Respiratory Flashcards
1
Q
Name causes of restrictive lung disease
A
Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders
Severe obesity
2
Q
Name causes of obstructive lung disease
A
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
3
Q
What spirometry results would you expect in obstructive lung disease?
A
FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced
4
Q
What spirometry results would you expect in restrictive lung disease?
A
FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased
5
Q
What diagnostic testing is done in asthma?
A
Patients >= 17 years:
* Assess occupational asthma if symptoms are better on days away from work/during holidays.
* All patients to have spirometry with a bronchodilator reversibility (BDR) test
* All patients should have a FeNO test
Children 5-16 years:
* All patients to have spirometry with a BDR test
* FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
6
Q
What should be done for a pregnant woman who is smoking?
A
- Smoking clinic referral
- Nicotine replacement therapy
Bupropion and varenicline are contraindicated
7
Q
When should a patient with COPD be offered long-term oxygen therapy according to BTS guidelines.
A
Two arterial blood gases measurements with pO2 < 7.3 kPa (at least 3 weeks apart)
8
Q
What are the most common causes of superior vena cava syndrome?
A
Lung cancer - more common
Non-Hodgkin’s lymphoma
9
Q
What would a patient with acute moderate asthma present with?
A
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
10
Q
What would a patient with acute severe asthma present with?
A
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
11
Q
What would a patient with acute life-threatening asthma present with?
A
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
*a normal pCO2 also indicates exhaustion (too tired to breathe so CO2 creeps up)
12
Q
What is the typical features of a patient with aspergilloma?
A
Often past history of tuberculosis.
Haemoptysis may be severe
Chest x-ray shows rounded opacity
13
Q
A 71-year-old woman presents with dyspnoea and haemoptysis for the past two weeks. Clinical examination reveals a loud first heart sound, a diastolic murmur and new-onset atrial fibrillation.
What is the likely cause of her symptoms?
A
Mitral stenosis. It can present with:
* Dyspnoea
* Haemoptysis - rupture of the bronchial veins caused by raised left atrial pressure
* Atrial fibrillation
* Malar flush on cheeks
* Mid-diastolic murmur
14
Q
What are pleural plaques?
A
Areas of benign fibrous thickening on the pleura (the lining of the lungs) and are often associated with exposure to asbestos. They are usually asymptomatic and do not typically affect lung function.
They usually develop 2-4 decades after exposure. They are benign and do not require regular monitoring.
CXR shows bilateral pleural thickening.
15
Q
What general COPD management should be offered to patients?
A
- Smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
- Annual influenza vaccination
- One-off pneumococcal vaccination
- Pulmonary rehabilitation
16
Q
In which lung zones would you see fibrosis for TB patients?
A
Upper zone fibrosis
TB is an aerobic organism. Therefore, it needs plenty of oxygen to survive. Due to V/Q mismatch, there is more ventilation at the top of the lungs, especially near the apex. So naturally, TB has better survival in those areas, leading to upper zone fibrosis
17
Q
What is the management of primary pneumothorax?
A
- If the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
- Otherwise, aspiration should be attempted
- If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
18
Q
What is the management of secondary pneumothorax?
A
- If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
- Otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
- If the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
19
Q
What are the different classifications of pneumothorax?
A
Spontaenous - primary or secondary
Traumatic
Iatrogenic
20
Q
Name causes of transudative pleural effusion
A
Heart failure
Hypoalbuminaemia (e.g. liver disease, nephrotic syndrome)
Meigs syndrome
21
Q
Name causes of exudative plerual effusion
A
Infection (e.g. pneumonia, tuberculosis)
Lung cancer or metastases
Connective tissue diseases (e.g. rheumatoid arthritis, SLE)
22
Q
What is the difference between a transudate and an exudate?
A
Transudate protein level <30 g/L
Exudate protein level >30 g/L
23
Q
What does Light’s criteria define?
A
An exudate is likely if at least one of the following criteria are met:
* pleural fluid protein : serum protein >0.5
* pleural fluid LDH : serum LDH >0.6
* pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
24
Q
What is the most common cause of occupational asthma?
