Respi SAQ Flashcards
chronic smoker, months of SOB, 5 years of dry cough, 3 years of whitish + occasionally yellowish sputum + a few episodes of fever and sputum, says pneumonia; referred to SOPD clinic. PE: prolonged expiratory phase, LLZ coarse crackles, also raised JVP, bilateral ankle edema and central cyanosis. FEV1 1.3L FVC 2.4L FEV/FVC 54% CXR hyperinflated lung fields;
1. 2 most likely ddx
2. 1 Ix to differentiate the two
3. What complication from PE. Explain physiology of complication
4. Definition of reversibility on bronchodilator change
- COPD, bronchiectasis
- HRCT thorax
- Cor pulmonale due to pulmonary hypertension as a result of obliteration/occlusion of blood vessels. VQ mismatch hypoxia –> polycythemia –> hypervolemia causing increased cardiac output and causes pulmonary hypertension and increases RV workload –> resulting in congestion –> elevated JVP, peripheral edema
- Increased FEV1 >12% by bronchodilator/ >200ml increae in FEV
a) Respiratory acidosis as there is hyperventilation to compensate for the dead space. This is type 2 respiratory failure: wasted expenditure of energy.
b) Drugs: Short acting inhaled salbutamol +/- ipratropium bromide with spacer. Corticosteroids (hydrocortisone 100mg iv q6-8h or oral prednisolone 30-40mg daily). Steroids discontinued after the acute episode (e.g. 5-10 days)
Non drugs: supplemental oxygen (start with 1-2L/min by nasal prongs) to maintain spO2 88-92%. NIV to relieve dyspnea by decreasing work of breathing: consider when respiratory acidosis (pH<7.35), severe dyspnoea with signs of respiratory muscles fatigue, persistent hypoxemia despite supplemental O2 therapy)
c) cigarette smoking, occupational exposure to dust/fumes, indoor biomass combustion (wood, coal –> not in HK)
a) severe asthma, non responsive phenotype, poor inhaler technique, poor adherence, ongoing exposure to triggers, inadequately controlled comorbidities (rhinitis), misidagnosis
b) house dust, pollen, animal danders
c) Bronchodilator as reliever, increase to medium dosage ICS. Can add LABA if not well controlled (formoterol).
a) aspiration pneumonia due to impaired consiousness caused by stroke. Given IV because patient may be unable to swallow well.
b)
Ampicillins and cephalosporins (apart from 2nd gen cephalosporins) don’t cover anaerobes which is needed in aspiration pneumonia
aspiration pneumonia pathogens
Gram +ve: strept pneumoniae, staph aureus, alpha hemolytic streptococci
Gram -ve: haemophilus influenzae, pseudomonas aeruginosa, e.coli, klebsiella pneumoniae (DM+ elderly)
Anaerobic: bacteroides, peptostreptococus, fusobacterium
A 27/F found unconscious on the street. Respiratory rate 8 breaths per minute. Pinpoint pupils. The blood gas shows the following (pH 7.25, PaO2 low, PaCO2 high, HCO3 12, BE +2)
a. Interpret the blood gas findings
b. Most likely diagnosis
c. What drug treatment would you give for the diagnosis
d. Three alternative causes for the blood gas picture
a. Type 2 respiratory failure: hypoxia + hypercapnic due to hypoventilation (this is a ventilatory failure) + respiratory acidosis. There is no renal compensation as HCO3- is low (insufficient time to compensate).
b. Opioid intoxication (inability to dilate pupils)
c. Naloxone
d. GBS/ myasthenic crisis/ BDZ overdose
Bronchiectasis exacerbation with Gram-negative rod cultured
a. 2 typical features of bronchiectasis on CXR
b. Name one other confirmatory investigation
c. What is the Gram-negative bacteria cultured likely to be?
d. Three groups of antibiotics for the above bacteria
e. Name one evidenced based drug which has been proven to reduce the frequency and severity of exacerbations, 2 adverse effects to monitor associated with long-term use
a. tramline opacities, thickened and abnormally dilated bronchial walls, parallel linear densities
b. HRCT
c. Pseudomonas aeruginosa
d. Fluoroquinolones, aminoglycosides, at least 3rd gen cephalosporins, carbapenems, extended spectrum penicillins
e. immunomodulation by macrolide (azithromycin): takes at least 6 months for effect. AE: hepatotoxicity, ototixicity, QTc prolongation
Other immunomodulation
Inhaled antibiotics for PsA colonizer: inhaled gentamicin
Intermittent IV antibiotics
a. 2 types of cells affected by HIV
b. 3 groups of drugs in HAART
c. Pneumonia picture. Diffuse haziness on CXR. Give 2 ddx
d. CD4 140. AFB smear of sputum negative. What is most likely dx?
