answer 19

Acute SOB
Pink frothy sputum
Chest pain
Triple/ gallop rhythm

Question 20

Management of pulmonary oedema

Answer 20

O2
If wheezy: salbutamol nebs, ipratropium bromide + hydrocortisone
Diamorphine 2.5mg, anti-emetic, furosemide GTN

Question 21

Diagnostic criteria for acute respiratory distress syndrome

Answer 21

Hypoxaemia

Bilateral CXR infiltrates

Question 22

S+S of acute respiratory distress syndrome

Answer 22

SOB
RR
Bilateral crackles

Question 23

What is type 1 resp failure?

Answer 23

Hypoxaemia (eg asthma)

Question 24

What is type 2 resp failure?

Answer 24

Hypoxia + hypoventilation causing high CO2

Question 25

Causes of type 2 resp failure

Answer 25

COPD, opiate OD

Question 26

Management of resp failure

Answer 26

O2 in venturi mask, nebs, steroidsCPAP

Question 27

Organisms causing pneumonia + characteristics

Answer 27

Strep pneumoniae = most common, high fever, rapid onset, pleuritic chest pain, herpes labialis H influenza = common in COPD Staph aureus = follows influenza infection Mycoplasma pneu = dry cough, atypical x ray Legionella = hyponatraemia + lymphopenia Klebsiella = alcoholics, causes cavitation Jiroveci = HIV Chlamydia psittaci = pet bird dead Coxiella bunetii = Q fever - people working in animal houses

Question 28

Simple vs tension pneumothorax

Answer 28

``` Simple = air in pleural cavity, not under pressure Tension = air drawn into pleural space with each breath ```

Question 29

Causes of pneumothorax

Answer 29

``` Primary: Spontaneous (tall young males) Trauma Secondary: Chronic disease - COPD (bullae), pneumonia, cancer, connective tissue diseases, asthma Iatrogenic - from PICC lines ```

Question 30

Management of primary pneumothorax

Answer 30

Aspirate if >2cm, discharge if <2cm  | If failed, chest drain (5th IC space, mid axillary line) + admit

Question 31

Management of secondary pneumothorax

Answer 31

If >2cm, insert chest drain (5th IC space, mid axillary line) If 1-2cm, aspirate then admit

Question 32

How to determine between primary + secondary pneumothorax?

Answer 32

Primary = spontaneous, <50 y/o, no comorbidities

Question 33

CXR for pneumothorax

Answer 33

Black - no lung markings

Question 34

Follow up for pneumonia

Answer 34

CXR in 6 weeks

Question 35

When else is d dimer raised?

Answer 35

Pregnancy Cancer PE Renal disease

Question 36

What is a PERC score?

Answer 36

Pulmonary embolism rule out criteria

Question 37

How does LMWH work?

Answer 37

LMWH - Factor 10a inhibitor - affects clotting cascade 

Question 38

When can you get a stroke from a DVT?

Answer 38

If you have PFO | All stroke pts have an echo to check for PFO

Question 39

Clinical signs (chest expansion, trachea, percussion, breath sounds, vocal resonance) for pneumothorax

Answer 39

chest expansion: reduced on affected side trachea: shifted to affected side in simple + away from affected side in tension percussion: hyperresonant on affected side breath sounds: reduced on affected side vocal resonance: reduced on affected side

Question 40

Clinical signs (chest expansion, trachea, percussion, breath sounds, vocal resonance) for pneumonia

Answer 40

chest expansion: can be reduced on affected side trachea: central or shifted towards side of lobar collapse percussion: dull over affected area breath sounds: reduced, coarse creps, bronchial breathing vocal resonance: increased

Question 41

Clinical signs (chest expansion, trachea, percussion, breath sounds, vocal resonance) for pleural effusion

Answer 41

chest expansion: reduced on affected side trachea: central or shifted away from affected side if large percussion: stony dull breath sounds: reduced vocal resonance: reduced

Question 42

Clinical signs (chest expansion, trachea, percussion, breath sounds, vocal resonance) for pulmonary oedema

Answer 42

``` chest expansion: equal trachea: central percussion: dull bases breath sounds: fine inspiratory creps vocal resonance: reduced ```

Question 43

Ix for TB

Answer 43

Sputum Early morning urine Tissue biopsy = needs to be in saline (some to micro, some to pathology)