A
Isocyanates - from spray paiting and foam moulding with adhesives
25
What is the management of occupational asthma?
Serial measurements of peak expiratory flow are recommended at work and away from work.
Referral should be made to a respiratory specialist for patients with suspected occupational asthma.
26
What would a patient with acute near-fatal asthma present with?
Raised pC02
Requiring mechanical ventilation with raised inflation pressures
*This is a 4th category after life-threatening
27
What are the common features of sarcoidosis?
Acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
Insidious: dyspnoea, non-productive cough, malaise, weight loss
Skin: lupus pernio
Hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
28
What is the mechanism of montelukast?
Leukotriene receptor antagonist
Leukotrienes are produced in response to allergens. They cause narrowing and swelling of airways in the lungs, leading to asthma symptoms
29
Name causes of acute respiratory distress syndrome
* Infection: sepsis, pneumonia
* Massive blood transfusion
* Trauma
* Smoke inhalation
* Acute pancreatitis
* Covid-19
* Cardio-pulmonary bypass
30
Which lung zones are commonly affected in aspiration pneumonia?
**Right middle and lower zones** due to the larger calibre and more vertical orientation of the right main bronchus.
31
What are the severity categories of COPD?
Stage 1 - Mild - symptoms should be present to diagnose COPD in these patients: FEV1 >80%
Stage 2 - Moderate: FEV1 50-79%
Stage 3 - Severe: FEV1 30-49%
Stage 4 - Very severe: FEV1 <30%
*Post-bronchodilator FEV1/FVC should be <0.7 for all categories
32
What arterial blood gas do you usually see in a stable longterm COPD patient?
Chronic respiratory acidosis (due to COPD) with a compensatory metabolic alkalosis (the elevated bicarbonate is the main clue to the chronic nature of the respiratory acidosis)
33
When do you offer longterm oxygen therapy (LTOT) to COPD patients?
If pO2 of < 7.3 kPa or those with a pO2 of 7.3 - 8 kPa and one of the following:
* secondary polycythaemia
* peripheral oedema
* pulmonary hypertension
34
What are common features of alpha-1 antitrypsin deficiency?
Lungs: panacinar emphysema, most marked in lower lobes
Liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
Investigations: Low A1AT concentrations + obstructive picture on spirometry
35
What is the difference between centriacinar and panacinar emphysema?
Centrilobular (mostly upper lung zones) - seen in smoking and pneumoconiosis
Panacinar (mostly lower lung zones) - seen in alpha-1 antitrypsin deficiency
36
What pulmonary issue is commonly associated with low glucose on pleural fluid?
Empyema (with associated high protein - exudate)
37
What is the management of an empyema?
Prompt drainage with antibiotic therapy
38
What is the investigation of choice in suspected idiopathic pulmonary fibrosis?
High resolution CT
39
What does the total gas transfer (TLCO) measure?
Overall measure of gas transfer for the lungs from the alveoli into the capillaries and reflects how much oxygen is taken up into the red cells
40
Which conditions would have a raised total gas transfer (TLCO)?
* Asthma
* Pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture's)
* Left-to-right cardiac shunts
* Polycythaemia
* Hyperkinetic states
* Male gender, exercise
41
Which conditions would have a low total gas transfer (TLCO)?
* Pulmonary fibrosis
* Pneumonia
* Pulmonary emboli
* Pulmonary oedema
* Emphysema
* Anaemia
* Low cardiac output
42
What is the transfer coefficient (KCO)?
TLCO divided by the alveolar volume, which makes it a measure of how efficient gas exchange is in relation to the alveolar-capillary surface to volume ratio
43
What is the mechanism of varenicline, what side effects does it cause and what are its contraindications?
Nicotinic receptor partial agonist
Nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
Contraindicated in pregnancy and breast feeding
44
What is the mechanism of bupropion, what side effects does it cause and what are its contraindications?
A norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Small risk of seizures (1 in 1,000)
Contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
45
What is the most common organism isolated from patients with bronchiectasis?
