Resp

Question 1

A 27-year-old female is admitted with acute shortness of breath. She is known asthmatic, has had one previous admission with an asthmatic attack. Ambulance crew administered 100% oxygen and nebulisers.
On examination, has pulse 110 bpm, O2 sats 92%, temp 37.5°C, BP 160/88 mmHg and resp rate 27/min. Chest auscultation reveals numerous wheezes.
What is most appropriate initial investigation for this patient?

a) Arterial blood gas
b) Blood cultures
c) Chest x ray
d) Full blood count
e) Serum IgE concentration

Answer 1

a) Arterial blood gas

These are features of acute severe asthma. She has tachycardia, tachypnoea and low oxygen saturations associated with high flow oxygen. Elevated BP typical of anxiety associated with acute asthma. Most relevant initial investigation would be ABG as these have prognostic significance.
One should also obtain a chest x ray because of possible other pathology such as pneumothorax or pneumonia that has sparked off this asthmatic attack, but this does not have prognostic significance in asthma.

Question 2

In a pleural effusion, what is difference between transudate and exudate?

Answer 2

a) transudate: hydrostatic forces favour fluid forced out of vessels so accumulation of fluid in pleura. Exudate: there is damaged or altered pleura (due to inflammatory process) resulting in deposition of PROTEIN AND FLUID in pleural space.

Question 3

If a patient presented to you with transudative pleural effusion, name 1 likely cause.

Answer 3

Any of: heart failure (most common), hypoalbuminaemia (e.g. nephrotic syndrome, cirrhosis), constrictive pericarditis, hypothyroidism, ovarian fibro producing right-sided effusion (Meig’s Syndrome)

Question 4

Name 1 common cause of exudative pleural effusion.

Answer 4

Any of: infection (empyema/parapneumonic effusion/tb), malignancy, PE with infarction, connective tissue disease

Question 5

How is hospital acquired pneumonia defined?

Answer 5

Pneumonia acquired 48 hours after admission to hospital

Question 6

What organisms cause hospital acquired pneumonia?

Answer 6

Hospital acquired pneumonia tends to be caused by Gram Negative organisms

Question 7

How would you empirically treat hospital acquired pneumonia?

Answer 7

Aminoglycoside + antipseudomonal penicillin or 3rd generation Cephalosporin
examples of each
aminoglycoside = vancomycin, clarithromycin, clindamycin
antipseudomonal penicillin = piperacillin
3rd gen cephalosproin = ceftriaxone, cefuroxiteme

Question 8

What are risk factors for COPD - give 1 lifestyle, environmental and genetic risk factor

Answer 8

Lifestyle: cigarette smoke, occupational exposure
Environmental: air pollution, infections
Genetic: alpha-1 antitrypsin deficiency

Question 9

How would you differentiate between asthma and COPD? Give 3 differences

Answer 9

Main differences are

1) asthma has diurnal variation of peak expiratory flow (also diurnal variation of symptoms) and COPD no difference.
2) on spirometry asthma may be normal but COPD is always abnormal (i.e. FEV1/FVC<0.7)
3) Asthma resp symptoms reversible on medication whereas COPD less convincing reversibility

Question 10

A 26 year old male was brought in following a collapse. He complained of sudden onset shortness of breath and pleuritic chest pain. On examination his trachea is deviated to the left and there is hyperresonance on the right side of his chest. What is the next appropriate management step?

a) CXR
b) CT Chest
c) Chest drain
d) Large bore cannula in left second intercostal space mid-clavicular line
e) Large bore cannula in right second intercostal space mid-clavicular line

Answer 10

e) Large bore cannula in RIGHT second intercostal space mid-clavicular line

Explanation: Pt has TENSION PNEUMOTHORAX on his RIGHT side as indicated by tracheal deviation (because trachea is deviated to left and hyperressonance is on right side of chest).

