Pulmonary medicine Flashcards
Patient with pulmonary embolism symptoms. First line investigation
CXR to rule out other pathologies!!!
Before CTPA
A 28 year old man has right sided chest pain of sudden onset and dyspnoea.
His oxygen saturation is 98% breathing air. A chest X-ray shows a
pneumothorax with a 4 cm rim of air measured at the hilum. There is no
mediastinal shift.
most appropriate initial management?
perform aspiration!!!
Primary pneumothorax >2cm or with
symptoms can be treated with aspiration or an ambulatory device if available.
Secondary pneumothorax would require chest drain for pneumothorax greater
than 2cm.<
or if any of these are present you put in chest drain:
Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history!!!!
Haemothorax
tension pneumothorax = needle thoracostomy
minimally symptomatic regardless of size = observation!!
A 68 year old woman has worsening chest discomfort over 11 days. She has a dry cough and has lost 3 kg in weight over the last 2 months. She is a non- smoker. She retired as a builder 15 years ago.
She has a temperature of 37.1°C. Both lung fields sound clear. Her chest X-ray is shown (see image).
CXR shows multiple nodules
Most likely diagnosis?
Metastatic cancer
Not mesothelioma
Lung cancer, superior vena cava obstruction. First initial treatment ?
IV dexamethasone
A 35-year-old man presents to you with symptoms of an acute exacerbation of asthma. You test his peak expiratory flow rate. This is 210 litres per minute. His usual best is 600 litres per minute.
Using his peak expiratory flow rate, which category is his asthma exacerbation stratified into?
210/600 = 35% = severe
life threatening = <33% of predicted or best
severe = 33-50%
moderate = 50-75%
75 year old woman attends GP with breathlessness on exertion and a cough productive of white sputum throughout the day. she has never had hemoptysis and has lost 2kg in weight. She descrives 2 chest infections in the past year treated with a short course of steroids and antibiotics. she has a 15 pack-year smoking history.
HR 82. CXR is normal.
most appropriate investigation to establish the diagnosis?
spirometry
A 62 year old man attends the Emergency Department following a road traffic
collision. He has severe bruising of the right upper shoulder from the seat belt,
but no other injuries.
Chest X-ray (performed to exclude a pneumothorax) shows a 2 cm mass in
the right upper zone.
CT scan of chest!! -> given the likely diagnosis of lung cancer
A 53 year old woman has had a non-productive cough for 3 months. She has
felt fatigued and has gained weight around her face and abdomen. She is an
ex-smoker with a 30 pack year smoking history. She has multiple purple, wide
striae on her abdomen. She has bruising on her arms. Her BP is 179/100
mmHg. Investigations: CT scan of chest: small lesion in the left lung.
small cell carcinoma
fundoscopy picture exhibiting papilloedema in left eye. blurry vision in 7 year old boy. most likely cause?
optic nerve tumour
A 37-year-old man presents to his general practitioner with a wheezy cough and difficulty breathing that developed in the last six months. He has never experienced anything like this before. He recently changed his job and started to work in a spray painting factory. The doctor decides to ask the patient to keep a diary and after seeing the results decides to refer the patient to the respiratory specialist.
Which one of the following substances is the most likely to have caused his symptoms?
Isocyanates are the most common cause of occupational asthma
A raised pCO2 > 6.0 kPa indicates near-fatal acute asthma
Not just severe
A 54-year-old man presents to the respiratory outpatient clinic after being referred by his GP for persistent shortness of breath and a non-productive cough. He has a 10-pack-year smoking history and smoked in his teenage years but has not smoked for the past 30 years. He feels systemically well, but his symptoms have been progressively getting worse over the past six months. Spirometry is performed, and the results are shown below.
Ix to confirm diagnosis?
High resolution CT chest
FVC 2.67
FEV1/FVC 0.95
Increased ratio = restrictive picture. Idiopathic pulmonary fibrosis most likely
Mycoplasma pneumoniae patient with anaemia, raised LDH, raised unconjugated bilirubin → autoimmune haemolytic anaemia
Pyrazinamide Side effects?
