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Internal Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Signs of pleural effusion on inspection (2)

A

Trachea and apex beat deviated to opposite side if large

Reduced chest expansion

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2
Q

Signs pleural effusion on auscultation (3)

A

Reduced vocal resonance
Reduced or absent breath sounds
May be bronchial breathing heard above effusion

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3
Q

Sign pleural effusion on percussion

A

Stony dull

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4
Q

2 broad causes of pleural effusion

A

Transudate

Exudate

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5
Q

What is exudate

A

At least one of light’s criteria
High protein - fluid protein: serum protein more than 0,5
High LDH- fluid LDH: serum LDH more than 0,6 or more than 2/3 normal upper limit LDH in serum.

= local problem eg malignancy, inflammation, pulmonary infarct , chemo and radiation

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6
Q

What is transudate

A

Transported fluid from elsewhere to pleural space
= systemic problem eg hf, hypoproteinaemia

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7
Q

causes transudative pulmonary effusion 3

A

Hypothyroid
Hypoalbuminaemia eg from cirrhosis, kidney failure
Cardiac failure

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8
Q

6 causes exudative pleural effusion

A

Malignancy: bronchial carcinoma, metastatic carcinoma…
TB
Pneumonia
Meigs syndrome -ovarian fibroma causing pleural effusion and ascites
Connective tissue disease-rheumatoid arthritis, SLE
Acute pancreatitis
Chemo /radiation
Pulmonary infarct

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9
Q

What is consolidation

A

Lobar pneumonia

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10
Q

Chest inspection findings of consolidation

A

Reduced chest wall movement (expansion)

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11
Q

Percussion signs of consolidation

A

Dull

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12
Q

Auscultation findings of consolidation (4)

A 
Bronchial breathing
Coarse crackles inspiratory
Vocal resonance increased
Reduced breath sounds.
(Pleural rub may be present)
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13
Q

Symptoms of consolidation (6)

A 
Dementia!
Cough (painful and dry at first)
Fever and rigors
Pleuritic chest pain
Dyspnoea
Tachycardia
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14
Q

Diagnosis COPD?

A

Spirometry: post-bronchodilator FEV 1 / FvC <70%

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15
Q

What is emphysema

A

Increase in air spaces distal to terminal bronchioles (alveoli) (hyperinflation)

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16
Q

Inspection signs of COPD chest (4)

A

Barrel- shaped chest (hyperinflation)
Use of accessory muscles
Hoover’s sign
Reduced expansion

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17
Q

Lay term for emphysema patients

A

Pink (face) puffers (dyspnoea)

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18
Q

Face and neck signs copd (3)

A

emphysema
• Pink face
• Pursed -lip breathing
• tracheal tug

Chronic bronchitis
• central cyanosis later

Reduced cricosternal distance
Raised JvP

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19
Q

Complications of COPD (2)

A

Emphysema
•Hypercapnia - drowsy/ coma state. May be caused by oxygen supplements which further diminishes respiratory drive. Also lead to warm peripheries, bounding pulses, flapping tremor

Chronic bronchitis
• R ventricular failure

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20
Q

Chest percussion signs COPD (2)

A

Hyper-resonant

Emphysema: decreased liver dullness

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21
Q

Auscultation COPD signs (3)

A

Decreased breath sounds
Early inspiratory crackles
Chronic bronchitis: wheezes
Heart sounds loudest in epigastrum

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22
Q

Lay term for chronic bronchitis patients

A

Blue (cyanosis) bloaters (oedema from right ventricular failure)

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23
Q

What is Chronic bronchitis definition

A

Daily production of sputum for 3 months a year for at least 2 consecutive years. Subtype of COPD.