DO NOT WAIT FOR CXR, ONCE DIAGNOSED CLINICALLY, TREAT PATIENT STR AIGHT AWAY

Question 11

52 yo man presents in primary care unwell with cough with green sputum with occasional blood flecks. He is also complaining of shortness of breath and has a cold sore. On examination he is pyrexial, tachypneoic, tachycardic and there is left basal coarse crackles. What is the most likely diagnosis?

a) Viral Pneumonia
b) Pneumonia due to Streptococcus pneumoniae
c) Pneumonia due to Staphylococcus aureus
d) Pneumonia secondary to H. Influenzae Klebsiella pneumoniae

Answer 11

b) Pneumonia due to Strep. pneumoniae

= most common cause of community acquired pneumonia. Also further clues are the cold sore and blood stained sputum which points towards Strep. pneumoniae

Question 12

Define respiratory failure

Answer 12

Respiratory failure is when pulmonary gas exchange is inadequate and sufficiently impaired to cause HYPOXAEMIA ± hypercapnia. Hypoxia is defined as PaO2 < 8 kPa

Question 13

Define Type 1 resp failure

Answer 13

Type 1 resp failure is hypoxia (PaO2 < 8 kPa) with low or normal CO2

Question 14

Define Type 2 resp failure

Answer 14

Type 2 resp failure is hypoxia (PaO2 < 8 kPa) WITH hypErCAPNIA (high CO2 PaCO2 > 6 kPa)

Question 15

If pt had an angina pectoris & asthma, how would they be treated differently compared to if they didn’t have asthma?

Answer 15

if prescribing β-blockers for angina with asthma, use β1 selective blockers bc non-selective can induce bronchoconstriction via blockage β2 adenoceptors

Question 16

What commonly causes Type 1 resp failure?

Answer 16

Type 1 resp failure mainly caused by issues of V/Q mismatch, hypoventilation, abnormal diffusion, R to L cardiac shunts. So, most commonly caused by diseases that damage lung tissue (e.g. emphysema, asthma, ARDS, pulmonary fibrosis)

Question 17

What commonly causes Type 2 resp failure?

Answer 17

Type 2 resp failure mainly alveolar hypOventilation ±V/Q mismatch. E.g., pulmonary disease (emphysema, asthma, obstructive sleep apnoea), neuromuscular disease like Guillan-Barre, conditions reduced resp drive ( sedative drugs, CNS tumour), thoracic wall disease (flail chest, kyphoscoliosis)

Question 18

Who is at risk of respiratory failure and needs monitoring?

Answer 18

Patients on sedatives, COPD, neuromuscular disease (Guillan-Barre, myasthenia gravis, cervical cord lesions, poliomyelitis), inpatients in general (PE), pulmonary fibrosis, pneumonia, asthma

Question 19

How would you monitor patients for respiratory failure?

Answer 19

Simple monitoring = pulse oximetry, clinical assessment (tachypnoea, tachycardia, pulsus pardoxus), FVC
But in those you are particularly worried about = ABG, CXR, Sputum and blood cultures (if febrile) and spirometry on top of normal simple monitoring

Question 20

QUICKFIRE RAPID ROUND

a) Name a short acting β agonist (SAβA)
b) What would you use a SAβA for?
c) Name a long-acting β agonist (LAβA) indicated in COPD and asthma
d) Name an inhaled corticosteroid indicated in asthma
e) Name 2 combination treatments in management for stable COPD

Answer 20

a) Salbutamol
b) for quick relief of asthma symptoms
c) Salmeterol
d) Any from Beclometasone, budesenide, ciclesonide, fluticasone, mometasone
e) either beta2 agonist + theophylline
Or anticholinergic + theophylline

Question 21

What are 2 broad categories of lung tumours?

Name the subtypes under each broad categories

Answer 21

Small-Cell Lung Cancer (minority of cases, poor Px) and Non-Small Cell Lung Cancer (majority of cases).
For NSCLC, there are adenocarcinomas, squamous cell carcinomas, large cell carcinomas
For SCLC, there’s no subtype. SCLC are endocrine-secreting lung tumours - they may secrete hormones like ACTH, ACE. SCLC can lead to paraneoplastic syndrome

Question 22

List 4 risk factors for lung cancer

Answer 22

Smoking, asbestos, radiation e.g. radon, air pollution, family hx

Question 23

What hormone do lungs produce?