e. Name 1 Ix to confirm dx?
f. What drug treatment for dx?
a. macrophage, dendritic cell, helper T cell (CD4+)
b. NRTI, NNRTI, PI
c. PJP, miliary TB
d. PJP
e. BAL with methanamine silver stain
f. Septrin (cotrimoxazole). If G6PD+ve –> give pentamidine.
A 54-year-old man, with diabetes mellitus for 10 years and chronic alcoholism for 20 years, presented with high swinging fever, cough and greenish sputum for 1 week. He had no recent travel for the past few months. He attended A&E Department with temperature 39°C, blood pressure 130/85 mmHg, pulse rate 120/min regular, and bronchial breath sounds with coarse crackles in the right lower chest posteriorly. Initial blood tests revealed WBC 25 × 109/L (75% neutrophils), urea 10.5 mmol/L (N: 3– 8.8), and creatinine 97 umol/L (N: 67–109). Sputum Gram stain showed Gram-negative bacilli. Chest x-ray showed right lower zone consolidation.
(a) What is the most likely causative microbial agent for his medical illness?
(b) Name two appropriate choices of empirical antimicrobial drug.
On the third day after hospital admission and empirical antibiotic treatment, he complained of right pleuritic chest pain and persistent fever. Physical examination showed decreased breath sound and stony dullness in the right lower chest. Chest x-ray showed a moderate right pleural effusion.
(c) What is the most appropriate diagnostic procedure to be performed?
(d) Explain how four investigation results of the above procedure can help in making your diagno- sis in this case.
(e) What additional therapeutic procedure may need to be performed after the above diagnostic workup?
a) klebsiella pneumoniae (most associated with DM)
b) augmentin (+ azithromycin), ceftriaxone/ceftazidime/cefotaxime
c) pleural tap (thoracentesis)
d) Biochemistry (LDH, protein to use Lights criteria), micbio (gram stain and C/S), cell count (bacterial/TB, fungal), glucose, pH
e) pleural drainage via chest drain for complicated pleural effusion/empyema (if multi loculated pleural collections –> may need intrapleural fibrinolytic to decompress
Madam Fung has a diagnosis of asthma for about 4 years, when she was 25 years old. The diagnosis was made after spirometric testing when she had protracted nocturnal cough. Her asthma symptoms, which were only mild and intermittent several years ago, has become worse with increased cough and some shortness of breath in the past three months. She was previously on short-acting beta-agonist MDI on a demand basis, and she subsequently bought the medicine over the counter. She now needs to use it at least once daily.
(a) She is now referred to your clinic. Name three investigations you would do and their purposes in this patient.
(b) List six possible factors you have to exclude for the worsening of symptoms in her case.
(c) Your working diagnosis is asthma, what further medication is appropriate at this point and
why?
(d) Name two further instructions / explanations you need to provide, other than writing out the
medication prescription for the patient.
a) PEF to confirm dx (with reversibility upon bronchodilator) and deteremine if there is nay airway obstruction
CXR to rule out other ddx and look for any complications (e.g. pneumothorax)
Skin atopy to advise on allergen avoidance
b) poor compliance, wrong technique, home environment (allergens), wrong dx, smoking, infection
c) ICS because she has frequent exacerbation
d) Home monitoring with PEF, home modification, correct technique of using bronchodilators
a) pulmonary embolism due to unexplained desaturation with minimal clinical/CXR findings. Underlying hx of advanced CA colon + bilateral leg swelling. T1RF pattern (suggesting a ventilation/perfusion mismatch) on ABG. Sinus tachycardia on ECG
b) CTPA
c) LMWH, ABC, morphine PRN
d) IV fluid resuscitation, IV thrombolytics +/- catheter directed thrombolysis or even embolectomy if refractory
e) Warfarin, VKOR1 and reducing the production of factor 2,7,9,10
A 50-year-old man, previous smoker but quitted for one year, who worked in the gem industry polish- ing precious stones for over 20 years, was admitted for sudden haemoptysis of about 10 mL of fresh blood. He has been told previously that he has some “occupational lung disease”. He also has mild dia- betes mellitus, and urticaria to shrimps and crabs. He has no symptoms of acute illness or other signifi- cant respiratory symptoms preceding this presentation, though he had non-specific constitutional symptoms of malaise for several weeks.
