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Yr 3: CN2 > Resp II > Flashcards

Resp II Flashcards

1
Q
A
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2
Q

Which type of organisms are most likely to cause HAP? [1]

Which infective organisms are most likely to cause HAP? [4]

A

Gram negative organisms:

PEKA:
Pseudomonas aeruginosa,
Escherichia coli
Klebsiella pneumoniae
Acinetobacter species.

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3
Q

Which organisms are most likely to cause atypical pneumonias? [5]

A

TOM TIP: You can remember the 5 causes of atypical pneumonia with the mnemonic: “Legions of psittaci MCQs”:

Legions: Legionella pneumophila
Psittaci: Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)

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4
Q

State 4 clinical consequences of untreated Mycoplasma pneumonia [4]

A

Haemolytic anaemia
Erythema multiforme
Encephalitis
Peri / myocarditis

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5
Q

How do you treat Mycoplasma pneumonia? [2]

A

1st line:Erythromycin OR Clarithromycin

2nd line: Doxycycline or a macrolide (e.g. )

Because generally there is no diagnosis of the pathogen at the time of treatment, initiation of the treatment is usually empirical

BMJ BP

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6
Q

State and describe this complication of Mycoplasma pneuomia [2]

A

bullous myringitis: painful vesicles on the tympanic membrane

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7
Q

What clinical presentation may indicate COVID caused pneuomonia? [1]

A

Silent hypoxia: Patients may not feel particularly short of breath despite having low oxygen saturations

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8
Q

Alongside CURB65, describe which test is sometimes used to determine Abx therapy in the primary care setting [3]

A

NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:

CRP < 20 mg/L - do NOT routinely offer antibiotic therapy

CRP 20 - 100 mg/L - consider a DELAYED antibiotic prescription

CRP > 100 mg/L - OFFER antibiotic therapy

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9
Q

Describe the treatment algorithm for mild / low severity CAP? [2]

A

First line: 5 day course
- Amoxicillin
- If if penicillin allergic: clarithromycin (macrolide) OR doxycycline (tetracycline)

Second line:
- No respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).

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10
Q

Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | moderate-severity (CURB-65 = 2)?

A

7-10 day course is recommended

1st line:
- ORAL amoxicillin plus a macrolide: clarithomycin
- For patients who are allergic to penicillin in whom oral antibiotics are contraindicated: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone)

PLUS
clarithromycin, or intravenous levofloxacin monotherapy

2nd line:
- Change to doxycycline or a fluoroquinolone: ciprofloxacin AND pneumococcal cover: levofloxacin or moxifloxacin

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11
Q

Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | high-severity (CURB-65 = 3-5)?

DOUBLE CHECK

A

1st line:
- A broad-spectrum beta-lactamase-resistant penicillin: amoxicillin/clavulanate plus a macrolide: clarithromycin
- If allergic to penicillin: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) PLUS a macrolide (e.g., clarithromycin)

2nd line:
- Doxycycline OR
- Cefalexin OR
- Trimethoprim

3rd Line:
- levofloxacin

BMJ BP

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12
Q

In patients with suspected or confirmed Staphylococcus aureus MRSA infection, what are the two treatments? [2]

A

IV Vancomycin
OR
IV teicoplanin

with or without

Rifampicin (orally or intravenously)

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13
Q

State the treatments for these atypical pneumonias [5]

A

A: Clarithromycin (orally or intravenously)

B: Fluoroquinolone (ciprofloxacin) (orally or intravenously)

C: Amoxicillin (orally) or
D: benzylpenicillin
(intravenously)

E: Doxycycline (orally)

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14
Q

In patients with suspected or confirmed Staphylococcus aureus non-MRSA infection, what are the two treatments? [2]

A

Flucloxacillin (intravenously)

with or without

Rifampicin (orally or intravenously)

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15
Q

What is the treatment algorithm for mild to moderate symptoms/signs and not at higher risk of resistance for HAP? [2]

How long for? [1]

A

5 day prescription

ORAL:
- amoxicillin/clavulanate (aka Co-amoxiclax)
- If allergic: Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole

NICE

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16
Q

What is the treatment algorithm for severe symptoms/signs and not at higher risk of resistance for HAP? [2]

How long for? [1]

A

1st line:
- piperacillin/tazobactam OR
- ceftazidime OR
- cefuroxime OR
- meropenem

2nd line:
- levofloxacin

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17
Q

Label the progress expected post-pneumonia from 1 week - 6 months

A

1 week:
- Fever should have resolved

4 weeks:
- Chest pain and sputum production should have substantially reduced

6 weeks:
- Cough and breathlessness should have substantially reduced

3 months
- Most symptoms should have resolved but fatigue may still be present

6 months:
- Most people will feel back to normal.