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24
Q

Symptoms of Chronic bronchitis (2)

A

Loose cough and sputum esp in morning

Oedema

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25
Q

Classic symptoms of TB (5)

A 
Cachexia or weight loss
Night sweats
Cough
Hemoptysis
Malaise
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26
Q

Name 4 risk factors for pulmonary embolism

A

Previous PE
Immobilisation
Known clotting factors abnormalities
Known malignancy

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27
Q

Hand signs of Chronic liver disease (5)

A 
Leuconychia
Clubbing
Palmar erythema!
Bruising
Asterixis (flapping tremor)
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28
Q

Face signs of chronic liver disease (4)

A

Jaundice
Scratch marks (itch) ( higher levels bile salts under Skin)
Spider naevi
Fetor hepaticus (breath strong, musty dead smell-liver not clearing toxins)

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29
Q

Chest signs of Chronic liver disease (5)

A 
Gynecomastia
Loss body hair
Spider naevi
Bruising
Pectoral muscle wasting
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30
Q

Abdomen and genital signs Chronic liver failure (4)

A

Hepatosplenomegaly
Ascites
Signs of portal hypertension (splenomegaly, collateral veins: haematemesis from oesoph/gastric varies, ascites)
Testicular atrophy

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31
Q

Leg signs of chronic liver disease (3)

A

Oedema
Muscle wasting
Bruising

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32
Q

Signs of liver cirrhosis (10)

A
  • Encephalopathy!!!
  • jaundice
  • Palmar erythema!
  • endocrine: loss libido, hair loss; men: gynaecomastia, testicular atrophy, impotence; women: breast atrophy, irregular menses, amenorrhaea
  • PHT: Prominent abdominal veins!!!!, splenomegaly, variceal bleeding
  • haemorrhagic: bruises, purpura, epistaxis
  • Ascites!!
  • Spider naevi!, cyanosis
  • pigmentation, clubbing, Dupuytren’s contracture
  • Hepatomegaly at first and firm

(2 or more = strong suggestion cirrhosis)

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33
Q

Define pulmonary HT

A

Mean pulmonary a pressures >25 and systolic pressures >50

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34
Q

Harrison sulcus vs hoover sign (3)

A

Hoover for balloon

  • chronic vs acute
  • sign of abnormally weak bones (eg rickets) or chronic respiratory disease (eg chronic severe asthma) vs sign of hyperinflation
  • in drawing of ribs by diaphragm at lower end of rib cage at 6th rib during inspiration and expiration vs flat diaphragm causing pulling in of inferior ribs on inspiration bc diaphragm contract inward instead of downward
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35
Q

Name and describe the score used for pneumonia clinical prediction for admission

A

Curb 65 score

  • Confusion (1 point)
  • Urea > 7 mmol/l or BUN > 20 mg / dl (blood urea nitrogen) (1 point)
  • respiratory rate > 30 (1 point)
  • blood pressure systolic < 90 or diastolic <60 ( 1 point)
  • age 65 or older (1 point)

Score 0-1 < 5% mortality: treat as outpatient
2-3 5-15%: admit
4 -5 15-30%: admit to ICU

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36
Q

Which criteria is used to determine if pleural effusion is exudative or transudative? Describe.

A

Lights criteria for exudative effusion - at least one: (otherwise transudative)

( PLeural effusion )

  • Protein pleural fluid: protein serum > 0,5
  • LDH fluid: LDH serum > 0,6
  • LDH pleural fluid > 2/3 normal upper limit of LDH in serum
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37
Q

Clinical classification of pneumonia? (4)

A
  • Community acquired
  • nosocomial
  • aspiration
  • occurring in immunocompromised patient eg PCP
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38
Q

Anatomical classification of pneumonia? (3)

A
  • Lobar ( alveoli infected)
  • bronchopneumonia
  • interstitial
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39
Q

Name 3 infective causes lobar pneumonia

A
  • Streptococcus pneumonia most common
  • klebsiella pneumonia (usually upper lobes)
  • legionella
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40
Q

Name 3 infective causes bronchopneumonia

A

Wide variety bacteria eg mycoplasma, chlamydia, staph, pseudomonas

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41
Q

Name 3 infective causes interstitial pneumonia

A
  • Viruses
  • PJP
  • mycoplasma pneumonia
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42
Q

Common viral cause community acquired pneumonia?

