Respiratory

Question 1

dx: Pink frothy sputum, swollen ankles

Answer 1

Acute pulmonary edema
LMNOP reverse
NYHA criteria (note beta-blocker only when fluid status is stabilized)
Daily weighs, salt and water restriction.
Device therapy if indicated

Question 2

Precipitants of acute pulmonary edema

Answer 2

MAD HATTER 3P
Myocardial infarction
Anemia
Drugs - NSAID, negative inotropes, compliance 
Hypertension
Arrythmia 
Temperature (infection)
Thyroid (hyper or hypothyroid) 
Endocarditis, eclampsia
Renal failure, rupture of chordae
3P - peri-op, PE, pregnancy

Question 3

70 yo M retired army officer, constant dyspnea 2 years at rest, productive cough, thick sputum

Answer 3

COPD

Spirometry to confirm diagnosis

Question 4

Typical organisms for bronchiolitis

Answer 4

RSV (most common in children

Question 5

12 month old M 
o	increased  work of breathing (link)
o	widespread expiratory wheeze and crepitations, expiration is also prolonged + hyperinflation
o	+/- fever
o	May have reduced oxygen saturation
o	signs of dehydration

Answer 5

Bronchioliitis

Diagnosis is clinical
Treatment is supportive - oxygenation, fluid, nutrition. Admit to hospital for signs of moderate-severe

CXR will show hyperinflation - flattened diaphragm on AP, barrel-chest on lateral

Question 6

inspiratory stridor, increased work of breathing + absent cough with low pitched expiratory stridor (often snoring) and drooling. No swallowing. Prefers to sit upright.

Answer 6

Acute epiglottitis

Emergency, give IV abx and send to hospital

Question 7

Typical organism for acute epiglotitis

Answer 7

H inluenzae type B

Question 8

Chest tap - what are the anatomical landmarks

Answer 8

5th AAL
2nd MCL
Done immediately above costal margin

Question 9

Recurrent attacks of slow onset SOB, uncoordinated breathing, palpitaitons, lightheadedness, fatigue, agitation O/E chest normal

Answer 9

Anxiety

Paper bag rebreathing

Question 10

COPD - Outline main management for acute exacerbation

Answer 10

Bronchodilator - inhaled, dual if not responsive
Systemic steroid - pred po once daily, 7-14 days
Antibiotics - amoxicillin or doxycycline
Oxygen therapy - target O2 saturation levels of 88 – 92, and nasal prongs (2L/min) OR venturi mask (28% and 4L/min) .Take ABG, If ABG results show respiratory acidosis (pH 45 OR signs of CO2 retention – asterexis, confusion  consider NIPPV (biPAP)

Question 11

Diagnosis of bronchiectasis

Answer 11

high resolution CT scan

Question 12

Most likely diagnosis of persistent morning cough

Answer 12

smoking

Question 13

Yellow sputum in the absence of infection

Answer 13

Asthma (eoisnophilis)

Smoking

Question 14

Copious quantities of yellow-green sputum

Answer 14

Pseudomonas

Bronchiectasis

Question 15

Red flags of sick child with resp. illness

Answer 15

Behaviour - irritability, fatigue, drowsiness
Resp rate
Accessory muscle use
Poor feeding

Question 16

22 yo migrant from east timor, 4 months of persistent cough, mucus production and flecks of blood, anorexia, tired, night sweats, weight loss, feverish and mild headache.

Answer 16

Probability diagnosis - TB
Must not miss - carcinoma of lung
Pitfalls - bronchiectasis, cystic fibrosis, sarcoidosis, wegeners, churg-straus, whooping cough

Question 17

Common benign causes of persistent cough

Answer 17

URTI with post-viral cough
chronic bronchitits
post-nasal drip 
ASthma 
Smoker's cough

Question 18

TB investigations and diagnosis

Answer 18

Quantiferon (does not distinguish latent vs active disease)
Ziel-Neelson stain of sputum (3x early morning)
PCR
CXR

Question 19

TB management

Answer 19

Isolation and quarantine
Reportable disease 
Medications 2x4, 4x2
-  2 months of 4 agents - rifampicin, isoniazid, pyrazinamide, ethambutol
- 4 months of rifampicin and isoniazid