Answer 23

ACE - Angiotension Converting Enzyme

Question 24

Describe management of acute severe asthma attack (7 points)

Answer 24

1) high flow oxygen STAT
2) Beta agonist STAT: Neb salbutamol with OXYGEN (not air) + ipratropium neb (antimuscarinic).
If still not responsive, prednisolone iv ±hydrocortisone iv
If still not responsive, Mg or amiophylline
3) Monitor response to treatment: ABG, oximetry, PEFR
4) CXR if infection/pneumothorax/consolidation suspected
If deteriorating despite max treatment with worsening hypoxia, hypercapnia or coma/exhaustion, transfer to ITU. Watch K+, glucose. Consider rehydration.

Question 25

What are the symptoms of lung cancer?

Answer 25

Cough, dyspnoea, haemoptysis, wheeze, unintentional weight loss, malaise, drenching night sweats, dysphagia, chest pain

Question 26

How may mediastinum be involved with lung tumours?

Answer 26

Pancoast Tumour: tumours high up in lung around first rib - brachial plexus can be affected causing pain and weakness shoulder and arm ipsilaterally, Horner’s Syndrome ipsilaterally due to compression of sympathetic ganglion (ptosis with miosis, reduced sweating) Pleural effusion, pericardial effusion Superior vena cava compression -> early morning headache, facial congestion, oedema in upper limbs, Recurrent laryngeal N (hoarse voice), phrenic N involvement

Question 27

a) Name 5 risk factors for pneumonia | b) What is the most common causative organism of community-acquired pneumonia?

Answer 27

a) inpatients, infants & elderly, immunocompromised, alcoholics & IVDUs, Diabetes Mellitus, COPD or other chronic lung disease, impaired swallow b) Strep. Pneumoniae

Question 28

What are the atypical pathogens that can cause community-acquired pneumonia?

Answer 28

Legionella pneumophila, Mycoplasma pneuominae, Chlamydia pneumoniae

Question 29

In immunocompromised, what pathogens do you have to worry about in pneumonia?

Answer 29

Susceptibility to FUNGAL infections - e.g. Aspergillus (poor px, treatment=amphotericin), pneumocystitis carinii pneumoniae, cytomegalovirus

Question 30

What are common causative organisms of hospital-acquired pneumonia?

Answer 30

Gram-Neg bacteria

Question 31

``` 68-year-old male presents long-standing breathlessness and cough. Smokes 20 cigarettes daily. On exam, he has bluish discolouration of lips, is obese and nicotine stained fingers. Has temperature of 36.7°C, resp rate of 20/min and oxygen sats 92% on air. Chest exam reveals reduced expansion of generally expanded chest, widespread scattered wheezes & occasional crackles. What is most likely dx? a) Bronchial carcinoma b) COPD c) Asthma d) Pulmonary fibrosis ```

Answer 31

b) COPD The history is most suggestive of chronic obstructive pulmonary disease - long standing productive cough with a blue bloater appearance. There is nothing else in the history to suggest underlying bronchial carcinoma.

Question 32

a) What are some atypical pathogens that can cause community-acquired pneumonia? b) What makes them atypical?

Answer 32

a) Legionella pneumophila, Mycoplasma pneumoniae, Chlamydia pneumomiae b) Legionella pneumophila causes a severe pneumonia and get it from air-conditioning units/cooling towers/hot tubs/spa units Mycoplasma pneumoniae - no cell wall so penicillin ineffective. Occurs in epidemics every 3-4 years and affects young people Chlamydia pneumoniae - headache is common presenting feature.

Question 33

``` A 62-year-old female presents acute breathlessness of one hour duration. Smokes occasionally. On exam, she is sweaty and needs to sit up, has oxygen sats 89% on air, temperature of 37.5°C and has resp rate of 30/min. Auscultation of chest reveals widespread expiratory wheezes & extensive basal crackles. Which is most likely dx? a) Asthma b) Pneumothorax c) Pulmonary oedema d) Pneumonia ```

Answer 33

c) Pulmonary oedema This woman presents with severe acute breathlessness and most salient finding is extensive bibasal crackles - this would suggest pulmonary oedema. Wheeze/bronchospasm is a frequent feature of pulmonary oedema. Asthma and pneumonia are less likely scenarios - the former as there are no other features and the latter as the temperature and acute nature would argue against this.