A

Influenza

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43
Q

Common bacteria cause community acquired pneumonia? (6)

A

Cause 75% of all community acquired pneumonias

Pyogenic

  • streptococcus pneumonia (most common, 50%)
  • haemophilus influenza (esp smokers)
  • staphylococcus aureus

Atypical

  • mycoplasma pneumonia (10%)
  • chlamydophila pneumonia (10.%.)
  • legionella pneumophila
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44
Q

Treatment mild pneumonia with CURB65 0-1?

A
  • Amoxicillin 500mg TDS

Or

  • clarithromycin 500 mg bd
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45
Q

Treatment moderate pneumonia with CURB65 3?

A

Amocycillin 500mg TDS

And

Clarithromycin 500mg bd

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46
Q

Treatment moderate pneumonia with CURB65 3?

A

Amocycillin 500mg TDS

And

Clarithromycin 500mg bd

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47
Q

Treatment severe pneumonia with CURB65 3 or more or clinically?

A

CoamoxiclaV 1,2g TDS (penicillin + b lactam) (augmentin)
And
Clarithromycin 500 MG bd (macrolide)
For 5 days

48
Q

Define respiratory failure

A

Pa 02 < 60 mmhg ( < 8kpa )

49
Q

Type 1 vs 2 respiratory failure? (4)

A

Both hypoxia paO2 < 60 mmhg

Type 1

  • normal / low paco2
  • caused by vq mismatch eg pneumonia, pulmonary oedema, pe, asthma,emphysema, ARDS

Type 2

  • hypercapniA PACO2 > 45 mmhg (>6 kpa)
  • caused by alveolar hypoventilation with or without Vq mismatch eg pulmonary disease (asthma, COPD, pneumonia, OSA, pulmonary fibrosis) , reduced resp drive (sedatives,CNS tumour,trauma), neuromuscular disease (cervical cord lesion, poliomyelitis, myasthenia gravis, GBS ), thoracic wall disease (flail chest)
50
Q

Define tachypnoea

A

> 25 bpm

51
Q

What is pancoast’s syndrome

A

Apical lung cancer + ipsilateral horner’s from invasion of cervical sympathetic plexus

52
Q

Name causes bronchiectasis (10)

A

Post Infective

  • pneumonia!: H influenza, strep pneumonia, S aureus, pseudomonas aeruginosa !, klebsiella
  • bordetella pertussis
  • Tb!
  • HIV
  • viral: measles (rubeola), bronchiolitis (rsv)
  • fungal: allergic bronchopulmonary aspergillosis

Non infective

  • congenital: cystic fibrosis, primary ciliary dyskinesia, alpha 1 antitrypsin deficiency
  • bronchial obstruction
  • hypogammaglobulinemia, ulcerative colitis
  • rheumatoid arthritis
53
Q

Name 3 symptoms bronchiectasis

A
  • persistent Cough
  • copious purulent sputum
  • intermittent haemoptysis
54
Q

Name 5 complications bronchiectasis

A
  • Pneumonia (frequent infections bc dilation airways → can’t clear airway)
  • pleural effusion, pneumothorax
  • haemoptysis
  • Cerebral abscess
  • Amyloidosis
55
Q

CXR features bronchiectasis? (3)

A
  • Cystic shadows - honeycomb sign
  • thickened bronchial walls: tramline and ring shadows
56
Q

Name 4 causes pulmonary oedema

A
  • Cardiovascular: LHF! (Post mi or ihd), mitral stenosis, arrhythmia, malignant hypertension
  • Ards
  • fluid overload
  • neurogenic eg head injury
57
Q

Symptoms pulmonary oedema (3)

A
  • Dyspnoea
  • pink frothy sputum
  • orthopnoea
58
Q

Signs pulmonary oedema (4)

A
  • General:, distressed, pale, sweaty, sitting up + leaning forward
  • vitals: decreased oxygen saturations! Tachypnoea! Tachycardia
  • CvS: raised JvP! Pulses alternans, s3 gallop
  • resp: pink frothy sputum, fine crackles!, wheeze (cardiac asthma)
59
Q