Isoniazid side effects?
Hepatitis, gout
Peripheral neuropathy
A 77-year-old woman is investigated by her GP for a chronic cough.
Her past medical history is significant for rheumatoid arthritis, recurrent urinary tract infections (for which she has required repeated courses of nitrofurantoin), previous asbestos exposure, and lung cancer many years ago for which she received radiotherapy.
As part of the workup, a chest x-ray is performed.
The chest x-ray shows marked bilateral upper zone fibrosis.
What is the most likely cause of this patient’s fibrosis?
Previous radiotherapy
Severe asthma RR > 25/min
Life threatening =
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Strong suspicion of PE but a delay in the scan: start on treatment dose anticoagulant meanwhile
if the CTPA is negative then consider a proximal leg vein ultrasound scan if DVT is suspected
Pleural plaques in asbestosis are benign and do not undergo malignant change. They, therefore don’t require any follow-up.
asthma attack order of escalation treatment?
Oxygen
2. Salbutamol nebulisers
3. Ipratropium bromide nebulisers
4. Hydrocortisone IV OR Oral Prednisolone
5. Magnesium Sulfate IV
6. Aminophylline/ IV salbutamol
But if PEFR is < 33% best or predicted, then rather than picking the next drug, you refer to itu
Sputum culture is used to assess drug sensitivities in TB
Important for meLess important
Latent tb treatment?
Offer rifampicin and isoniazid (with pyridoxine) for three months
All cases of pneumonia should have a repeat chest X-ray at X weeks after clinical resolution
6
Patients presenting to primary care who have pneumonia can usually be managed in the community with oral antibiotics if their CRB-65 score is 0
Bronchiectasis: most common organism = Haemophilus influenzae
Sputum test is the most sensitive test for TB
A 25-year-old man presents to the Emergency Department with a spontaneous pneumothorax, confirmed on a chest X-ray. He reports no significant pain or breathlessness, and his vital signs are stable; however, the chest X-ray shows a 3 cm gap between the lung edge and the chest wall at the level of the hilum.
What is the most appropriate management for this patient?
Minimally symptomatic pneumothorax, regardless of size, can be treated with conservative treatment / regular follow-up
Important for meLess important
A 21-year-old woman presents to her GP after suffering from breathlessness and a productive cough over the past 6 months. There are occasional specks of blood in the sputum. Auscultation reveals normal heart sounds, bilateral coarse crackles, and a widespread polyphonic wheeze. She has a past medical history of pertussis as a toddler and recurrent pneumonia as a teenager. She has never smoked and drinks alcohol occasionally. Bloods are performed and shown below.
Hb 134 g/L Male: (135-180)
Female: (115 - 160)
WBC 10.8 * 109/L (4.0 - 11.0)
Eosin 0.2 * 109/L (0.0 - 0.4)
What is the most likely diagnosis?
Bronchiectasis
What is the most appropriate test to check for latent tuberculosis?
Mantoux test
A 43-year-old lady presents with central chest pain, worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells’ score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?
Chest X-ray
The causes of upper lobe fibrosis can be remembered with the mnemonic ‘CHARTS’
Coal workers’ pneumoconiosis
Histiocytosis
Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis
Radiation
Tuberculosis
Silicosis (progressive massive fibrosis), sarcoidosis
FEV1 (of predicted) Severity
< 0.7 > 80% Stage 1 - Mild - symptoms should be present to diagnose COPD in these patients
< 0.7 50-79% Stage 2 - Moderate
< 0.7 30-49% Stage 3 - Severe
< 0.7 < 30% Stage 4 - Very severe
Measuring peak expiratory flow is of limited value in COPD, as it
Breathing problems with clear chest, think pulmonary embolism
which type of lung cancer is associated with siadh, cushings, and lambert eaton syndrome?
small cell lung cancer
A normal pCO2 in a patient with acute severe asthma is an indicator that the attack may classified as?
life threatening!