Haemophilus influenzae
46
What is the criteria for discharge following an acute asthma attack?
* Been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
* Inhaler technique checked and recorded
* PEF >75% of best or predicted
47
What is the golden S sign on CXR and CT?
Caused by collapse of lung around a central mass (generally right upper lobe), commonly seen in lung cancers
48
What is the recommended amount of time to wait between each puff of an inhaler?
30 seconds
49
What should you do to patients with acute life-threatening asthma that do not respond to treatment?
Refer to ICU to consider for potential intubation and ventilation
50
What is hypoxaemia and what can cause it?
PaO2 <8kPa
Caused by:
* Hypoventilation
* V/Q mismatch
* Diffusion impairment (impairment of blood-gas barrier)
* High altitude
51
What is the difference between ventilation and perfusion?
Ventilation = insufficient movement of air into alveoli
Perfusion = impaired blood supply to ventilated alveoli
52
What is the definition of pulmonary hypertension?
Pulmonary artery systolic pressure >25 mmHg
53
What are the different mechanisms of pulmonary hypertension?
Group 1: Pulmonary Arterial Hypertension (idiopathic, hereditary, drug/toxin, CT)
Group 2: PH secondary to left sided heart failure (raised capillary wedge pressure)
Group 3: PH secondary to underlying lung disease and hypoxia
Group 4: Chronic thromboembolic pulmonary hypertension
Group 5: Secondary to conditions with multifactorial mechanisms causing PH
54
What is the pathophysiology of bronchiectasis?
Bronchial obstruction (airway dilation) with mucous stasis and bacterial colonisation
55
What is interstitial lung disease?
* Combination of chronic inflammation and various degrees of lung fibrosis
* Some ILD's present as more inflammatory disease and respond better to anti-inflammatories and immunosuppressive therapy
* However in idiopathic pulmonary fibrosis there is predominately a fibrotic process which responds poorly to anti-inflammatory/immunosuppressive therapy
56
What is the difference between interstitial lung disease and idiopathic pulmonary fibrosis
ILD: Combination of chronic inflammation and various degrees of lung fibrosis
IPF: predominately a fibrotic process which responds poorly to anti-inflammatory/immunosuppressive therapy
57
What is used to treat idiopathic pulmonary fibrosis?
* Pirfenidone (anti-fibrotic)
* Nintedanib (tyrosine kinase inhibitor)
* Lung transplantation
58
What is hypersensitivity pneumonitis?
* Also referred as extrinsic allergic alveolitis
* Excessive immune response of an
* environmental antigen (e.g avian proteins, mould or farming)
* A detailed environmental and occupational history needs to be taken
* Usually presents as upper lobe fibrosis on imaging
59
What is the treatment for obstructive sleep apnoea?
CPAP
Avoid smoking and alcohol
Surgery
60
What does sarcoidosis treatment involve?
Corticosteroids
Azathioprine
Hydroxychloroquine
Anti-TNF therapy
61
What is the aetiology of ARDS?
End result of intrinsic and extrinsic insults to lung
Interstitial and alveolar oedema
Pro-inflammatory state leading to increased capillary permeability
62
What does ARDS treatment include?
Treat underlying cause
Mechanical ventilation
Inhaled pulmonary vasodilators
Proning
Neuromuscular blockade
ECMO
63
What investigation will prove a definitive diagnosis of mesothelioma?
Histology of sample through thoracoscopy
*This is different to bronchoscopy!!
64
What are indications of NIV?
* COPD with respiratory acidosis with pH 7.25-7.35 (for those <7.25 ventilation and intubation should be considered)
* T2RF secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
* Cardiogenic pulmonary oedema unresponsive to CPAP
* Weaning from tracheal intubation
65
Why do all CXRs in pneumonia patients need to be repeated and at how many weeks?
To ensure that the consolidation has resolved and there is no underlying secondary abnormalities (e.g. a lung tumour)
All cases of pneumonia should have a repeat chest X-ray at 6 weeks .
66
When does atelectasis commonly present?
