Resp3 Flashcards
Acute resp
What is the definition of a pulmonary embolus?
An emboli lodged within the pulmonary circulation.
The lung parenchyma is ventilated but not perfused.
What are the risk factors for a pulmonary embolus?
Hx/FHx of DVT Long periods of stasis (eg. flights) Recent surgery Pregnancy OCP/oestrogen Smoking Malignancy Cardio-respiratory Dx Hypoxaemia
What is the presentation of a PE?
Sudden onset Pleuritic chest pain SOB \+/- haemoptysis \+/- haemodynamic compromise
What will you find on examination of a Pt with a PE?
Tachypnoea Tachycardia Lower limb swelling/redness/hotness Cyanosis May have signs of shock
What is the scoring system used to dictate an investigation?
Well’s score
What should you do if the Well’s score is >4?
Admit to hospital
Perform a CTPA
What should you do if the Well’s score is <4?
Measure the D-dimer
If D-dimer is positive, admit and do CTPA
If D-dimer is negative, consider alt diagnosis
What other investigations other than CTPA/D-dimer can you do for a PE?
ECG
CXR
What would an ECG show on a Pt with a PE?
Sinus tachycardia
Right axis deviation
RBBB
S1Q3T3
What would an CXR show on a Pt with a PE?
Pleural effusion
Elevation of hemidiaphragm
What would your first line manage be for a Pt with a PE?
Analgesia
Oxygen >94%
Fluids
How would you manage a haemodynamically unstable Pt with a PE?
Thrombolysis (eg. alteplase)
Embolectomy
How would you manage a haemodynamically stable Pt with a PE?
LMWH/fondaparinux for 5 days/INR>2
Start warfarin at the same time
What is the definition of a pneumothorax?
Accumulation of air in the pleural space
What are the types of pneumothoraces?
Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
What is the difference between a primary and secondary spontaneous pneumothorax?
P- no underlying respiratory illness
S- associated with lung pathology
What is the presentation of a pneumothorax?
Sudden onset
SOB
Chest pain
What are the risk factors for a pneumothorax?
Underlying lung disease
Smoking
CTD
Trauma
What will you find on examination of a Pt with a pneumothorax?
Reduced/absent breath sounds
Reduced/absent vocal resonance
Hyper-resonance
Reduced chest expansion
What investigations would you do on a Pt with a pneumothorax?
CXR
CT
Why is a CXR important for a pneumothorax?
Can differentiate between a bullae and pneumothorax
Can locate the pneumothorax
Why is a CT important for a pneumothorax?
Can differentiate between a bullae and pneumothorax
Can locate the pneumothorax
Is more sensitive than a CXR
What is the management plan for a 40 yr old Pt with a primary pneumothorax <2cm?
O2
Consider discharge
What is the management plan for a 40 yr old Pt with a primary pneumothorax >2cm?
Aspirate
If unsuccessful, insert an intercostal drain
What is the management plan for a Pt >50yr OR with a secondary pneumothorax <1cm?
High flow O2
What is the management plan for a Pt >50yr OR with a secondary pneumothorax 1-2cm?
Aspirate
If <1cm, high flow O2
If still >1cm, intercostal drain
What is the management plan for a P t>50yr OR with a secondary pneumothorax >2cm?
Intercostal drain
What would you find on examination of a tension pneumothorax that you wouldn’t find in a normal pneumothorax?
Tracheal deviation
Distended neck veins
Displaced apex beat
What is the definition of a pneumonia?
Inflammation of the alveoli which can be caused by bacteria, viruses or fungi.
Inflammation results in air sacs filling with fluid or pus
What are the types of pneumonia?
Community-acquired pneumonia
Hospital-acquired pneumonia
Aspiration pneumonia
What are the common causes of CAPs?
Streptococcus pneumoniae
Haemophilus influenzae
What is the presentation of pneumonias?
Fever Malaise Rigors Productive cough Pleuritic chest pain
What will you find on examination of a Pt with pneumonia?
Pyrexia Cyanosis Tachypnoea Confusion Decreased expansion Dull percussion Increased vocal resonance Bronchial breathing
What investigations would you do on a Pt with pneumonia?
Bloods (FBC, CRP)
Sputum sample- MC&S
Blood cultures if severe
CXR
What is the scoring system to assess the severity of a pneumonia?
CURB 65 Confusion Urea >7mmol/L RR >=30 BP: SBP<90mmHg, DBP<=60mmHg Age >=65
What would you do for a Pt with a CURB-65 score of 0-1?
Treat at home if possible
What would you do for a Pt with a CURB-65 score of 2?
Consider hospital treatment
What would you do for a Pt with a CURB-65 score of 3+?
Severe, treat in ITU
What is the management for a Pt with pneumonia?
Antibiotics
Oxygen
Analgesics
Fluids
What antibiotics would you give a low severity pneumonia?
Oral amoxicillin
What antibiotics would you give a moderate severity pneumonia?
Oral/IV amoxicillin + macrolide (eg. clarithromycin)
What antibiotics would you give a high severity pneumonia?
IV co-amoxiclav + macrolide (eg. clarithromycin)
Where is Legionella pneumophila commonly found?
Aqueous environments
- air conditioning
- whirlpool spas
- contaminated water supplies
- airplanes
What is the difference between Legionnaire’s disease and Pontiac fever?
Legionnaire’s disease- Legionella pneumonia
Pontiac fever- non-pneumatic Legionella
What is the presentation of a Legionella pneumonia?
Prodromal flu-like symptoms Dry cough (can become productive) GI symptoms (nausea, D+V)
What investigations would you do for a Legionalla pneumonia?