Define ARDS

A

Diffuse neutrophilic alveoli’s caused by range of conditions, characterised by
- bilateral radiographic infiltrates and
- hypoxaemia

60
Q

Name 10 causes ARDS

A

Pulmonary

  • pneumonia
  • gastric aspiration
  • inhalation
  • injury eg transfusion related (trali), contusion
  • vasculitis

Abdomen

  • acute liver failure
  • Pancreatitis
  • malaria

Drugs / toxins

  • aspirin
  • heroin
  • chemo

Other

  • shock
  • septicaemia
  • haemorrhage
  • DIC
  • trauma, head injury, burns
  • fat embolism
  • obstetric events eg eclampsia, amniotic fluid embolism
61
Q

Diagnostic criteria ARDS (4)

A

All 4:

  1. Acute onset
  2. Bilateral infiltrates on CXR
  3. PCwP (pulmonary capillary wedge pressure to see of LHF by catheter ) < 19 mmhg or a lack of clinical CCF
  4. Refractory hypoxaemia with Pa02: fio2 < 200

+/- total thoracic compliance < 30ml / cm H2O

ARDS = Acute, refractory hypoxia, diffuse CXR infiltrates, Schwann catheter PCWP <19

62
Q

Management ARDS? (8)

A

Treat underlying cause.

  • Oxygen! + CPAP ; but most need mechanical ventilation (lung protective: low tidal volumes 4-8 ml/kg, peep, )
  • circulatory support:
    → invasive monitoring with arterial line and swan-ganZ catheter to aid diagnosis and monitor PCwP
    → conservative fluids
    → maintain cardiac output and oxygen delivery with inotropes eg dobutamine, vasodilators, transfusion
    → consider treating PHT with low dose nitric oxide (pulmonary vasodilator)
  • enteral nutritional support with high fat, antioxidant formulations
  • steroids treat those at risk for fat embolism and with pneumocystOsis and may improve outcome
63
Q

Diagnosis Mac? (6)

A

Diagnosis of exclusion!

Clinical criteria

  • pulmonary symptoms or
  • nodular/ cavitary opacities on CXR or
  • high resolution Ct with multifocal bronchiectasis with multiple small nodules

Microbiological criteria

  • At least 2 expectorated sputum samples or
  • 1 bronchial lavage or
  • lung biopsy positive for non-tb mycobacterium with mycobacteria histopathological features
  • if disseminated MAC, use culture from bone marrow/ lymph node/blood ( sputum unreliable)
64
Q

Treatment mycobacterium avium complex

A
  • Azithromycin or clarithromycin (don’t use if on arvs) and
  • ethambutol

For 12 months , only stop if CD4 % > 15%

If poor response, add rifabutin, ciprofloxacin

65
Q

Prevention MAC

A

Start prophylaxis when CD4 <50

Azithromycin or clarithromyCIN or rifabutin

66
Q

Label spirogram picture 7

A

See picture 8

67
Q

Name 5 causes /mechanisms arterial hypoxaemia and give 2 examples each

A
  • Low inspired oxygen: high altitude, air flight
  • hypoventilation: CNs depressant drugs, cenebrovascular accident, head injury
  • diffusion impairment: interstitial lung disease, emphysema, pe, PHT
  • vq mismatch: COPD, atelectasis, ARDS, pulmonary oedema
  • R to l shunt: eisenmenger syndrome, pulmonary av malformation
68
Q

What is the alveolar arterial gradient?