Should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
67
What is the management of atelectasis?
Positioning the patient upright
Chest physiotherapy: breathing exercises
68
What is Kartagener's syndrome?
Also known as primary ciliary dyskinesia
69
What are features of primary ciliary dyskinesia?
* dextrocardia or complete situs inversus
* bronchiectasis
* recurrent sinusitis
* subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
70
What are indications for initiation of steroid therapy in sarcoidosis?
P- Parenchymal lung disease
U- Uveitis
N- Neurological involvement
C- Cardiac involvement
H- Hypercalcaemia
71
A 64-year-old man with a 40-pack-year smoking history presents with a 3-month history of a severe chronic cough and 5kg in weight loss. He is sent to the hospital for further investigations. You suspect a diagnosis of lung cancer.
What finding on a blood test would support this?
1. Raised erythrocytes
2. Raised lymphocytes
3. Raised platelets
4. Reduced lymphocytes
5. Reduced platelets
Raised platelets
72
What is the treatment of superior vena cava obstruction?
Sit them up
Stat dose of Steroids
Stenting
73
What are contraindications to surgery in lung cancer?
* malignant pleural effusion
* tumour near hilum
* vocal cord paralysis
* SVC obstruction
* presence of metastases
74
What is the role of alpha-1 antitrypsin?
The role of A1AT is to protect cells from enzymes such as neutrophil elastase.
It classically causes emphysema (i.e. chronic obstructive pulmonary disease) in patients who are young and non-smokers + signs of early liver damage
75
What is the management of allergic bronchopulmonary aspergillosis (ABPA) infection?
oral glucocorticoids
* itraconazole is sometimes introduced as a second-line agent
76
What is the procedure for asthma management step down?
BTS guidelines recommend that we should consider stepping down treatment every 3 months or so - taking into account duration of treatment, side-effects and patient preference
When reducing the dose of inhaled steroids the BTS advise us to do this by 25-50% at a time
77
What is the most common bacterial cause of infective COPD exacerbation?
Haemophilus influenzae
78
What should be given in COPD patients diagnosed with pneumonia?
Corticosteroids even if no evidence of the COPD being exacerbated
79
What causes upper lung zone fibrosis?
CHARTS:
Coal Worker Pneumoconiosis
Histiocytosis
Ankylosing Spondylitis/ABPA
Radiation Pneumonitis
Tuberculosis
Sarcoidosis/Silicosis
80
What causes lower lung zone fibrosis?
RAID
R = Rheumatoid arthritis/ connective tissue disease (except ankylosing spondylitis)
A = asbestosis
I = idiopathic pulmonary fibrosis
D = drugs --> amiodarone, bleomycin, methotrexate
81
What is the presentation of extrinsic allergic alveolitis?
Acute (occurs 4-8 hrs after exposure):
* dyspnoea
* dry cough
* fever
Chronic (occurs weeks-months after exposure):
* lethargy
* dyspnoea
* productive cough
* anorexia and weight loss
82
What is the hypersensitivity reaction in extrinsic allergic alveolitis?
Largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
83
What are the most common causes of anterior mediastinum mass?
4Ts
Teratoma
Terrible lymphadenopathy
Thymic mass
Thyroid mass
84
When do you consider abx in patients with acute bronchitis?
* are systemically very unwell
* have pre-existing co-morbidities
* have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
85
What condition is associated with early inspiratory crackles?
COPD
86
What condition is associated with bilateral end-inspiratory crackles?
Asbestosis
87
What condition is associated with bibasal fine end-inspiratory crepitations?
Idiopathic pulmonary fibrosis
88
What condition is associated with focal monophonic wheeze?
Foreign body inhalation or tumour
*Heard due to a singular obstruction to an airway and is a red-flag sign
89
What condition is associated with polyphonic wide-spread wheeze?
Asthma
*This is heard where there is constriction of the airways
90
What investigation is diagnostic for obstructive sleep apnoea?
Sleep studies (polysomnography)
Ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry
91
What sleep assessment scales can be used in obstructive sleep apnoea?