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18
Q

All patients with moderate-severe pneumonia should have what investigations? [3]

(NICE & BTS)

A

All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats

Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum

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19
Q

All patients with severe + outbreaks of pneumonia should have what investigations? [3]

(NICE & BTS)

A

All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats

Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum

Severe+:
- Mycoplasma PCR
- Chlamydophilia PCR
- Viral PCR

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20
Q

BTS guidelines:

What are the treatments for

S. aureus non-MRSA? [1]
S. aureus MRSA? [2]

A

S. aureus non-MRSA: flucloxacillin

S. aureus MRSA: vancomycin OR linezolid OR teicoplanin +/- rifampicin

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21
Q

State what is meant by Lofgren’s syndrome [1]

How does Lofgren’s syndrome usually present? [4]

A

Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.

It usually carries an excellent prognosis

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22
Q

Explain what is meant by Heerford’ts syndrome [1]

What is the classical presentation? [3]

A

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

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23
Q

Describe the clinical features of sarcoidosis if each of the following are effected:

  • Skin [3]
  • Lungs [3]
  • Systemically [3]
A

Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.

24
Q

What treatment might be given to for treating skin sarcoid? [1]

A

Hydroxychloroquine

25
Q
A

a prolonged PR interval

26
Q

Describe the classic triad of yellow nail syndrome [3]

A
  • Yellow fingernails
  • Bronchiectasis
  • Lymphoedema

TOM TIP: Yellow nail syndrome is characterised by yellow fingernails, bronchiectasis and lymphoedema. Patients are stable and have good clinical signs, making it a good choice for OSCEs. As it is rare, examiners will score high marks if you can combine these features and name the diagnosis.

27
Q

Asides from imaging investigations, describe what else you would investigate for bronchiestasis [7]

A

Sputum culture
- Most commonly Haemophilus influenzae and Pseudomonas aeruginosa

FBC:
- may reveal high eosinophil count in bronchopulmonary aspergillosis

specific IgE or skin prick test to Aspergillus fumigatus

serum alpha-1 antitrypsin phenotype and level

serum immunoglobulins
- to identify individual immunoglobulin deficiencies as underlying aetiology

Rheumatoid factor

Serum HIV antibody

28
Q

Describe the treament algorithm for bronchiestasis for the initial presentation? [5]

A

initial presentation
1ST LINE: exercise and improved nutrition.
- Including vitamin D supplementation
- Higher BMI has beneficial outcomes
- Excercise is considered form of airway clearance

PLUS –
airway clearance therapy (ACT):
- maintenance of oral hydration; percussion, breathing, or coughing strategies
- positioning and postural drainage; positive expiratory pressure devices; and oscillatory devices
- recommended for 15 to 30 minutes, 2 or 3 times daily

PLUS –
self-management plan

CONSIDER –
inhaled bronchodilator:
- salbutamol inhaled

CONSIDER –
mucoactive agent
- hypertonic saline

BMJ BP

29
Q

acute exacerbation: mild to moderate underlying disease if is first or new presentation of Pseudomonas aeruginsoa

A

1ST LINE –
short-term oral antibiotic:
- For adults, prescribe amoxicillin 500 mg three times a day for 7–14 days

PLUS –
increased airway clearance

PLUS –
continued maintenance therapy:
- Healthy diet & exercise
- Higher BMI
- Nebulised bronchodilators
- Nebulised hyperosmolar agents, such as hypertonic saline,

30
Q

Describe how treatment for bronchiectasis would be escalated in a stepwise manner if they were suffering ≥ 3 exacerbations in one year despite following the initial management?

A

3 or more exacerbations per year despite maintenance therapy
1ST LINE –
reassess physiotherapy ± mucoactive treatment

PLUS –
continued maintenance therapy
- Azithromycin 500 mg three times a week, or
- Azithromycin 250 mg daily, or
- Offer a minimum of 6 months treatment, but up to 1 year may be required.

CONSIDER –
long-term antibiotic

CONSIDER –
surgery:
- Surgical resection is considered in patients with localised disease whose symptoms are not controlled by optimal medical treatment
- Complete resection of the bronchiectatic area is associated with the best results

CONSIDER –
treatment of respiratory failure

31
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Streptococcus pneumoniae. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

Amoxicillin 500 mg three times daily

32
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzaebeta lactam negative. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzae. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily

Amoxicillin 500 mg three times daily

  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
33
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzae (beta-lactamase positive). What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

Co-amoxiclav 625 mg three times daily

34
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Pseudomonas aeruginosa. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Pseudomonas aeruginosa. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
35
Q

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Klebsiella. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
A

A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Klebsiella. What is the approriate first line treatment

  • Co-amoxiclav 625 mg three times daily
  • Amoxicillin 500 mg three times daily
  • Flucloxacillin 500 mg four times daily
  • Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
  • Ciprofloxacin 500 or 750 mg twice daily
36
Q

[] is the usual choice for infective exacerbations caused by Pseudomonas aeruginosa

A

Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa

37
Q

State 5 common causes of T1RF [6] (and the cause of hypoxia)

