resp

Question 1

4-month history of increasing breathlessness, fatigue and weight loss.

He is now retired but previously worked as a shipyard worker for 50 years

and he has a 40 pack-year smoking history.

cancer?

Answer 1

mesothelioma

Question 2

Pneumothorax- what to avoid in lifestyle?

Answer 2

Pneumothorax -> life long ban on deep sea diving

Question 3

Restrictive spirometry example?
FVC, FEV1, FEV1/FVC, TLCO?

Answer 3

pulmonary fibrosis, scoliosis, neuromuscular disorder, ARDS

FVC and FEV1 are reduced proportionately so the FEV1/FVC is normal/increased
FVC reduced <70% (significantly)
FEV1 reduced/normal
TLCO reduced (impaired gas exchange)

Question 4

Obstructive spirometry example?
FVC, FEV1, FEV1/FVC, TLCO?

Answer 4

COPD, ASTHMA, CF, Bronchiatasis, alpha 1 antritrypsin

FEV1 AND FVC are reduced disproportionately FEV1/FVC reduced <70%
FVC normal or reduced
FEV1 reduced <80%
TLCO reduced (impaired gas exchange)

Question 5

most common causes of bilateral hilar lymphadenopathy

Answer 5

sarcoidosis and tuberculosis.

Question 6

All cases of pneumonia should have a …….. at 6 weeks after clinical resolution

Answer 6

All cases of pneumonia should have a repeat chest X-ray at 6 weeks after clinical resolution

Question 7

admitted with acute severe asthma.

reatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone.

no improvement. What is the next step in management?

Answer 7

IV MAG SULPHATE

Question 8

A 23-year-old woman comes for review. Despite using beclometasone 200mcg bd she is regularly having to use her salbutamol inhaler. Her inhaler technique is good. next addition?

Answer 8

Question 9

What is the main therapeutic benefit of inhaled corticosteroids in patients with COPD?

Answer 9

reduce frequency of exacerbations

Question 10

diagnosed as having bilateral bronchiectasis following a high resolution CT scan. Which one of the following is most important in the long term control of his symptoms?

Answer 10

Symptom control in non-CF bronchiectasis - inspiratory muscle training + postural drainage

Question 11

Most common organisms isolated from patients with bronchiectasis:

Answer 11

Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae

Question 12

prescribed bupropion to help him quit smoking. What is the mechanism of action of bupropion?

Answer 12

Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist

Question 13

COPD- best type of oxygen device?

Answer 13

Bilevel Positive Airway Pressure (BIPAP)

Question 14

first-line pharmacological treatment of COPD

Answer 14

SABA or SAMA (ipratropium)

LAMA(tiotropium)

Question 15

target sats COPD

Answer 15

88% to 92%

Question 16

CURB 65 score?
what score means treat at home?

Answer 16

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

Confusion = 1
Respiratory rate ≥ 30 = 1
Blood pressure, SBP ≤ 90mmHg or DBP ≤ 60mmHg = 1
65 years and above = 1

(Urea is removed as this cannot be routinely tested in primary care).

Question 17

distinguish pleural effusion
exudate vs transudate?

Answer 17

EXUDATE IF:
Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of serum (blood) LDH

Pleural fluid LDH divided by serum LDH >0.6

Pleural fluid protein divided by serum protein >0.5

Question 18

The commonest causes of an anterior mediastinum mass?

Answer 18

4 T’s:
teratoma

terrible lymphadenopathy

thymic mass

thyroid mass

Question 19

anti-acetylcholine receptor antibodies in her blood.
dx?

Answer 19

Myasthenia gravis

Question 20

The most common organism causing infective exacerbations of COPD is

Answer 20

Haemophilus influenzae

Question 21

Pleural plaques indicate the patient has been exposed to asbestos 20-40 years prior.

This is seen on x ray findings, what todo next?

Answer 21

Pleural plaques are benign and do not undergo malignant change. They, therefore don’t require any follow-up.