Epworth Sleepiness Scale - questionnaire completed by patient ± partner
Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
92
A 72-year-old gentleman presents to the respiratory clinic with worsening shortness of breath. On examination, he has obvious thoracic kyphosis. Assuming that this is the only cause of his breathlessness, which pulmonary function test results would you expect to see?
FEV1/FVC = 85%, reduced total gas transfer (TLCO) and increased transfer coefficient (KCO)
FEV1/FVC = 55%, reduced total gas transfer (TLCO) and increased transfer coefficient (KCO)
FEV1/FVC = 55%, reduced total gas transfer (TLCO) and reduced transfer coefficient (KCO)
FEV1/FVC = 85%, reduced total gas transfer (TLCO) and reduced transfer coefficient (KCO)
FEV1/FVC = 85%, increased total gas transfer (TLCO) and increased transfer coefficient (KCO)
FEV1/FVC = 85%, reduced total gas transfer (TLCO) and increased transfer coefficient (KCO)
1. FEV1/FVC: FEV1 is the volume of air exhaled at the end of the first second of forced expiration, FVC is the maximum volume of air a person can exhale after a maximum inhalation given as much time as they require. The FEV1/FVC of a normal healthy lung is 70-80%. Thoracic kyphosis is a restrictive chest wall disease, which means that the air can leave the lungs very quickly, giving a high FEV1, however, due to poor lung expansion resulting in small lung volumes, the FVC is low. Hence the FEV1/FVC is higher than usual, making 85% the correct answer.
2. The total gas transfer (TLCO) is an overall measure of gas transfer for the lungs from the alveoli into the capillaries and reflects how much oxygen is taken up into the red cells. In thoracic kyphosis, this is typically normal or reduced. This is reduced because the chest-wall disease can cause incomplete alveolar expansion, which results in less gas being present in the alveoli and available for gas exchange.
3. KCO is TLCO divided by the alveolar volume, which makes it a measure of how efficient gas exchange is in relation to the alveolar-capillary surface to volume ratio. In chest-wall disease, KCO is increased because there is a small alveolar volume, so in proportion to the alveolar volume, there is increased pulmonary blood flow which increases the relative surface area to volume ratio.
93
When do you prescribe antibiotics in an exacerbation of COPD?
NICE only recommend giving oral antibiotics in an acute exacerbation of COPD in the presence of purulent sputum or clinical signs of pneumonia
94
What are features of COPD on a CXR?
* Hyperinflation
* Flattened hemidiaphragms
* Hyperlucent lung fields
95
What discharge advice should be given to patients with a pneumothorax?
Smoking: patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Fitness to fly: British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
Scuba diving: BTS recommend to permanently avoid diving unless bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively has been identified
96
What is lupus pernio?
Bluish-red or violaceous nodules and plaques over the nose, cheeks and ears.
This is a cutaneous form of sarcoidosis
97
What is a Ghon focus?
A tuberculous caseating granuloma seen in primary TB infection
*A Ghon focus alongside ipsilateral mediastinal lymphadenopathy is known as a Ghon complex.
98
What does NICE use to determine whether a patient has asthmatic/steroid responsive features in the management of chronic COPD?
* Any previous, secure diagnosis of asthma or of atopy
* A higher blood eosinophil count
* Substantial variation in FEV1 over time (at least 400 ml)
* Substantial diurnal variation in peak expiratory flow (at least 20%)
*Note that formal spirometric reversibility testing is not recommended
99
What is the first-line management of chronic COPD?
SABA or SAMA
100
What is the second-line management of chronic COPD?
After a SABA/SAMA if symptoms are still uncontrolled, depending on whether a patient has asthmatic/steroid responsive features:
Yes - SABA/SAMA PRN, LABA + ICS regularly
No - SABA PRN, LABA + LAMA regularly
101
What do you interpret the results of a Mantoux test?
Mantoux negative - Induration less than 6 mm
Mantoux positive - Induration 6 mm or greater
Mantoux strongly positive- Induration 15 mm or greater
*This is a type 4 hypersensitivity reaction
102
What type of drug is ipatropium?
