Pulmonology

Question 1

Pneumonia(Consolidation)

Answer 1

Fairly acute onset
Increased vocal resonance (Whispering pectoriloquy, aegophony)
Bronchial breathing
Crackles
Dullness
Increased vocal fremitus

Question 2

COPD (Asthma)

Answer 2

Mostly strong smoking history
Barrel shape
Decreased air entry
Prolonged expiration
Wheezes
Resonant
Reduced cardiac dullness
Liver dullness downward
Decreased expansion

Question 3

Pleural Effusion

Answer 3

Depend on cause
Potential pleuritic chest pain
Possibly reduced chest movement
Reduced vocal resonance
Reduced / Absent breath sounds
Maybe Bronchial breathing at top of effusion
Stony Dullness
Trachea shifted away if massive

Question 4

Bronchiectasis

Answer 4

Significant sputum production
Localised & longstanding = reduced movement over the specific area
Coarse crackles over area
wheeze due to element of obstruction
maybe some dullness
upper lobe is affected and it is severe, the trachea may be shifted towards
clubbing

Question 5

Lung Cancer

Answer 5

Smoking history
Chronic cough
Weight loss
educed movement over the specific area
clubbing
Nodes
Horner’s / SVC syndrome

Question 6

Pneumothorax

Answer 6

Acute onset
Pleuritic chest pain
Decreased chest expansion on the side
Decreased / Absent breath sounds
Resonant
Decreased expansion on side
Trachea shifted away if Tension
Possible Surgical emphysema

Question 7

Interstitial fibrosis

Answer 7

Chronic history of progressive dyspnea
Dry cough
Fine inspiratory crackles (becomes coarse as disease progress)
Decreased expansion
Clubbing
Maybe signs of underlying connective tissue disease

Question 8

Collapse

Answer 8

Decreased chest expansion
Decreased breath sounds
Dullness
Trachea shifted towards
Depend on cause – maybe loss of weight

Question 9

Liver Failure

Answer 9

Jaundice
Bruising
Encephalopathy

Question 10

Chronic liver disease (failure)

Answer 10

Palmar erythema
Dupuytren’s
Spider Nevi
Gynecomastia
Testicular Atrophy

Question 11

Portal Hypertension

Answer 11

Ascites
Varices
Splenomegaly

Question 12

Liver Function tests

Answer 12

Bilirubin
INR
Albumin
Cholesterol

Question 13

Hepatocellular damage

Answer 13

Raised ALT (AST)
Look for: Viral, Drugs, AIH

Question 14

Cannicular / Obstructive

Answer 14

Raised GGT (ALP)
Look for: Malignancies, Infiltrative process (TB), Drugs, Ultrasound

Question 15

Ascites (High SAAG)

Answer 15

> 12
Portal Hpt
Cirrhosis
CCF
Etc
Do Ultrasound, liver functions, hepatitis studies etc

Question 16

Asites (Low SAAG)

Answer 16

<11
Non Portal Hpt (so membrane damage)
Infective
Malignancy
Inflammatory (sarcoid, SLE etc)
Do MC&S, cell-count, ADA, cytology etc depending on suspected cause

Question 17

Jaundice (Pre-Hepatic)

Answer 17

( = Haemolysis )
Increased unconjugated bilirubin, normally not severe (40 - 80)
ALT normal, AST raised
LDH raised
Reticulocytes

Question 18

Jaundice (Hepatic)

Answer 18

(Hepatocellular vs Canicular)
Frequently mixed picture
Hepatitis
Specific syndromes like Gilbert’s

Question 19

Jaundice (Post Hepatic)

Answer 19

Can be very severe, deeply jaundiced, bilis > 300
Conjugated to Unconjugated bilirubin > 65%
Gull stones
Head of Pancreas
Sclerosing Cholangitis
(pale stools, dark urine)

Question 20

Cirrhosis

Answer 20

signs of chronic liver disease

Causes
ETOH
Hepatitis B
Other Hepatitis
Metabolic
Hemochromatosis, Wilson’s
Autoimmune
PBC, AIH

Complications
Portal Hypertension
HCC
Liver failure

Question 21

Rx of liver failure

Answer 21

Find the cause and treat the cause

Supportive:
Avoid liver toxins
Address clotting
Watch for Hypoglycaemia
Low threshold for antibiotics
Transplantation

Parvolex:
No RCT data
But natural anti-oxidant in liver, working via glutathione
Especially in Paracetamol OD, but potentially any over cause

Question 22

Hepatitis B (Clinical pic)

Answer 22

Via bodily fluids
Long incubation 12/52
Symptomatic 4-8/52
10% become chronic – go on to cirrhosis without Rx

Question 23

Hepatitis B (Dx)

Answer 23

HepB Ag – you currently have the virus
HepBs Ab – gives immunity, so you had it, but cleared it
HepBc Ab – does NOT give immunity, so shows you have been exposed and now:
Is in early phase and still may develop s Ab
If you do not develop s Ab, you will develop Chr HepB

Question 24

Hepatitis B (Treatment)

Answer 24

Acute = Supportive
Avoid hepato-toxins
Regular small, non fatty meals
Rest
Chronic = Tenofovir / Lamividine

Question 25

Hep A

Answer 25

Fecal-oral transmission
Short incubation 1-2/52
99% recovery, NO chronic state

Question 26

Hep C

Answer 26

90% becomes chronic

Question 27

Portal Circulation

Answer 27

Portal vain – liver sinusses – hepatic vain - IVC

Question 28

Hepatic

Answer 28

Cirrhosis

Question 29

Post-hepatic

Answer 29

Hepatic vein or IVC
Budd Chiari
Congestive cardiac failure

Question 30

Pre-Hepatic

Answer 30

Portal Vein thrombosis
Bilharzia

Question 31

Hemoptysis (Causes)

Answer 31

Bronchiectasis / Post TB structural lung disease
Any pneumonia which causing cavitation
TB
Necrotising pneumonia
Lung abscess
Aspergiloma
Bronchus carcinoma
Autoimmune disease
Wegener’s / SLE / Goodpasture’s
AV malformation / aneurism
Pulmonary embolism
LV disease (mitral stenosis)

Question 32

massive hemoptysis

Answer 32

If hemodynamic unstable
OR
More than 400ml

Question 33

Hemoptysis (Management)

Answer 33

Supportive:
ABC’s
Opioids
Treat the cause
Definitive treatment
Bronchial artery embolization
Lobectomy
Less evidence
Vasopressin nebs
Tranexamic acid
Antibiotics