1. SABA 2. Inhaled steroid 3. increased steroid dose. LABA 4. Leukotriene receptor antagonists, b2 agonist tablets [5. addition of oral low dose steroids]

resp SBAs Flashcards by denise lin

Decreased air entry
Decreased vocal fremitus
Dull percussion
on R side of chest

R sided pleural effusion

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Extrapulmonary manifestations of sarcoidosis

splenomegaly, uveitis, erythema nodosum, bilateral parotitis and swelling, hepatic granuloma infiltration

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Resp causes of clubbing

Abscess
Bronchogenic carcinoma
Bronchiectasis
CF
Fibrosing alveolitis
Empyema
Mesothelioma

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PE signs on ECG

S1Q3T3

Deep S wave in lead I
Pathological Q wave in lead III
Inverted T wave in lead III
(RAD)

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Chronic asthma Rx

SABA
Inhaled steroid
increased steroid dose. LABA
Leukotriene receptor antagonists, b2 agonist tablets
[5. addition of oral low dose steroids]

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A 42 year old previously healthy plumber is brought to hospital very confused by his wife with a fever, bradycardia and SOB. Investigations reveal elevated WBC count and Na 127mmol/l, K 4.2mmol/l, urea 6.5mmol/l. The doctor orders a urine sample. What is the diagnosis?

Legionella (Gram -ve rod)

Found in lakes, contaminated water systems etc. Smoking is a risk factor.

It can cause confusion, abdo pain, hypoNa+, diarrhoea and bradycardia.

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Legionella diagnostic test

Urine Ag detection

Legionella does not grow on routine culture media

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Pseudomona type of bacteria?

Gram -ve bacilli

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What is Pott’s disease

Presentation of extrapulmonary TB which affects the spine

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Mr D is an eco warrior who has spent the last 6 months in India. He has come back very thin with a persistent cough which occasionally produces blood streaked sputum. He has never smoked cigarettes.

pulmonary TB

DDx: bronchial carcinoma

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Which NSCLC is located peripherally in the lung

Adenocarcinoma

Commonest in non-smokers

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Gram +ve cocci

Streptococcus
Staphylococcus
Enterococcus

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Gram +ve bacilli

Clostridium

Listeria

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Gram -ve cocci

Neisseria

Haemophilus

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Gram -ve bacilli

Salmonella
Shigella
Pseudomonas
Legionella
Vibrio
ESBL
Proteus

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A young adult with a 2 day history of left sided pleuritic chest pain, fever and cough productive of rusty coloured sputum. A CXR was obtained which showed left lower lobe shadowing suggestive of consolidation. On agar the sputum grew gram +ve cocci. What is the diagnosis?

Strep pneumoniae

Management is guided by the CURB-65 score.

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A 26 year old man presents with severe shortness of breath and a dry cough for several weeks. He is an IV drug user. There are purple patches on the arms and in the mouth. CXR shows reticular perihilar/fine mottling opacities.

PCP is caused by Pneumocystis jirovecii, previously called Pneumocystis carinii. It is a fungal organism and an AIDS defining illness

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A 51 year old social worker presents to her GP with haemoptysis. On further questioning she admits to having a productive cough for 6 months + to losing 2 stones in weight over the same time. Chest x-ray shows patchy consolidation & scarring in both apices

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A 20 year old presents with general malaise, severe cough + breathlessness which has not improved with a 7 days of amoxicillin. CXR: patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins.

Mycoplasma - cold type agglutinins and a cold AIHA. Humans are the only host for Mycoplasma. Most commonly affected are young adults living in close proximity. PCR can be used in diagnosis.

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A 20 year old man with CF presents with haemoptysis. He has had a cold for a fortnight with increased sputum production, fever + rigors. Sputum shows Gram +ve cocci in clusters

Staph aureus - post-influenza pneumonia. It causes a cavitating pneumonia on CXR (some abscesses seen). Another risk factor is CF.
Rx of staphyloccocal infection: flucoxacillin or vancomycin

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Trachea deviated to left. Dull to percussion + reduced breath sounds at left base.

This is a lobar collapse. Collapse pulls the trachea TOWARDS the affected side. There is dullness and reduced/absent breath sounds due to a lack of air filled lung in this space. . A ‘sail sign’ will classically be seen behind the cardiac shadow on CXR with left lower lobe collapse

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A 36 year old popstar presents with fever, a cough + an itchy vesicular rash. Chest x-ray shows mottling through both lung fields

The pruritic vesicular rash (dewdrop on a rose petal) = VZV. The rash is usually on torso and face; pneumonia is a complication in those with immunosuppression. The lesions are often crusted over by 7-10 days.

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Types of aspergillosis

Type 1 hypersensitivity reaction causing atopic asthma through inhalation of fungal spores
Allergic bronchopulmonary asperillosis (ABPA) from type 3 hypersensitivity reaction
Aspergilloma – fungus ball in a pre-existing cavity, often caused by TB and sarcoidosis
Invasive aspergillosis – in immunocompromised, SLE, burns, post-broad spectrum Abx
Hypersensitive pneumonitis (EAA)

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Bilateral cavitating bronchopneumonia causative organisim…

Staph aureus

Rx: flucloxacillin

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Extrinsic allergic alveolitis (EAA) definition [also known as hypersensitivity pneumonitis]

Occurs from inhalation of organic allergens e.g. fungal spores or avian proteins that initiate a hypersensitivity reaction. Individuals are commonly exposed to allergens by their occupation or hobbies

Acute phase of EAA

alveolar infiltration with inflammatory cells, leading to non-caseating interstitial granulomas 4-6hrs post-exposure: fever, rigors, dry cough, SOB, fine inspiratory creps

Chronic phase of EAA

well-formed granulomas, obliterative bronchiolitis, alveolar destruction (honeycombing on CXR) = fibrosis wt loss, increasing SOB, T1 resp failure, RHF, fine inspiratory creps.