Question 34

55-year-old female presents acute 1 day hx left sided chest pain and breathlessness. Smokes 10 cigarettes per day, takes hormone replacement therapy and three days ago returned from holiday in Greece. On examination, she is tanned, has some nicotine staining of the fingers, temperature of 37°C, a resp rate of 25/min, tachycardia 110/min and oxygen sats 93% on air. Chest examination reveals no specific abnormalities on the chest. Which is most likely dx? a) Pulmonary embolism b) Pulmonary oedema c) Pneumonia d) Pneumothorax e) Pulmonary fibrosis

Answer 34

a) Pulmonary embolism Most salient features here are acute breathlessness, reduced oxygen saturations increased respiratory rate and tachycardia. In a patient who has had a recent flight and in absence of any overt chest signs one must consider a pulmonary embolism. ECG may show S1Q3, T3(with massive PE) and gases may reveal hypoxia with hypocapnia. A ventilation perfusion scan or computed tomography pulmonary angiogram (CTPA) should be requested. There are no features to suggest pneumonia .

Question 35

a) What special request would you make to microbiology if you wanted to confirm TB from a sputum sample for cultures and sensitivities? b) What is a common TB co-infection?

Answer 35

a) Would ask for gram stain AND Ziehl-Nielsen stain (aka ACID-FAST BACILLI) b) HIV

Question 36

c) It is estimated that 2 billion people in the world are have latent TB - that is ⅔ of the world. How come there’s not same number of people with active TB? d) So out of those 2 billion people, some will turn into active TB. What risk factors predispose latent to active?

Answer 36

c) Because not everyone who has latent TB develops active TB. TB can lie dormant inside MO and immune system is able to contain it d) HIV/AIDS, old age, any form of immunocompromised, silicosis, IVDU, malnutrition, high-risk settings (e.g. homeless shelter, prison), low SE status, haemodialysis

Question 37

What are the symptoms of TB?

Answer 37

WT LOSS AND NIGHT SWEATS - MOST INDICATIVE OF TB! Low grade-fever, malaise, anorexia, cough, chest pain, SOB haemoptysis pleural effusion

Question 38

What are drugs used to treat TB?

Answer 38

R.I.P.E | = RIFAMPICIN + ISONIAZID + PYRAZINAMIDE + ETHAMBUTOL

Question 39

A previously fit 50-year-old man with no hx of resp illness, presents to you in A&E. He has 4 day hx fever, cough productive yellow-brown sputum, bilateral chest discomfort and increasing breathlessness. CXR already performed by A&E staff consistent with dx pneumonia. a) It is important for you to assess the severity of his presumed community-acquired pneumonia. List four features that would indicate a particularly severe pneumonia. (4 marks)

Answer 39

CURB65 Confusion Respiratory rate greater than 30/min Urea greater than 7mmol/L Low blood pressure less than 90/60 mmHg

Question 40

A previously fit 50-year-old man with no hx of resp illness, presents to you in A&E. He has 4 day hx fever, cough productive yellow-brown sputum, bilateral chest discomfort and increasing breathlessness. CXR already performed by A&E staff consistent with dx pneumonia. b) Apart from a full blood count, urea and electrolytes, glucose, and liver function tests, what two essential investigations should you perform on this gentleman at this stage? (2 marks)

Answer 40

arterial blood gas | blood cultures

Question 41

A previously fit 50-year-old man with no hx of resp illness, presents to you in A&E. He has 4 day hx fever, cough productive yellow-brown sputum, bilateral chest discomfort and increasing breathlessness. CXR already performed by A&E staff consistent with dx pneumonia. c) Clinical features and results of Ix indicate a severe community-acquired pneumonia. He has no drug allergies. What antimicrobial regimen would you commence and state the route of administration? (2 marks)

