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Question 1

Causes of upper lobe fibrosis

Answer 1

SCATO

Silicosis/Sarcoidosis
Coal miners pneumoconiosis
Ankylosing spondylitis
TB
Other: hypersensitivity pneumonitis

Question 2

Causes of lower lobe fibrosis

Answer 2

RASID

Rheumatoid arthritis
Asbestosis
Scleroderma/SLE
IPF
Drugs: Amiodarone, bleomycin, methotrexate

Question 3

Causes of transudative pleural effusion

Answer 3

Cardiac failure
Nephrotic syndrome
Liver failure 
Meig’s syndrome (Ovarian fibroma and pleural effusion)
Hypothyroidism

Question 4

Causes of exudative pleural effusion

Answer 4

Pneumonia
Neoplasm – lung carcinoma, metastatic carcinoma, mesothelioma 
TB
Sarcoidosis
Pulmonary infarction 
Subphrenic abscess
Pancreatitis 
Connective tissue disease (RA, SLE)
Drugs – nitrofurantoin, drugs inducing lupus
Radiation

Question 5

Respiratory causes of clubbing

Answer 5

Lung carcinoma
Chronic pulmonary suppuration (bronchiectasis, cystic fibrosis, lung abscess, empyema)
Idiopathic pulmonary fibrosis
Mesothelioma
Mediastinal disease (Thymoma, lymphoma, carcinoma)

Question 6

Causes of bronchial breath sounds

Answer 6

Lobar pneumonia
Localised fibrosis or collapse
Above a pleural effusion
Large lung cavity

Question 7

Causes of reduced breath sounds:

Answer 7

Emphysema
Large lung mass
Collapse, fibrosis
Effusion
Pneumothorax

Question 8

Common signs of ILD

Answer 8

Dry cough
Crackles
Clubbing

Question 9

Common signs of Bronchiectasis

Answer 9

Loose cough
Full sputum mug
Coarse crackles and wheezes
Clubbing

Question 10

Common signs of COPD

Answer 10

Overinflated chest
Possible cyanosis
Pursed lip breathing
Reduced breath sounds and wheezes
Hoovers sign

Question 11

Common signs of pleural effusion

Answer 11

Stony dullness
Bronchial breathing on top
Needle marks from previous aspirations

Question 12

Common signs of treated carcinoma

Answer 12

Sometimes clubbing
Scar
Radiotherapy marks
Signs of effusion or collapse 
Lymph nodes

Question 13

X-ray changes in sarcoidosis

Answer 13

Symmetric hilar and mediastinal lymphadenopathy
Pulmonary fibrosis
Peri-lymphatic micronodules
Airspace opacities/consolidation (less common)
Pleural effusion (usually small)

Question 14

Causes of cyanosis

Answer 14

Decreased arterial oxygen saturations

• High altitude
• Lung disease
• Cyanotic heart disease

Polycythemia
Haemoglobinopathies (methaemaglobinaemia)

Hypovolaemia, vascular obstruction (peripheral only)

Question 15

Causes of a low DLCO with obstructive spirometry

Answer 15

Emphysema
Cystic fibrosis
Alpha 1 antitrypsin deficiency 
Bronchiolitis obliterans
Bronchiectasis

Question 16

Causes of a low DLCO with restrictive spirometry

Answer 16

ILD
Pneumonitis
Sarcoidosis
Asbestosis
Congestive cardiac failure

Question 17

Causes of a low DLCO with normal spirometry

Answer 17

PE
Pulm HTN
Pulmonary vasculitis
Early ILD
Anaemia (ensure correction with Hb)
Increased carboxyhaemoglobi
Hepatopulmonary syndrome

Question 18

Causes of a high DLCO

Answer 18

Asthma
Pulmonary haemorrhage 
Severe obesity
Polycythaemia 
Left to right cardiac shunting

Question 19

Causes of deviated trachea towards the lesion

Answer 19

Collapse
Fibrosis
Pneumonectomy
Lobectomy
Consolidation

Question 20

Causes of deviated trachea away from the lesion

Answer 20

Tension pneumothorax
Massive effusion
Mediastinal mass

Question 21

Causes of a widened mediastinum

Answer 21

Tumour - thymoma, lymphoma
LN enlargement
Retrosternal thyroid
Unfolded aorta
Aortic aneurysm/dissection

Mediastinal fat
Bronchogenic cysts
Paravertebral mass - TB

Question 22

Light’s Criteria

Answer 22

At least 1 of:

Pleural fluid protein / Serum protein > 0.5

Pleural fluid LDH / Serum LDH > 0.6

Pleural fluid LDH > 2/3 Serum LDH Upper limit of normal

Question 23

HRCT findings for UIP pattern ILD

Answer 23

• Subpleural and basal predominance
• Reticular abnormality
• Honeycombing (with or w/o traction bronchiectasis)

Question 24

What investigations would you request for an ILD Short?

Answer 24

Confirm the diagnosis:
oCXR: tracheal deviation (UL), decreased expansion, reticular markings
oPFTs: restrictive spirometry, reduced lung volumes, reduced DLCO (Provides assessment of severity, progression over time)
oHRCT: particularly for UIP or NSIP patterns
oReview bronchoscopy or lung biopsy results if performed

Investigate for possible secondary cause:
o FBE, ANA, ENA, dsDNA, ACE, CMP, RF, anti-CCP, CK, ANCA
o Review medications
o Review environmental exposures +/- fungal precipitins
o History of cancer (chemotherapy, radiotherapy)
o Smoking history

Screen for Complications
o ABG on room air for hypoxia or hypercapnoea
o TTE +/- right heart catheter for PHTN and RVF
o Exercise capacity (marker of severity)

Question 25

What investigations would you request for a COPD Short?

Answer 25

Confirm the diagnosis and assess the severity o PFTs – obstructive pathology o Review chest imaging – CXR +/- CT o ABG on room air – hypoxia and/or hypercapnoea o FBE – Hb (anaemia or polycythemia), WCC (infection or steroids) o ECG/TTE – pulmonary HTN and cor pulmonale

Question 26

What investigations would you request for a Bronchiectasis Short?

Answer 26

Confirm the diagnosis o History of symptoms and time course o CXR and HRCT o PFTs (obstructive most common) – trend of FEV1 over time Assess severity o Degree of FEV1 reduction (severe <40%) and trend over time o ABG on RA for hypoxia and/or hypercapnoea o History of exacerbations and admission Additional tests of relevance o Sputum MCS for colonization o Inflammatory markers, WCC, albumin, anaemia (infection) Investigating underlying cause o Review history of childhood or recurrent infections and immunisations o Family Hx, genetic testing and/or sweat test for CF (younger people) o Serum immunoglobulins o Testing for immotile cilia (younger people) o Aspergillus testing