Main causes of EAA

``` farmer’s lung mushroom picker’s lung bird/pigeon fancier’s lung malt worker’s lung humidifier's lung (bagassosis) ```

The most common organisms responsible for LRTIs in cystic fibrosis are ...

Staph aureus, Haem influenza and Pseudomonas aeruginosa. Chronically: pseudomonas (80%). Rx = ciprofloxacin

Diagnosis of CF is made by ...

NaCl sweat test >60mmol/l

Pancoast tumour signs

Hoarse voice | Horner's syndrome

A 55 year old smoker presents with rapidly progressing weight loss with severe burning pain in his hands + feet. Chest x-ray shows a small round opacity in the right upper lobe. What is the likely diagnosis?

This patient has lung cancer and paraneoplastic syndrome with manifestations of sensory neuropathy associated with small cell lung cancer. Small cell lung cancer is treated with chemotherapy and is also associated with SIADH and ectopic ACTH.

Bounding pulse in a patient who is short of breath suggests...

Acute rather than chronic CO2 retention other causes of bounding pulses: hepatic failure, sepsis

Mycoplasma pneumonia extra-pulmonary features

``` Erythema multiforme (rashes) Myocarditis Haemolytic anaemia Meningoencephalitis Transverse myelitis GBS ```

Commonest community acquired pneumonia organism

Strep pneumoniae (70%)

Commonest community acquired pneumonia organisms in COPD/smoking patients

Haemophilius influenzae | +Moraxella catarrhalis

Community acquired pneumonia organisms with birds/parrot contact

Chlamydia pneumoniae | Chlamydia psittaci

Hospital acquired pneumonia organisms

Gram -ve enterobacteria (Pseudomonas, Klebsiella) Anaerobes (aspiration pneumonia) [and staph aureus]

Bronchial breathing definition

Inspiration phase lasts as long as the expiration phase present in pneumonia

Most definitive investigation for Pneumocystic cariini pneumonia (or when pneumonia fails to resolve or there is clinical progression)

Bronchoscopy | +bronchoalveolar lavage

Pneumonia 0 markers on guidelines Rx

Oral amoxicillin | ±O2, IV fluids, drain empyema/abscesses

Pneumonia 1 marker on guidelines Rx

Oral or IV amoxicillin Oral or IV erythromycin (±O2, IV fluids, drain empyema/abscesses)

Pneumonia >1 markers on guidelines Rx

IV cefuroxime/cefotaxime/co-amoxiclav IV Erythromycin (±O2, IV fluids, drain empyema/abscesses, add metronidazole for aspiration pneumonia)

Tension pneumothorax Rx

Maximum O2 Insert large-bore needle into 2nd ics MCL on side of pneumothorax to relieve pressure Insert chest drain soon after

Complications of pneumonia

Spread of infection: pleural effusion, empyema, abscess, septicaemia Damage to local structures: bronchiectasis, pneumothorax

Common causes of chronic cough in non-smokers

``` Asthma (+atopy, allergies) Post-nasal drip GORD ACEi Non-smoker lung cancer i.e. NSCLC adenocarcinoma ```

Pleural pH <7.2 when normal blood pH is found in

Pleural infection (e.g. pneumonia and empyema) TB Malignancy Oesophageal rupture n.b. these along with SLE and RhA also have low glucose levels. Exudate pleural fluids have high LDH levels.

Exudate pleural fluids (high protein levels in pleural effusion) have high or low LDH levels?

High LDH levels

CURB-65 score

``` Confusion Urea >7mmol/L RR >30/min BP <90/60 Age >65 ``` (±hypoxia <8kPa, WCC <4/>20)

A 30yr old man presents with repeated episodes of fever, rigors, dry cough and SOB with onset several hours after starting work. CXR shows mid-zone mottling. What is the likely diagnosis?

Extrinsic allergic antigens (EAA) He is a farmer and this is a hypersensitivity reaction to inhaled antigens. In chronic EAA, CXR may show honeycommb lung.

Community acquired pneumonia organism common in IVDU users and post-influenza elderly patients

Staph aureus

A 65yr old dockyard worker presents with weight loss and SOB. He is clubbed and cachectic. CXR shows pleural calcification and lobulated pleural mass. What is the likely diagnosis?

Malignant mesothelioma Due to previous asbestos exposure: Mass with lobulated margin on CXR Pleural calcification

A 40yr old woman presents with gross clubbing and progressive SOB. O/E: fine end-inspiratory crackles. CXR: ground glass appearance of lungs. What is the likely diagnosis?

Idiopathic pulmonary fibrosis Combination of SOB, clubbing, fine end-insp creps. CXR findings include ground-glass shadowing and chronically, a honeycomb lung.

A 35yr old patient on the ward admitted to hospital 10days ago develops a severe pneumonia. What is the appropriate Rx?

HAP = Gram-ve organisms e.g. Pseudomonas Tazocin can be used (b-lactam abx)

Fine crepitations suggest

Pulmonary oedema | Pulmonary fibrosis

Early onset emphysema + liver disease

a1-antitrypsin deficiency

Fever, cough, SOB Hours after exposure to antigen +ve serum precipitins

Extrnsic allergic alveolitis

``` Asymptomatic with BHL Progressive SOB/dry cough Non-pulmonary manifestations High serum ACE High Ca2+ ```

Sarcoidosis

Progressive SOB and cyanosis Gross clubbing Fine end-inspiratory crackles CXR groundglass -> honeycomb lung

Idiopathic pulmonary fibrosis

Swinging fever Copious foul-smelling sputum Persistent, worsening pneumonia

Lung abscess