(a) Based on this history, list two top differential diagnosis for the cause of hemoptysis in his case, and explain your choice.
(b) CXR showed a cavitating lesion in right middle zone. Name and explain the rationale for three sputum tests that you would order as an intern.
(c) The medical officer asked to see his blood glucose and renal function test results. Briefly discuss how each of these two tests may relate to his lung condition.
(d) Three days later, the three previous test results you ordered came back but did not yield any diagnosis. You think he needs further thoracic imaging for the CXR lesion. Name two and explain the rationale and the information you will get.
a) CA lung (likely underlying silicosis), TB: increased risk in silicosis
b) Cytology, AFB smear (ziehl neelson stain)/ culture (Lowenstein Jenson culture), gram stain C/ST
c) Poorly controlled DM, renal failure = predisposes to TB. Renal failure also causes bleeding tendency probably relevent in treatment of CA lung as well
d) contrast CT thorax: contrast enhancement >25HU likely malignant, other features including pleural tethering, spiculating shape, eccentric calcification, irregular border
Bronchoscopy/CT guided biopsy of the lesion
Ms. S Leung is 38 years old and works as a cashier in a restaurant. She smokes about 5 cigarettes/ day for I0 years. She has a history of systemic lupus erythematosis, given immunosuppressants. For the past 6 months, she has only been on prednisolone 5 mg daily for lupus nephritis. She was told that she was having more proteinuria, but otherwise still stable, at her last follow up about 4 weeks ago. She present- ed this time with progressive cough and scanty mucoid phlegm for past 2 months, associated with mild malaise.
Physical examination did not reveal much significant findings except percussion dullness and decreased breath sounds at right base. CXR showed a right pleural effusion up to about one third of the hemitho- rax, and lung fields were otherwise clear.
(a) List three possible causes, in priority of likelihood, of the right pleural effusion. Chest tapping was done and 30 mL of straw coloured fluid was aspirated.
(b) List the tests that need to be done with the pleural fluid and explain how each test would help you to make a diagnosis of the suspected underlying cause of the effusion.
a) Parapneumonic effusion, lupus serositis, TB
b)
Biochemistry: lights criteria (exudative if pleural fluid LDH >0.6, protein >0.5, LDH >2/3)
Low pH, glucose suggestive of empyema, lupus serositis
Micbio: gram stain, C/ST. AFP smear, culture, ADA (if > 70 suggest TB)
Cell count: lymphocytosis (TB, SLE), neutrophilia (parapneumoic effusion, empyema), eosinophilic (blood air, absestos, EPGA, PE)
Cytology to look for malignant cells
A 40-year-old salesman with history of renal transplantation 2 years ago for chronic glomerulonephritis was admitted with low grade fever, non-productive cough and progressive shortness of breath for one week. He denied any upper respiratory tract symptoms. His renal function was normal. CXR showed normal heart size and diffuse ground glass abnormality in the lung fields. Temperature was 38°C. Chest: few crackles bilaterally. BP 140/90 mmHg, pulse 90/minute. Oxygen saturation on room air was 90%.
(a) List four salient features in his medical history and how they would assist in making a differen- tial diagnosis to the cause of his respiratory problem.
(b) Name the two microbes which are likely aetiologic agents in this clinical setting.
(c) Name two further investigations that would be indicated to help in making a definitive diagno- sis and briefly describe how they can help
a) renal transplant on immunosuppressive drugs –> note intracellular pathgens. low grade fever, non productive cough, SOB –> not typical pyogenic pathogens
no URTI symptoms: unelikely flu
b) pneumocystic jirovecii, TB
c) sputum AFB culture/smear
Induced sputum/BAL/lung specimen for microscopy under silver stain: cyst/alveolar casts in PJP
You have been asked to review a 57-year-old diabetic woman who moved to the UK 2 years ago from Washington DC. She presents with a 15-day history of fever and cough productive of green sputum. On examination her respiratory rate is 22, pulse rate 120 with BP 110/65. On auscultation she has bronchial breath sounds on the left. Chest x-ray reveals left lower lobe consolidation. You decide to treat her for community-acquired pneumococcal pneumonia.
(a) What 3 microbiological tests would you like to perform in order to confirm your diagnosis?