Sputum culture
Urinary antigen detection
U+E for hyponatraemia
CXR- bi-basal consolidation
What is the treatment for Legionella pneumophila?
IV macrolide or fluoroquinolone
Clarithromycin or ciprofloxacin
What is Pneumocystis jirovecii?
Opportunistic fungal infection
AIDS defining illness
Causes pneumocystis pneumonia (PCP)
What are the risk factors for a Pneumocystis jirovecii infection (PCP)?
Recurrent bacterial pneumonias
Significant weight loss
HIV
What is the treatment for a Pneumocystis jirovecii infection (PCP)?
High dose IV co-trimoxazole
Which patients are at risk of a Pseudomonas aeruginosa infection?
Bronchiectasis
Cystic fibrosis
What is the treatment for a Pseudomonas aeruginosa pneumonia?
Piptazobactam
Piperacillin + tazobactam
What is the presentation of a Mycoplasma pneumoniae infection?
Insidious onset
Persistent cough
Low grade fever
Seen in close community settings (boarding school, uni, army bases)
What investigations would you do for a Mycoplasma pneumoniae infection?
CXR
PCR
What is the treatment for a Mycoplasma pneumoniae pneumonia?
Erythromycin/clarithromycin
What kind of patients commonly present with Staphylococcus aureus infections?
IVDU
What are the risks of Staphylococcus aureus infections?
Can arise from blood-borne spread of organisms form an area of infection
Can develop into septicaemia
What investigation would you do for a Staphylococcus aureus infection?
CXR
What is seen on a CXR for a Staphylococcus aureus pneumonia?
Patchy consolidation
Breaks for form abscesses which appear as cysts
What is the treatment for MSSA?
Flucloxacillin
What is the treatment for MRSA?
Vancomycin
A gentleman presents with acute breathlessness and chest pain. O/E his respiratory rate is 25bpm with good air entry in all fields. His ECG shows right axis deviation. What is the most likely diagnosis?
A. Pneumothorax
B. Pneumonia
C. COPD
D. Pulmonary embolism
D. Pulmonary embolism
A 35 year old lady presents with acute onset SOB, chest pain and one episode of haemoptysis. She has recently noticed a swelling in the left leg. O/E her RR is 28 and HR is 105. You suspect a pulmonary embolism. What is the most appropriate investigation to perform?
A. Chest X-Ray
B. CTPA
C. D-Dimer
D. ECG
B. CTPA
A 23 year old student presents to A&E with SOB. He says it came on suddenly. O/E his trachea is undisplaced with reduced breath sounds on the left. A CXR confirms a 1cm pneumothorax. What is the most appropriate management?
A. Immediate chest decompression
B. Intercostal drain
C. Aspiration
D. High flow oxygen
D. High flow oxygen
What signs would you expect on physical examination of someone with pneumonia?
A. Deviated trachea, ↓ expansion, dull to percussion
B. Bronchial breathing, ↓ expansion, ↓ vocal resonance
C. Pyrexia, ↓ expansion, ↑ vocal resonance
D. Dull to percussion, ↑ expansion, pyrexia
C. Pyrexia, ↓ expansion, ↑ vocal resonance
A 55 year old man has a 3 day history of shivering, general malaise & productive cough and is vomiting. The x-ray shows right lower lobe consolidation. He is diagnosed with a moderate pneumonia, what is the first line therapy?
A. Oral Amoxicillin
B. IV Co-Amoxiclav + Clarithromycin
C. Doxycycline
D. IV Amoxicillin + Clarithromycin
D. IV Amoxicillin + Clarithromycin
A 71 year old gentleman is brought in by his carer with a 4 day history of a fever and a cough. As you go to examine him he shouts and asks that you leave his bedroom. His RR is 30, BP 103/68. The lab phones you a hour later and lets you know his urea is 7.8mmol/L. Where would you manage this patient?
A. Admit and treat
B. Treat at home
C. Consider ITU
D. Refer for palliative care
C. Consider ITU
CURB-65 score: 4
25M presents to A&E with a fever and a cough. He says he has been generally unwell over the last year. O/E he is acutely SOB with a RR of 28. You also note an incidental finding of purple patches on his nose. What is the most likely causative organism?
A. Pseudomonas aeruginosa
B. Streptococcus pneumoniae
C. Pneumocystis jirovecii
D. Mycoplasma pneumoniae
C. Pneumocystis jirovecii
Purple patch- Kaposi’s sarcoma (HHV 8)
Indicative of a HIV Pt
55M presents with a cough and fever. He recently travelled to New York to speak at a conference. After bloods revealed Na+ of 130, you decide to test the urine. What is the most likely causative organism?
A. Haemophilus influenzae
B. Pseudomonas aeruginosa
C. Legionella pneumophilia
D. Pneumocystis jirovecii
C. Legionella pneumophilia
Flu-like symptoms
Recent travel- airplane
Hyponatraemia
Urine sample for antigens
10F presents to A&E with a fever and a cough and O2 sats: 92%. Her parents don’t seem worried as they are used to bringing her into hospital for treatment for her respiratory illness.
A. Pseudomonas aeruginosa
B. Haemophilus influenzae
C. Staphylococcus aureus
D. Coronavirus
A. Pseudomonas aeruginosa
Commonly seen in bronchiectasis or cystic fibrosis, which is what this Pt has.
A known IVDU is brought into A&E, he was found unconscious by two friends who were worried he might have overdosed. You notice an abscess in his groin. Temp 39, HR 120, BP 90/50. You immediately admit him.
A. Haemophilus influenzae
B. Staphylococcus aureus
C. Coronavirus
D. Legionella pneumophila
B. Staphylococcus aureus
IVDU
Infected abscess
Likely in septic shock