Question 20

TB drug side effects

Answer 20

o Risk factors;
 10% serious AE
 Risk factors: age, female, pre existing liver disease/Hep B or C co infection)
o Ethambutanol: reversible optic neuritis/neuropathy (need to monitor color vision)
o Isoniziad: epilepsy, peripheral neuritis, hepatitis (pyridoxine can be prescribed if peripheral neuropathy)
o Rifampicin: orange body fluids, CYP450 drug inducer (warfarin, steroids), severe drug interactions with pill (need alternative contraceptive) , hepatotoxicity
o Pyrazinamide: hyperurecemia (gout), polyarthralgia, hepatotoxicity (monitor LFTs)

Question 21

18 m.o female cough + vomit
Cough and coryza for one week (catarrhal phase), followed by a more pronounced cough in spells or paroxysms (paroxysmal phase). Paroxysms may be precipitated by feeding. Paroxysms cause redness of face.
Inspiratory whoop and vomiting often follows a coughing spasm.
Infants may develop apnoea and/or cyanosis with coughing spasms, instead of having inspiratory whoop.
?Sick contact
Other family members frequently have a cough (>70% of household contacts are also infected).

Answer 21

Whooping cough
Laboratory confirmation is not necessary for diagnosis, but may be helpful for infection control.
A nasopharyngeal aspirate/swab for PCR is the investigation of choice. The test is usually negative after 21 days, or 5-7 days after effective antibiotic therapy has been commenced.
Pertussis serology (IgA) may be detectable 2 weeks after the onset of the illness but rarely affects clinical management.

Question 22

CXR findings in TB

Answer 22

• primary: tuberculoma + ipsilateral hilar adenopathy
• latent TB: Ranke complex - subpleural calcified tuberculosis caseasting granuloma (tuberculoma) + calcified ipsilateral hilar node
• secondary TB: cavitary lesion in apical posterior segment of upper lobe, absence of lymphadenopathy

Question 23

3yo, recurrent bouts of cough for 18 months, associated wheeze, thin pale, failure to thrive, large pale, bulky offensive stools, basal crackles on auscultation

Answer 23

Cystic fibrosis
autosomal recessive
CFTR gene mutation 
Heel prick test - population screening 
Confirmed with sweat test 

Early and aggressive tx of respiratory infection - physio, early abx
High choloric diet
Replace enzymes + fat soluble vitamins supplementation
Dietary referral and weight monitoring
Male infertility
Delayed puberty

Question 24

18 months, recent URTI, 3 hours, loud, harsh brassy cough, worse when starts to cry, worse at night, fever, hoarse voice
Inspiratory stridor due to submucosal edema in trachea
Signs of respiratory distress - suprasternal and sternal retraction
Expiratory component suggests tracheal and subglottic component

Answer 24

Croup - acute laryngotracheobronchitis
Virus - parainfluenza virus, transmitted by respiratory drops
Usually occurs 6 months to 6 years

ddx - laryngitis (isolated hoarse voice), rule out epiglottitis foreign body, bacterial tracheitis

Admit to hospital if stridor at rest or biphasic stridor, irritable, restless, anxious
** stridor being soft despite substantial respiratory effort suggests significant obstruction**

Question 25

12 yo, 3 weeks after URTI, persistent dry cough, worse during night, nasal stuffiness, post nasal drip

Answer 25

Post-viral cough

? rhinosinusitis

Question 26

smoker, 2 days irritating cough, then yellow-green sputum, chest tightness with wheezing, fever, occasional crackles on auscultation

Answer 26

ddx - bronchitis (usually afebrile), pneumonia (constitutional symptoms, systemically unwell, pleuritic chest pain)

Acute bronchitis - watchful waiting

Question 27

58 yo, salesman, 3 month dry bovine cough, retrosternal tenderness, 1 week horseness, O.E no abnormalitity

Answer 27

ddx - bronchial carcinoma, GERD, recurrent laryngeal nerve palsy

diagnosis- GERD

Question 28

36 yo F, 2 month dry cough, malaise, fever, tender rash on legs (erythema nodosum) for past 2 days. Bilateral hilar lymphadenopathy in CXR

Answer 28

Sarcoidosis
- confirm with ACE level

ddx lymphoma

Question 29

Risk factors for severe croup

Answer 29

Risk Factors for severe croup

• pre-existing narrowing of upper airways
• subglottic stenosis (congenital or secondary to prolonged neonatal ventilation)
• Down Syndrome
• previous admissions with severe croup
• uncommon <3 months of age. Consider alternative diagnosis. Acute upper airway obstruction.