A raised pCO2 > 6.0 kPa indicates near-fatal acute asthma
what is associated with a poor prognosis in patients with community-acquired pneumonia?
Urea 12 mmol/l
pleural thickening on xray = mesothelioma not asbestosis
acute bronchitis management?
consider antibiotic therapy if patients:
are systemically very unwell
have pre-existing co-morbidities
have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
the BNF currently recommends doxycycline!!!! first-line
A 59-year-old man presents to the emergency department with right-sided chest pain and shortness of breath. He has no past medical history. He has smoked ten cigarettes a day since the age of 18.
On examination, he has mild increased work of breathing and minimal reduced air entry on the right side of his chest. His observations are all stable, including an oxygen saturation of 98% on room air.
A chest X-ray demonstrates a 2.4cm right-sided pneumothorax.
What is the appropriate management?
chest drain!!
Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history!!!!
Haemothorax
before starting azithromycin in COPD, what tests do you have to perform?
ECG (to rule out prolonged QT interval)!!!
and baseline liver function tests
Bipap!!!/ NIV used in copd not CPAP
so Cs not aligned
if a patient is diagnosed with TB, what is your next step in management?
HIV test
pulmonary embolsim causes what acid base finding?
respiratory alkalosis
Pulmonary embolism causes hyperventilation, causing a drop in arterial carbonic dioxide partial pressure and thus alkalosis.
what intervention is most likely to increase survival in patients with COPD?
Long-term oxygen therapy
management of non CF bronchiectasis?
Physiotherapy for inspiratory muscle training and postural drainage
most common organism in bronchiectasis?
pseudomonas
when do you give LTOT in COPD?
LTOT if 2 measurements of pO2 < 7.3 kPa
You are a GP trainee and a woman brings her 4-month-old baby to see you. She thinks he has picked up a virus. She says for the last 3 days he has had a runny nose, a dry cough and he feels hot.
On examination, the baby wakes on stimulation. He looks mildly dehydrated. His colour is normal and there is no cyanosis. He has a temperature of 38ºC and has a respiratory rate of 49 breaths per minute. There is a wheeze on chest auscultation and he is grunting at times.
What is your next course of action?
Admit immediately via ambulance
In bronchiolitis, the presence of grunting necessitates immediate referral to hospital
The left middle lobe of lung doesn’t exist, due to the presence of the heart. just upper and lower
Haemophilus influenzae is the most common cause of infective exacerbations of COPD.
also the most common organism in bronchiectasis
NIV is used in COPD. in life threatening asthma you call intensive care unit to intubate and ventilate, you dont use NIV
at what pH is NIV most likely to be beneficial in COPD?
7.25 - 7.35
Other than amoxicillin, first line antibiotic treatments for COPD?
clarithromycin, doxycycline!
other than methotrexate, name a drug that causes lung fibrosis
amiodarone, bleomycin
Community acquired pneumonia first line?
HAP first line
amoxicillin
co-amoxiclav. pneumonia occurring greater than 48 hours after admission is HAP
. People aged 50-70 years old with insidious, progressive shortness of breath on exertion, a dry cough, clubbing, and bilateral fine-end inspiratory crackles suggest a diagnosis of IPF.
a chest X-ray can be normal but may show bilateral interstitial shadowing and honeycombing. For this reason, a high-resolution CT scan is used which shows a ‘ground glass’ appearance, supporting a diagnosis of IPF.
If a patient on warfarin suffers from a p.e., you have to increase dose of warfarin
In the step-down treatment of asthma eg in pregnancy, aim for a reduction of 25-50% in the dose of inhaled corticosteroids (budesonide)
diagnostic test for ACTIVE TB i
sputum culture = gold standard
HIV decreases sensitivity of sputum smear
idiopathic pulmonary fibrosis predominantly affects lower lobes
Large bullae in COPD can mimic a pneumothorax
Whilst long-term oxygen therapy may increase survival in hypoxic patients, smoking cessation is the single most important intervention in patients with COPD to increase survival
Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline
if needle aspiration of a pneumothorax doesnt completely resolve it, next step in management?
chest drain insertion