SAMA
103
What is the most common subtype of lung cancer?
Adenocarcinoma
These are generally seen in non-smokers
104
What position is useful in patients with ARDS?
Prone positioning: reduced compression of lung tissue by the heart and abdominal organs when prone. This reduction in compression facilitates improved gas exchange and a more uniform distribution of blood flow throughout the lungs.
105
What is the preferred VTE management?
DOACs for at least 3 months
Provoked - usually 3 months (unless cancer which is 3-6 months)
Unprovoked - reconsider at 3 months for a further 3 months ± ORBIT score calculation
106
Which organism commonly causes pneumonia in alcoholics?
Klebsiella pneumonia
107
What are the features of Legionella pneumophilia infection?
Dry cough and is related to air-conditioning systems.
It can cause lymphopenia, hyponatraemia and deranged liver function tests.
108
What is mycoplasma pneumoniae typically associated with?
Atypical pneumonia seen in younger patients associated with erythema multiforme and cold autoimmune haemolytic anaemia
Diagnosis is generally by Mycoplasma serology, however you can also get a positive cold agglutination test → peripheral blood smear may show red blood cell agglutination
Treatment: doxycycline or a macrolide (e.g. erythromycin/clarithromycin)
109
What is the PESI score?
Pulmonary Embolism Severity Index (PESI) score is to be used to help identify patients with a pulmonary embolism that can be managed as outpatients
110
What are features of silicosis on CXR?
* Upper zone fibrosing lung disease
* 'egg-shell' calcification of the hilar lymph nodes
111
What pneumonia commonly follows an influenza illness?
Staphylococcus aureus pneumonia
*Pneumococcus is also common post-viral illness
112
What does asbestosis have a high risk of developing?
Bronchogenic carcinoma
Risk of developing bronchogenic carcinoma is greater than developing mesothelioma
113
How does pneumocystis jiroveci pneumonia commonly present?
* dyspnoea
* dry cough
* fever
* very few chest signs
* desturation on exercise
* sometimes oral candidiasis
114
What is a common complication of pneumocystis jiroveci pneumonia?
Pneumothorax
115
What are extra-pulmonary manifestations of pneumocystis jiroveci pneumonia?
Extra-pulmonary manifestations are rare (1-2%):
* hepatosplenomegaly
* lymphadenopathy
* choroid lesions in eye
116
What would the urine osmolality show in a water deprivation test in primary polydypsia?
urine osmolality after fluid deprivation: high
urine osmolality after desmopressin: high
117
What would the urine osmolality show in a water deprivation test in cranial diabetes insipidus?
urine osmolality after fluid deprivation: low
urine osmolality after desmopressin: high
118
What would the urine osmolality show in a water deprivation test in nephrogenic diabetes insipidus?
urine osmolality after fluid deprivation: low
urine osmolality after desmopressin: low
119
What are features of extrinsic allergic alveolitis?
Largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase
Examples:
* bird fanciers' lung
* mushroom workers' lung
* malt workers' lung
* farmers lung
Investigation:
* imaging: upper/mid-zone fibrosis
* bronchoalveolar lavage: lymphocytosis
* serologic assays for specific IgG antibodies
* blood: NO eosinophilia
Management
* avoid precipitating factors
* oral glucocorticoids
120
What are the most common isolated organisms in bronchiectasis?
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
121
What is refractory anaphylaxis and how do you manage it?
* defined as respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline
* IV fluids should be given for shock
* consider IV adrenaline infusion
122
What should you do if USS scan is negative but D-dimer positive in suspected DVT?
* Stop interim therapeutic anticoagulation
* Offer a repeat proximal leg vein ultrasound scan 6 to 8 days later
123
What is a complication of long-term mechanical ventilation?
Tracheo-oesophageal fistula formation - associated with ventilator pneumonias and aspiration pneumonias
124
What sign is commonly seen in bronchiectasis on CXR?
Tram lines - parallel line shadows that indicate dilated bronchi due to peribronchial inflammation and fibrosis