A

A-a = PA O2 (alveolar pressure of oxygen ) calculated - pao2 on blood gas

69
Q

How calculate PAo2 (alveolar pressure of oxygen)

A

PaO2 = pio2 (partial pressure of inspired oxygen) - paco2 / rq (respiratory quotient)

PiO2 = fio2 (patm - PH2O)

70
Q

How is the pf ratio (pao2/fi02) used in classifying hypoxia

A

<300 = moderate
< 200 = severe

71
Q

Pleural fluid characteristics of complicated parapneumonic effusion eg empyema? (2)

A
  • Ph<7,2
  • positive gram stain /culture
72
Q

Pleural fluid characteristics of chylothorax? (2)

A
  • Triglycerides > 110 mg/ dL
  • Presence of chylomicrons

Aka lymph, causes = trauma, congenital lymphatic malformations, tumours, Tb

73
Q

Name 4 causes lymphocytic pleural exudate

A
  • Tb
  • lymphoma
  • sarcoidosis
  • rheumatoid arthritis
  • post coronary artery bypass grafting chylothorax
  • Yellow nail syndrome: abnormal lymphatics. Triad yellow nails, lymphoedema,pulmonary sx
74
Q

Name 4 causes eosinophilia pleural exudate (>10% eosinophils)

A
  • Malignany: lung cancer
  • infection: Fungal disease, parasitic disease eg paragonimiasis most common, amebiasis
  • Churgg - Strauss syndrome
  • pleural irritation: pneumothorax, haemothorax, asbestos
  • drug induced effusions: warfarin, simvastatin
75
Q

Which bacteria would be suspected in pneumonia in an alcoholic? (2)

A
  • Strep pneumo!
  • Gram negatives: klebsiella pneumonia, H influenza (alcohol alters oropharyngeal flora so G- colonise more )
76
Q

Which bacteria would be suspected in pneumonia in aspiration (2)

A
  • Gut bacteria eg bacteroïdes
  • enteric G -: E. coli
  • gastric contents: chemical pneumonitis
  • bacteria in oral cavity: S aureus, strep pneumococcus
77
Q

Risk Score used for pulmonary embolism?

A

Wells score (uses clinical suspicion, no other dX likely, hr, immobilisation/ surgery, history, haemoptysis, malignancy) - need 3 RFs, 3 symptoms, 1 other

Or Geneva score

78
Q

Risk Score used for pulmonary embolism?

A

Wells score (uses clinical suspicion, no other dX likely, hr, immobilisation/ surgery, history, haemoptysis, malignancy) - need 3 RFs, 3 symptoms, 1 other

Or Geneva score

79
Q

Diagnostic approach pulmonary embolism? (5)

A

Assess clinical probability: wells score

Low to moderate probability: do D dimer (-ve excludes it)
→ positive: vq scan if normal CXR (perfusion defects with no corresponding ventilation defects),
→ inconclusive: CTPA

High probability: straight to CTPA. If contraindication, do vq scan. If this can’t be done, do Mr angiography/tee / digital subtraction angiography

80
Q

CXR findings pulmonary embolism? (7)

A
  • May be normal.
  • oligaemiA of affected segment (Westermark’s sign)
  • dilated pulmonary artery ( Pallas sign)
  • horizontal linear plate atelectasis, usually lower zone
  • elevated hemi diaphragm
  • small pleural effusion
  • wedge shaped opacities or cavitation (Hampton’s hump )
  • pulmonary opacities
  • Fleischner’s sign: prominent amputated pulmonary artery

Normal CXR = more likely pa. More abnormal = less likely

81
Q

Treatment pulmonary embolism?

A

• Low molecular weight heparin eg enoxaparin (clexane) subcutaneous 1 mg/kg bd
• warfarin oral initially 5 mg daily for 2 days then titrate according to INR. Maintenance dose usually 2,5-10 mg daily.

Start both at the same time due to initial pro-coagulant effect of warfarin for the first 3 days.
Stop heparin once INR reaches therapeutic range of 2-3 for 2 consecutive days
Continue warfarin for
-6 months If first episode of idiopathic DVT
-3 months if reversible cause
-12 months if thrombophilic disorders or antiphospholipid antibodies
- indefinitely for patients above and recurrent DVT

Consider vena cava filter.

82
Q

Pulmonary hypertension causes? (5)

A
  • Idiopathic or connective tissue disease eg SLE
  • L HF: usually from mi or ht
  • chronic lung disease and/or hypoxaemia: COPD, OSA, ILD, pulmonary fibrosis, high altitude
  • Pulmonary vascular disease eg pe (causes acute cor pulmonAle)
  • Miscellaneous: sarcoidosis, glycogen storage disease, haemotological disorders eg sickle cell, thoracic cage abnormality eg kyphosis, neuromuscular disease eg myasthenia
83
Q

Typical clinical findings pulmonary hypertension?