A

Diffusion abnormality:
- Pulmonary fibrosis
- Emphysema in COPD

V/Q mismatch: reduced V
- Pneumonia
- Pulmonary oedema
- Pneumothorax

V/Q mismatch: reduced Q
- Pulmonary embolism

Low inspired oxygen

Hypxoxia = increased V
More CO2 exhaled
Hypoxia but not hypercapnic

38
Q

What are common causes of chronic T2FR? [5]

A

Obstruction to airways:
* COPD
* Severe asthma

Hyperexpanded lungs:
- COPD

Thoracic cage problems:
- Kyphoscoliois
- Obesity

Weakness of resp. muscles
* Chronic neurological disorders (e.g. motor neuron disease)
* Chronic neuromuscular disorders (e.g. myopathies)

39
Q

Which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Lobar pneumonia causing V/Q mismatch

40
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Diffusion abnormality: patient has sarcoidosis

41
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Hypoventilation: patient has TB

42
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Hypoventilation: lobar collapse

43
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Diffusion limitation:
Pulmonary fibrosis

44
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Hypoventilation: COPD

Can be T1 or T2RF

45
Q

Out of which of the following would this cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Hypoventilition: motor neuron disease - can’t use muscles / diaphragm to breathe

46
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

VQ mismatch: pneumothroax

47
Q

Out of which of the following would this cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Morbid obesity: hypoventilation

48
Q

Out of which of the following would this CXR cause hypoxaemia?

V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space

A

Shunt: eisenmenger syndrome

49
Q

How do you manage acute T2RF? [4]

A

Controlled oxygen:
- 0.5 - 2l/min via nasal cannulae
- 24 to 28% masks using venturi valves

Regular ABG to monitor CO2 levels

Consider non-invasive ventilation (BIPAP) if pH and CO2 dont improve

Go over BIPAP - is this correct?

50
Q

Which inherited disorders increase the risk of PE? [5]

A

Factor V Leiden mutation:
- Normally used for blood clotting: helps enzyme reaction to form fibrin in blood clot
- Once the coagulation process is turned on in people with factor V Leiden, it turns off more slowly than in people with normal factor V

Antithrombin deficiency
- Normally anti-thrombin acts as the inhibitory component to thrombin formation

Prothrombin deficiency

Protein C & S deficiencies

Antiphospholiipid syndrome

51
Q

Describe the treatment algorithm for patients who have PE confirmed and are haemodynamically unstable [4]

A

First line:
- heparin: 10,000 units intravenously as a loading dose initially, followed by 18 units/kg/hour intravenous infusion

PLUS: thrombolysis: (involves injecting a fibrinolytic (breaks down fibrin) medication that rapidly dissolves clot)
- Alteplase or
- Streptokinase or
- Urokinase

PLUS:
- anticoagulation with unfractionated heparin (UFH) for several hours after the end of thrombolysis before: switching to apixaban or rivaroxaban; low molecular weight heparin (LMWH) is an alternative if these are unsuitable - this is preferable

CONSIDER: vasoactive drug if SBP < 90 mmHG after thrombolysis
- noradrenaline or
- dobutamine

-

52
Q

Describe the treatment algorithm for patients who have PE confirmed and are haemodynamically stable [4]

A

Stable, no renal impairment or co-morbidities: offer apixaban/rivaroxaban. If not-suitable, LWMH for 5 days then offer edoxaban/warfarin*

First line: anticoagulation:
- apixaban or
- rivaroxaban

OR

  • UFH / LMWH / Fondaparinux lead AND warfarin
  • Target INR 2-3 then stop heparin
53
Q

Describe three subacute complications of PE

A

Infarction and lung necrosis
- PE can cause ischemic injury to the lung parenchyma, leading to pulmonary infarction, haemorrhage, or lung necrosis.

Pleural effusion:
- Inflammatory processes triggered by PE may cause pleural effusion, which may be exudative or hemorrhagic.

Pneumothorax:
- Rarely, PE-induced lung infarction may lead to pneumothorax due to the rupture of a bulla or necrotic lung tissue

54
Q

PE would cause change to axis deviation? [1]

A

Right axis deviation

55
Q

Which of the following is used to treat chronic PEs unresolved after 3 months

  • Embolectomy
  • Mechanical fragmentation with R heart angiography
  • Pulmonary thombro-endarterectomy
  • IVC filter
A

Pulmonary thombro-endarterectomy (PTE)

56
Q

Describe the different bridging times for LMWH if using:
- Warfarin
- Dabigatran or edoxaban
- Rivaroxaban or apixaban

A

Warfarin:
- Start LMWH and initiate warfarin at same time then after 5-10 days change to just warfarin

Dabigatran or edoxaban
- 5 days of LMWH with both then switch to doac same day

Rivaroxaban or apixaban
- No bridge - only use them

57
Q

Describe the diagnostic pathway for PEs

A

Yr 3: CN2 (29 decks)

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