Question 22

Acute bronchitis management?

Answer 22

Management:
1. analgesia
2. good fluid intake
3. 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)

NICE Clinical Knowledge Summaries/BNF currently recommend doxycycline first-line
doxycycline cannot be used in children or pregnant women

Acute bronchitis is a type of chest infection which is usually self-limiting in nature. It is a result of inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum.

Question 23

Sarcoidosis presentation?

Answer 23

Painful shin rash- erythema nodosum,

cough

also affect the kidneys, giving hypercalcaemia- macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)

the lymphatic system, giving lymphadenopathy, and other organs/systems.

more common in people of Scandinavian or African descent.

Question 24

Syndromes associated with sarcoidosis

Answer 24

Lofgren’s syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis

In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma

Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

Question 25

Lung abscess presentation?

Answer 25

Subacute productive cough, foul-smelling sputum, bronchial breath sounds, night sweats → ?lung abscess

Question 26

ABG triad for chronic CO2 retention:

Answer 26

Normal pH
High pCO2
High HCO3

normal ph- 7.35 to 7.45
normal po2- 10 to14
normal co2- 4.5 to 6.0
bicarb 22-26

Question 27

Pneumothorax tx?
primary?
secondary?
iatrogenic?

Answer 27

Discharge advice:

Smoking
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Fitness to fly
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray

Scuba diving
the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’

Question 28

A 54-year-old HIV positive man who has just successfully completed treatment for pneumocystis jirovecii pneumonia comes to your clinic reporting haemoptysis and increasing shortness of breath. A chest x-ray reveals an apical mass in the right lung lobe. He is treated successfully with itraconazole and steroids.

Which bug?

Answer 28

Aspergilloma is a fungal growth affecting immunocompromised patients or those with underlying cavitating lung disease such as tuberculosis or emphysema.

Question 29

COPD patient- has asthma features, currently on salbutamol, next addition?

Answer 29

using flow diagram

salmeterol and beclomethasone bronchodilator

LAMA= tiotropium

Question 30

critically ill patient- sudden deterioration… oxygen therapy?

Answer 30

In patients who are critically ill (anaphylaxis, shock etc) oxygen should initially be given via a reservoir mask at 15 l/min. Hypoxia kills.

Question 31

low-dose ICS name?

Answer 31

budesonide

Question 32

difference in presentation with moderate vs severe vs life threatening asthma?

Answer 32

moderate: speech normal

severe: cant complete sentences

life threatening: silent chest, cyanosis, exhaustion, confusion

Question 33

Non-invasive ventilation - key indications?

Answer 33

COPD with respiratory acidosis pH 7.25-7.35
(NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used)

type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea

cardiogenic pulmonary oedema unresponsive to CPAP

weaning from tracheal intubation

Question 34

most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics

Answer 34

Klebsiella pneumoniae

Question 35

Varenicline to stop smoking.
moa?
s/e?

Answer 35

nicotinic receptor partial agonist

nausea

Question 36

CURB 65 secondary care- how much for U?

Answer 36

> 7

C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years

Question 37

pulmonary haemorrhage (haemoptysis), renal impairment (rapidly progressive glomerulonephritis) and flat or saddle nose (due to a collapse of the nasal septum) is characteristic of

Answer 37

granulomatosis with polyangiitis

Question 38

what patients meet criteria for COPD prohylaxsis due to exacerbations?

what is the treatment?

Answer 38

Question 39

patient with pleural effusion, pleural guided aspiration done. What factor determines if chest drain is needed?

Answer 39

Question 40

what does negative base excess mean?

Answer 40

metabolic cause

Question 41

Answer 41

partially compensated metabolic acidosis

Question 42

Bupropion should not be used in a patient with ….

Answer 42

epilepsy as it reduces seizure threshold

bupropion- smoking cessation, norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist

Question 43

pneumothorax- where to do needle decompression?

Answer 43