A
  • Loud pulmonary component of s2 @ L heart! Almost definitive.
  • s3
  • Pansystolic murmur from tr + diastolic from Pr

Later:

  • parasternal heave (RVH)
  • raised JVP with prominent A wave
  • ascites, peripheral oedema, hepatomegaly
84
Q

Diagnosis cor pulmonale?? (4)

A
  • Bloods: increased hb and Hct (secondary polycythaemia), hypoxia +/-hypercapnia
  • CXR: enlarged ra+ rv ( loss retrosternal space), prominent pulmonary arteries
  • ECG: p pulmonale (narrow + peaked P waves) , r axis deviation, rvh/strain
  • Doppler echo: rv enlarge, dilation coronary sinus, measure pa pressure
  • right heart catheterisation
85
Q

How is asthma graded?

A

NAEPP grading

  • intermittent asthma: symptoms 2 or less/week, wake up from symptoms 2 or less /month , no interference daily activities, use SABA 2 or less/week. Normal lung function. 1 or less exacerbations / year requiring systemic steroids.
  • mild persistent: symptoms > 2 /week, wake up 3-4/month, saba > 2 /week, minor limitation. Normal lung function. Exacerbations 2 or more / year
  • moderate persistent: daily symptoms. Wake up > 1/week. Some limitation. Daily use SABA. FEV1 60-80% predicted, decrease FEV 1 : FVC by < 5%. Exacerbations as above.
  • severe persistent: daily symptoms, wake up every night, extreme limitation, use SABA several times per day. FEV 1 < 60% predicted, decrease FEV 1 : FVC by > 5%. Exacerbations as above
86
Q

Spirometry findings asthma?

A
  • Obstructive defect: decrease FEV 1 : FVC, increase residual volume.
  • > 15% improvement FEV 1 following bronchodilator
87
Q

Stepwise treatment chronic asthma according to NAEPP? (6)

A
  1. Intermittent asthma: saba eg salbutamol only
  2. Mild persistent: add low dose ICS or rescue ics-saba only (alternative = LTRA eg montelukast)
  3. Moderate persistent: low dose ics (eg beclomethasone)- formoterOl (laba)
  4. Mod to severe persistent: medium dose ICS - formoterol
  5. Severe persistent: medium - high dose ICS - LABA + lama (tiotropium bromide )
  6. Severe persistent: high dose ICS - LABA + oral corticosteroids (prednisone). Consider biologics eg omalizumab.
88
Q

Define controlled asthma (5)

A
  • No daytime symptoms or nighttime waking due to asthma
  • No asthma attacks or need for rescue medications
  • No limitations on activity
  • normal lung function
  • minimal side effects
89
Q

How assess severity acute asthma attack? (4)

A
  • Mild asthma exacerbation: dyspnoea on exertion. Tachypnoea, wheezing on end exhalation. Pefr 70% or more than predicted, sp02 95% or more.
  • moderate: dyspnoea At rest, can talk in phrases, agitated,prefer sit up > lie down. Loud wheezing, accessory muscles, tachycardia <120. Pefr 40 - 69%, sp 02 90-95%
  • severe: talk in words, tripod position. Severe tachypnoea > 30, inspiratory+ expiratory wheeze, tachycardia > 120, pulsUs paradoxus (fall bp inspiration > 10). Pefr <40%, spo2 < 90%, hypercapnia paco2 >42
  • life threatening: can’t talk, drowsy, confused sweating. Silent chest, paradoxical breathing, bradycardia, altered mental status. Pefr <25%, signs respiratory failure.
90
Q

Treatment mild asthma exacerbation?

A

Saba + oral corticosteroids if necessary

91
Q

Treatment moderate asthma exacerbation?

