resp SBAs Flashcards
Decreased air entry
Decreased vocal fremitus
Dull percussion
on R side of chest
R sided pleural effusion
Extrapulmonary manifestations of sarcoidosis
splenomegaly, uveitis, erythema nodosum, bilateral parotitis and swelling, hepatic granuloma infiltration
Resp causes of clubbing
Abscess Bronchogenic carcinoma Bronchiectasis CF Fibrosing alveolitis Empyema Mesothelioma
PE signs on ECG
S1Q3T3
Deep S wave in lead I
Pathological Q wave in lead III
Inverted T wave in lead III
(RAD)
Chronic asthma Rx
- SABA
- Inhaled steroid
- increased steroid dose. LABA
- Leukotriene receptor antagonists, b2 agonist tablets
[5. addition of oral low dose steroids]
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.
Legionella diagnostic test
Urine Ag detection
Legionella does not grow on routine culture media
Pseudomona type of bacteria?
Gram -ve bacilli
What is Pott’s disease
Presentation of extrapulmonary TB which affects the spine
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
Which NSCLC is located peripherally in the lung
Adenocarcinoma
Commonest in non-smokers
Gram +ve cocci
Streptococcus
Staphylococcus
Enterococcus
Gram +ve bacilli
Clostridium
Listeria
Gram -ve cocci
Neisseria
Haemophilus
Gram -ve bacilli
Salmonella Shigella Pseudomonas Legionella Vibrio ESBL Proteus
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.
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
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
TB
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.
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
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
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.
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)
Bilateral cavitating bronchopneumonia causative organisim…
Staph aureus
Rx: flucloxacillin
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