Answer 41

co-amoxiclav and erythromycin

Question 42

A previously fit 50-year-old man with no hx of resp illness, presents to you in A&E. He has 4 day hx fever, cough productive yellow-brown sputum, bilateral chest discomfort and increasing breathlessness. CXR already performed by A&E staff consistent with dx pneumonia. d) Over next four day, condition improves after antibiotic treatment. However, one week later he remains unwell with continuing fever, cough and breathlessness. The diagnosis of pneumonia has been confirmed and the organism shown to be sensitive to the prescribed antimicrobial therapy. Give four likely reasons to account for the apparent failure of your treatment? (4 marks)

Answer 42

Pleural effusion Empyema Respiratory failure Septicaemia. Explanation: Ten percent of adults with severe pneumonia require hospitalisation and IV antibiotics and the condition carries a high mortality rate. ``` Severe pneumonia is indicated by: Confusion Urea >7 mmol/L Respiratory rate >30/min BP <90/60 mmHg. ``` Important complications of pneumonia include: - Pleural effusion - Empyema - Lung abscess - Respiratory failure - Septicaemia - Pericarditis - Myocarditis - Cholestatic jaundice, and - Renal failure. Severe pnuemonia is managed with intravenous co-amoxiclav or cefuroxime and erythromycin or clarithromycin

Question 43

A 25-year-old male with a long history of cystic fibrosis presents with deteriorating breathlessness, productive cough and dyspnoea. On examination he has a temperature of 38.9°C, a pulse of 100 bpm and has widespread crackles over both lungs. Chest x ray reveals bronchiectatic changes over both bases and some haziness over the right base. From the following list, choose the most likely causative organism: A Haemophilus influenzae B Klebsiella pneumoniae C Legionella pneumophila D Pneumococcus E Pneumocystis jirovecii F Pseudomonas aeruginosa G Staphylococcus aureus H Viral pneumonia

Answer 43

F Pseudomonas aeruginosa This young man with cystic fibrosis is likely to have been colonised with Pseudomonas aeruginosa which is extremely difficult to eradicate and is responsible for frequent infective exacerbations in the condition. Treatment revolves around third generation cephalosporins or ciprofloxacin.

Question 44

``` A 30-year-old male is admitted with a three week history of deteriorating breathlessness and fevers. He smokes 10 cigarettes per day and has a male sexual partner. On examination he has a temperature of 39.5°C, a pulse of 105 bpm but there is nothing to hear on the chest. Oxygen saturations at 94% in air at rest but he rapidly desaturates to 82% on exertion. Chest x ray is unremarkable. From the following list, choose the most likely causative organism: A Haemophilus influenzae B Klebsiella pneumoniae C Legionella pneumophila D Pneumococcus E Pneumocystis jirovecii F Pseudomonas aeruginosa G Staphylococcus aureus H Viral pneumonia ```

Answer 44

E Pneumocystis jirovecii The salient features here are the weight loss, fevers and dyspnoea in a young homosexual male which suggests Pneumocystis jirovecii (PCP). The disease used to be called Pneumocystis carinii. This organism is usually non-pathogenic but pneumonia occurs in patients with immune suppression. It is regarded as an AIDS defining illness and is treated with co-trimoxazole.

Question 45

An 82-year-old male presents with a one day history of fever and confusion. He was admitted to the ward two weeks ago with cognitive decline, weight loss and difficulty coping at home. On examination, he has a pulse of 105 bpm, a temperature of 40°C and a respiratory rate of 32/min. Chest examination reveals crackles over the right mid and lower lung, and chest x ray shows shadowing over this region. From the following list, choose the most likely causative organism: A Haemophilus influenzae B Klebsiella pneumoniae C Legionella pneumophila D Pneumococcus E Pneumocystis jirovecii F Pseudomonas aeruginosa G Staphylococcus aureus H Viral pneumonia

Answer 45

G Staphylococcus aureus This elderly male with dementia has developed a hospital acquired pneumonia and the most likely cause is Staphylococcus aureus. It is associated with a high mortality. Other organisms associated with hospital acquired pneumonia include Escherichia coli which this could also be.