A
  • Oxygen
  • saba
  • oral corticosteroids
92
Q

Treatment severe asthma exacerbation? (4)

A
  • High dose oxygen 100% via non -rebreathing bag
  • salbutamol 5 mg + ipratropium bromide 0,5 mg nebulized with oxygen
  • hydrocortisone 100 mg iv or prednisolone 40 -50mg po or both if very ill
  • if not improving: mgso4 1,2 - 2g iv over 20 min. Consider aminomphylline or salbutamol iv

(Cxr to exclude pneumothorax)

93
Q

Treatment life-threatening asthma exacerbation? (4)

A
  • High dose oxygen 100% via non -rebreathing bag, consider early intubation
  • salbutamol 5 mg + ipratropium bromide 0,5 mg nebulized with oxygen every 15 min
  • hydrocortisone 100 mg iv or prednisolone 40 -50mg po or both if very ill
  • mgso4 1,2 - 2g iv over 20 min.
    Consider aminomphylline or salbutamol iv if not improving. Transfer to ICU
94
Q

Normal pao2?

A

80 - 100

95
Q

Name 7 clinical features pulmonary fibrosis

A

Inspection

  • central cyanosis
  • tachypnoea
  • clubbing in idiopathic pulmonary fibrosis
  • raised JVP and peripheral edema iF cor pulmonale

Palpation

  • reduced expansion (small lungs)

Percussion

  • dull at bases (high diaphragm)

auscultation

  • fine inspiratory crackles at bases
96
Q

How is empyema confirmed (3)

A
  • Fluid thick + turbid pus
  • glucose < 3,3
  • Ldh > 1000
  • pH < 7
97
Q

Describe the modified medical research council (mrc) dyspnoea scale for COPD

A
  • Grade o: only with strenuous exercise
  • grade 1: when hurrying on level or walking up slight hill
  • 2: walk slow due to breathlessness, or has to stop to catch breath
  • 3: stop for breath after walk 100m or few minutes on level ground
  • 4: too breathless to leave house, breathless when dress
98
Q

Name signs bronchiectasis

A
  • iF no secretions and no lobar collapse, normal physical exam
  • copious secretions → coarse crackles
  • collapse with retained secretions blocking a proximal bronchus → locally diminished breath sounds
99
Q

Name 10 complications cystic fibrosis

A

Respiratory

  • progressive airway obstruction
  • infective exacerbations of bronchiectasis
  • respiratory failure
  • spontaneous pneumothorax
  • haemoptysis
  • Lobar collapse due to secretions
  • PHT
  • nasal polyps

Abdominal

  • malabsorption, steatorrhoea!
  • distal intestinal obstruction syndrome
  • pHt, varicies, splenomegaly
  • biliary cirrhosis
  • gallstones

Other

  • diabetes!
  • delayed puberty, male infertility
  • stress incontinence due to repeated forced cough
  • psychosocial problems
  • osteoporosis, arthropathy
  • Cutaneous vasculitis
100
Q

Differential of pneumonia? (6)

A
  • Pulmonary infarction
  • pulmonary/ pleural TB
  • pulmonary oedema (can be unilateral)
  • pulmonary eosinophilia
  • malignancy: bronchOalveolar cell carcinoma
  • cryptogenic organising pneumonia / bronchiolitis obliterans organising pneumonia (cop/boop)
101
Q

Which community acquired pneumonia is more common in young

A

Mycoplasma pneumonia

102
Q

Which community acquired pneumonia is more common in elderly

A

Haemophilus influenza

103
Q

Which community acquired pneumonia is more common in alcoholics

A

Klebsiella pneumonia

104
Q

Name 10 complications pneumonia

A
  • Para-pneumonic effusion: common
  • empyema
  • retention of sputum causing lobar collapse
  • DvT and pulmonary embolism
  • pneumothorax, especially with S aureus
  • suppurative pneumonia / lung abscess
  • ARDS, renal failure, multi organ failure
  • Ectopic abscess eg S aureus
  • hepatitis, pericarditis, myocarditis, meningoencephalitis
  • arrhythmic
  • pyrexia due to drug hypersensitivity
105
Q