Question 30

21 M, previously well, sudden onset dry cough, fever, headache, muscle ache and pains, NAD (apart from fever)
Likely and differential diagnosis?

Answer 30

Influenza : usually a higher fever, myalgia
 Fever > 38 + one systemic symptom + one respiratory symptom = 60-70% chance of influenza

Must not miss: meningitis

Question 31

4 month old, tachypnea, short-expiratory grunt, sick and restless, febrile, pallor (despite high fever)

Answer 31

pneumonia

Question 32

3 pathophysiological components of asthma

Answer 32

Bronchial smooth muscle spasm
Airway inflammation and oedema
Mucus plugging

Question 33

Triggers of asthma

Answer 33

Cigarette smoke,
Allergens,
Airborne/environmental,
Drugs (NSAIDS,aspirin, echinacea, betablockers), exercise,
URTI
Comorbid conditions - allergic rhinitis, rhinosinusitis, GERD, nasal polyposis

Question 34

Diagnosing asthma

Answer 34

clinical diagnosis
History - wheeze, exposures/triggers, PMHX of bronchiolitis, family history or known atopy
Examination
Exclusion of other diagnoses
Documenting variable, reversible airflow:

Question 35

Obstructive lung diseases

Answer 35

Asthma, COPD, bronchiectasis

Question 36

Restrictive lung disease

Answer 36

o Diffuse lung diseases: extrinsic allergic alveolitis (Farmer’s lung, bird fancier’s lung), pneumoconioses (Coal worker’s pneumoconiosis, asbestosis), collagen vascular diseases (scleroderma, rheumatoid, polymyositis, Sjogren’s), sarcoidosis, cryptogenic fibrosing alveolitis, toxins, drug damage (amiodarone, methotrexate, bleomycin), radiotherapy
o Space-occupying lesions: hiatus hernia, cardiomegaly, pleural effusion
o Thoracic wall disorders: pleural disease, skeletal (AS, thoracoplasty), obesity, neuromuscular (MND, GBS, bilateral diaphragmatic paralysis, muscular dystrophy, myopathy), dermatological (scleroderma)

Question 37

Lung function testing results in asthma

Answer 37

FEV1/FVC 20% decrease after exercise or > 10% diurnal variation

Question 38

Side effects of salbutamol

Answer 38

Risk is greatest when more than 10 puffs a day
Tremors
Palpitations
Increased risk of asthma flare-ups requiring oral corticosteroids
Regular use of SABA leads to receptor tolerance (downregulation) to their bronchoprotective and bronchodilator effects

Question 39

what is the classical clinical manifestation of allergic rhinitis?

Answer 39

nasal itching, rhinorrhea, nasal congestion and sneezing
other associated symptoms:
- post nasal drip
- cough
- irritability
- fatigue
- allergic conjunctivitis - bilateral itching, tearing, gritty sensation of the eyes

Question 40

what are some clinical manifestation of chronic allergic rhinitis?

Answer 40

allergic shiners - blue gray/purple discoloration under the eye
transverse nose crease
edematous and pale nasal mucosa
allergic facies

Question 41

investigations and diagnosis of allergic rhinitis

Answer 41

clinical diagnosis based on classical symptoms + suggestive fhx and phmx + supportive finding on exam

neither peripheral blood eosinophil, nor total serum IgE are sensitive enough to help diagnose allergic rhinitis

other tests available (but not required) are:

• skin prick testing
• blood testing

Question 42

treatment of allergic rhinitis (separate into intermittent vs persistent)

Answer 42

intermittent (mild): oral or intranasal antihistamine
intermittent (moderate - severe): oral or intranasal antihistamine OR montelukast OR intranasal corticosteroid + r/v after 2 - 4 weeks
persistent (mild): oral or intranasal antihistamine AND/OR intranasal corticosteroid OR montelukast + r/v in 2 - 4 weeks
persistent (moderate - severe): intranasal corticosteroid AND EITHER oral intranasal antihistamine or montelukast + r/v in 2 - 4 weeks

if tx works, continue for 1 month

Question 43

when is a specialist referral required

Answer 43

refractory to treatment
concomittant allergic rhinitis and asthma
recurrent episodes of sinusitis and otitis media

Question 44

what are the features of rhinitis medicamentosa?

