Respiratory

Question 1

📌 Bibasal Crackles - Differentials

Answer 1

🔹 Respiratory Causes: Pulmonary oedema, ILD, pneumonia, bronchiectasis, ARDS. 🔹 Cardiac Causes: CHF, valvular disease. 🔹 Other: Hypoalbuminaemia, drug-induced fibrosis.

Question 2

📌 Indications for a Midline Sternotomy (Respiratory-Related)

Answer 2

✅ CABG ✅ Aortic Valve Replacement ✅ Pulmonary Thromboendarterectomy ✅ Large Mediastinal Tumour Resection ✅ Bilateral Lung Transplantation

Question 3

📌 CREST Patient with Sclerodactyly, Telangiectasia, Fine Crackles, and Dull Bases

Answer 3

🔹 Differentials: Pulmonary fibrosis, pulmonary hypertension, ILD, heart failure. 🔹 Investigations: Autoimmune screen (ANA, anti-centromere), HRCT, echo. 🔹 Management: Nintedanib, Sildenafil, Oxygen therapy, Pulmonary rehab.

Question 4

📌 Chronic COPD Management (NICE Guidelines 2023)

Answer 4

✅ Stepwise Approach: 1️⃣ SABA/SAMA PRN 2️⃣ LABA + LAMA or LABA + ICS 3️⃣ Triple therapy (LABA + LAMA + ICS) 4️⃣ Roflumilast if severe. ✅ LTOT if PaO₂ < 7.3 kPa

Question 5

📌 Pulmonary Fibrosis in RA - Drug Causes (NICE/BTS)

Answer 5

🚨 Methotrexate 🚨 Sulfasalazine 🚨 Leflunomide 🚨 TNF Inhibitors (Infliximab, Etanercept)

Question 6

📌 Pulmonary Fibrosis Causes (Mnemonic: PANTER)

Answer 6

🔹 Pneumoconiosis (asbestosis, silicosis) 🔹 Autoimmune (RA, Scleroderma, SLE) 🔹 Neoplastic (radiation, chemotherapy) 🔹 Toxic (Amiodarone, Methotrexate, Nitrofurantoin) 🔹 Environmental (hypersensitivity pneumonitis) 🔹 Restrictive Idiopathic (Idiopathic Pulmonary Fibrosis - IPF)

Question 7

📌 COPD vs CREST - Presentation & Investigation

Answer 7

Feature | COPD | CREST |
|————|———|———|
| Symptoms | Chronic cough, sputum, wheeze, exertional SOB | Raynaud’s, skin tightening, telangiectasia |
| Signs | Hyperinflation, wheeze, cyanosis | Sclerodactyly, microstomia, pulmonary HTN |
| Spirometry | Obstructive (↓FEV1/FVC < 0.7) | Restrictive (↓TLC, ↓FVC, ↓DLCO) |

Question 8

📌 Upper-Lobe and Lower-Lobe Predominant Causes of Pulmonary Fibrosis

Answer 8

🔹 Upper-lobe Fibrosis: TB, Sarcoidosis, Hypersensitivity Pneumonitis, Silicosis. 🔹 Lower-lobe Fibrosis: IPF, Asbestosis, RA-ILD, Scleroderma. HRCT recommended for diagnosis (NICE).

Question 9

📌 Symptoms and Signs of Right- vs Left-Sided Cardiac Failure

Answer 9

Feature | Right-Sided HF | Left-Sided HF |
|————|—————-|—————-|
| Symptoms | Peripheral oedema, ascites, hepatomegaly | Dyspnoea, orthopnoea, crackles |
| JVP | Raised | May be raised |
| Lung Signs | Clear or pleural effusion | Bibasal crackles |

Question 10

📌 4L Oxygen - What FiO₂ is the Patient On?

Answer 10

🟢 FiO₂ = 21% + (O₂ flow rate in L/min × 4%)
🟢 4 L/min = 21% + (4 × 4%) = ~37%
✅ BTS Oxygen Guidelines: COPD Patients: Target 88-92% SpO₂, Normal Patients: Target 94-98% SpO₂

Question 11

📌 Causes of Interstitial Lung Disease

Answer 11

✅ NICE-recognised ILD causes: Idiopathic Pulmonary Fibrosis, Autoimmune diseases, Hypersensitivity Pneumonitis, Occupational ILD, Drug-induced ILD.

Question 12

📌 Conservative, Medical & Surgical Management of Idiopathic Pulmonary Fibrosis

Answer 12

✅ Conservative: Pulmonary rehab, oxygen. ✅ Medical: Antifibrotics (Nintedanib, Pirfenidone). ✅ Surgical: Lung transplant.

Question 13

📌 List 20 Common Causes of ILD

Answer 13

✅ Idiopathic pulmonary fibrosis, RA, Scleroderma, Sarcoidosis, Hypersensitivity Pneumonitis, Asbestosis, Silicosis, Drugs (Methotrexate, Amiodarone), Eosinophilic Pneumonia, etc.

Question 14

📌 Causes of Dullness to Percussion (NICE Pneumonia Guidelines)

Answer 14

1️⃣ Consolidation (Pneumonia, ARDS) 2️⃣ Pleural Effusion 3️⃣ Lung Collapse (Atelectasis) 4️⃣ Tumour/Malignancy

Question 15

📌 Likely Diagnosis (Man with Clubbing, Right Base Dullness, Crackles)

Answer 15

✅ Pulmonary Fibrosis with Effusion (RA-ILD, Asbestosis, Scleroderma) ✅ Lung Cancer with Pleural Effusion ✅ Empyema
🛠 Investigations: CXR, HRCT, Pleural Aspiration if effusion.

Question 16

📌 Investigations for CREST with Pulmonary Hypertension

Answer 16

✅ Autoimmune screen (ANA, anti-centromere, RF, anti-Scl-70) ✅ Echocardiogram ✅ HRCT Chest ✅ Right Heart Catheterisation

Question 17

📌 How to Clinically Differentiate COPD vs Asthma

Answer 17

✅ COPD: Irreversible obstruction, progressive symptoms, smoking history. ✅ Asthma: Reversible obstruction, diurnal variation, eosinophilia. NICE recommends spirometry and bronchodilator reversibility testing.

Question 18

📌 Management of COPD (NICE 2023)

Answer 18

✅ Smoking Cessation (Most Important!) ✅ Bronchodilators (SABA/LABA/LAMA) ✅ ICS (if eosinophilic phenotype or asthma overlap) ✅ Pulmonary Rehab ✅ Oxygen Therapy if Hypoxic

Question 19

📌 Bronchiectasis - Investigations (UK BTS)

Answer 19

✅ HRCT Chest (Gold Standard) ✅ Sputum Culture ✅ CF Sweat Test ✅ Immunoglobulin Levels (for primary immunodeficiency)

Question 20

📌 Bronchiectasis - Management (BTS)

Answer 20

✅ Airway Clearance (Physiotherapy, Postural Drainage) ✅ Sputum-guided Antibiotics ✅ Bronchodilators if Airway Hyperreactivity ✅ Surgery (for localised, severe cases)