Which drug should be prescribed with isoniazid

A

Pyridoxine for peripheral neuropathy

106
Q

Name 4 types /causes diffuse parenchyma (interstitial) lung diseases

A
  • Known cause eg drugs, connective tissue disease
  • Granulomatous DPLD eg sarcoidosis
  • other forms eg lymphangiolieomyomatosis, histiocytosis X
  • idiopathic interstitial pneumonia
    → idiopathic pulmonary fibrosis
    → idiopathic interstitial pneumonia other than idiopathic pulmonary fibrosis: desquamative intersitial pneumonia ( male smokers), acute interstitial pneumonia (after viral urti), non-specific interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia (women)
107
Q

Treatment interstitial pulmonary fibrosis

A

Pirfenidone (antifibrotic) or nintedanib (tyrosine kinase inhibitor)
Lung transplant

108
Q

Name 7 possible presentations of sarcoidosis

A
  • Asymptomatic: abnormal CXR (30%), abnormal LFT
  • respiratory and constitutional symptoms (20-30%): ILD, bilateral hilar lymphadenopathy
  • erythema nodosum and arthralgia (20 -30 % )
  • Ocular symptoms (5-10 % ): anterior uveitis, sicca syndrome
  • Skin sarcoid (including lupus pernio) (5 % )
  • superficial lymphadenopathy 5%
  • other 1%: hyper Ca, diabetes insipidus, CN palsy, cardiac arrhythmia, nephrocalcinosis
109
Q

Diagnosis sarcoidosis?

A

Characteristic = lymphopenia
Confident diagnosis= erythema nodosum + bilateral hilar lymphadenopathy on CXR
Confirm = biopsy

May also have hyper Ca, hypercalciuria,

110
Q

Name 4 drug causes ARDS

A
  • Hydrochlorothiazide
  • thrombolytic: streptokinase
  • IV B agonists eg for premature Labour
  • aspirin + opiate overdose
111
Q

Name 4 drug causes alveolitis

A
  • Amiodarone
  • gold
  • nitrofurantoin (UTI)
  • cytotoxic: bleomycin, methotrexate, sulfasalazine
112
Q

Name features of acute pulmonary embolism (5)

A
  • Symptoms: faint/collapse, crushing chest pain, apprehension, dyspnoea, pleuritic chest pain, restricted breathing, haemoptysis
  • sign: tachycardia, RHF if massive, pleural rub, raised hemidiaphragm, crackles, effusion,fever
  • CXR: pleuropulmonary opacities, effusion, linear shadows, raised hemidiaphragm
  • ECG: massive = S1Q3T3 anterior T wave inversion, rbbb; small/medium= sinus tachycardia
  • ABG: low Pa O2 or paco2
113
Q

Name 5 features chronic PE

A
  • Symptoms: exertion dyspnoea, late = PHT / RHF
  • sign: RHF: RV heave, loud p2
  • CXR: enlarged pulmonary artery trunk, big heart, prominent RV
  • ECG: massive = RV hypertrophy and strain
  • ABG: exceptional low Pa O2
114
Q

First line diagnostic test pulmonary embolism

A

CTPA

115
Q

Define pulmonary hypertension

A

Mean pulmonary artery pressure 25 mm/ hg at nest

116
Q

Classification/ causes pulmonary hypertension (5)

A
  • Pulmonary artery ht: primary/ secondary (ctd, portal ht, HIV )
  • pulmonary vein ht: left heart disease, pulmonary Veno - occlusive disease, pulmonary capillary haemangiomatosis
  • pulmonary hypertension associated with disorders of respiratory system andor hypoxaemia: COPD, diffuse parenchyma lung disease, high altitude, sleep disordered breathing
  • pulmonary hypertension caused by chronic thromboembolic disease: thromboembolic obstruction of proximal pulmonary arteries, sickle cell disease, in situ thrombosis
  • miscellaneous: inflammation, extrinsic compression of central pulmonary veins

Internal Medicine (20 decks)

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