Answer 44

on examination showing swollen red nasal mucosal membrane

history of use of nasal decongestants of more than 3 consecutive days

Question 45

what are the clinical features of a cold?

Answer 45

incubation period of around 24 - 72 hours, symptom duration of 3 - 10 days 
rhinitis/coryza 
sore throat 
cough 
malaise 
fever 
\+/- conjunctivitis 
\+/- nasal discharge

Question 46

how do you ddx these from a cold?

• influenzae
• allergic rhinitis
• bacterial pharyngitis/tonsillitis
• pertussis (whooping cough)

Answer 46

influenza has presence of high fever, myalgia, headache
allergic rhinitis - absence of sore throat, cough and prominent nasal itching
bacterial pharyngitis/tonsillitis - no nasal stuffiness, prominent rhinorrhea
pertussis (whooping cough) - usually persistent coughing for more than 2 weeks

Question 47

What are the features of croup?

Answer 47

usually worse at night around 2 - 3 times
harsh brassy cough that sounds barking
inspiratory stridor
associated widespread wheeze
increased work of breathing (respiratory muscles recruited)
will not have signs of toxicity but may be febrile

Question 48

what is the treatment of croup?

Answer 48

acute mx:
- minimal handling, do not change the patient’s posture

if the patient only has a cough, does not require treatment

mild to moderate croup: prednisolone 1mg/kg AND 2nd dose for next evening
severe croup; nebulized adrenaline and 0.6mg/kg IM/IV dexamethasone

Question 49

what is the pathogen that causes croup?

Answer 49

parainfluenza

Question 50

what are the features of bronchiolitis

Answer 50

fever 
wide spread wheeze and crepitations  
coughing 
cyanosis 
cough 
especially if child, may be accompanied by otitits media

Question 51

what are the features you look for when classifying the severity of bronchiolitis?

Answer 51

irritability
RR, tracheal tug, nasal flaring 
accessory muscle use 
ability to feed 
oxygen saturations 
apneic episodes

Question 52

what is the management of bronchiolitis?

Answer 52

mild - managed at home, supportive,
moderate - admission, o2 administration, supplemental fluid and monitoring
severe - monitoring, supplemental o2 and fluid support, consider cPAP or ventilation

Question 53

clinical features of influenza

Answer 53

incubation period of 1 - 3D 
high fever
systemic sx (myalgia, malaise, fever) 
cough 
\+/- sore throat
usually absence of rhinorrhea, sneezing

Question 54

clinical manifestations of whooping cough

Answer 54

catarrhal stage (1 - 2 weeks): URTI sx w/ mild cough and nasal drip
paroxysmal stage (2 - 8 weeks): coughing spells increased severity, paroxysmal coughing becomes distinctive (long series of cough w/ no respiratory effort).
child may become cyanotic/apneic post vomiting
convalescent stage: cough subsides over weeks to months

Question 55

investigations and diagnosis of whooping cough

Answer 55

can be diagnosed clinically based on classical clinical hx of:
catarrhal stage that worsens to cough in spells or paroxysms
vomitting after a fit or developing apnea/cyanosis between fits
investigations that can be done are:
nasopharyngeal PCR

Question 56

treatment of whooping cough

Answer 56

ind for abx: catarrheal phase, cough for less than 14 days, admittance to hospital, has existing complications of: pneumonia, cyanosis, apnea

children: azithromycin 10mg/kg oral first then 5 mg/kg oral for next 4 days

preventive:
- exclude from sch until 5 days of therapy or coughing for more than 21 days
- notify all cases to communicable diseases
- vaccination continue
- prophylaxis for;
ppl who were in close contact while case was infectious
children