(b) Which 4 groups of adult patients would you consider to be at higher risk of contracting pneu- mococcal disease?
a) sputum gram stain, C/ST, urine antigen test (for legionella), blood culture
b) >65y, chronic disease, AIDS/ cancer/ splenectomy/ institutionalized, smoker, cochlear implant, CSF leaks
Patricia is a 38-year-old housewife. She was diagnosed with asthma at the age of 4, but her symptoms completely disappeared by the age of 17. She and her family have recently moved from London to the Cotswolds. The house is very old and in spite of Patricia’s best efforts a little dusty. However, the move has been a great success. Patricia is now able to enjoy horse riding in the local woods and meadows, a new hobby she has started in order to keep fit. Her 8-year-old twin girls have been given a Labrador puppy, which makes them very happy. Patricia’s husband is also pleased with the move as he is now able to indulge his lifelong interest in exotic rabbits and smoke cigars in their new games room. However since her move to the country Patricia has been complaining of persistent dry cough, shortness of breath and occasional wheeze.
(a) Please list 6 potential asthma triggers in the above scenario.
(b) What 4 factors would you consider in a patient with asthma who fails to improve with appro- priate pharmacological treatment?
a) pollen, house dust mite, cigar smoking, animal fur (dog, rabbit, horse)
b) compliance, inhaler technique, trigger avoidance, alternative dx
a) FEV1/FVC =53.8%. Increased lung volume = air trapping. Obstructive lung defect. Acute on chronic T2RF –> respiratory acidosis with inadequate metabolic compensation. Overall suggestive of bronchiectasis exacerbation with cor pulmonale
b)
ABC. Prop up, low salt diet, fluid restriction.
BP/P RR SpO2 q4h
O2 by cannula/face mask, aim spO2 at 88-92%
Broad spectrum Abx with pseudomonal coverage, usually tazocin (course: 14d)
IV lasix for underlying HF
NIV with biPAP if refractory
a) FEV1/FVC is around 90% indicating that it is a restrictive lung disease. It also has reduced total lung capacity. Decreased residual volume so not obstructive.
Gas profile: acidosis, hypoxemic, hypercapnic with increased HCO3 so inadequate metabolic compensation. This is advanced ILD, acute on chronic T2RF. Secondary polcytyhemia, cor pulmonale
b) heart failure: upper lobe venous diversion, bat wing opacity (oligaemia), lower zone reticulonodular density, honeycombing
cx of asbestosis: mesothliom (pleural mass/ effusion), CA lung (lung mass)
a)
FEV1/FVC = 40%
Increased lung volumes
Low normal DLCO
Compatible with obstructive lung defect likley COPD
ABG: acute on chronic T2RF: resp acidosis with inadequate compensation (as still acidotic with increased HCO30
Hbhct high = polycythemia
Imp: COPD complicated by acute on chronic T2RF and polycythemia and cor pulmonale
b)
Ensure ABC
Fluid restriction and low salt diet, prop up on bed, vitals q4h
O2 by nasal cannula first, aim spO2 88-92%
Nebulized ventolin +/-atrovent +/- aminophylline
CXR to r/o other causes of acute deterioration
Otherwise, manage as ADHF
If stable BP, IV lasix, morphine, nitrates
NIV with BiPAP if refractory
a) FEV1/FVC = 89%, reduced lung volumes and DLCO compatible with restrictive lung defect with diffusion impairment, suggests dx of ILD
b)
CBC: polycythemia
ABG: chronic RF
ECG: cor pulmonale (RVH, RAH)
CXR: asbestos plaque, reticulonodular shadwos, honeycombing
HRCT for ILD features e.g. ground glass opacity, tramline, honeycombing, tractional bronchiectaasis
c) advise avoid further occupational dust exposure, pneumoconiosus usually has no specific Tx, avoid smoking, chest physio if necessary. Flu, PPV23 vaccination. Advise on increased CA lung and TB risk, discuss compensation (occupational lung disease)
Post bronchodilator FEV1/FVC = 46.9% < 70% diagnostic of COPD
Increased lung volumes with reduced FVC compatible with emphysema
DLCO reduced, compatible with emphysema with destruction of capillary bed. High Hb indicates polycythemia, likely a reaction to chronic hypoxemia
ABG: pH low normal, low pO2, high pCO2. chronic T2RF pattern which has resp acidosis with adequate metabolic compensation
