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* year 3 core conditions (detailed) > respiratory > Flashcards

respiratory Flashcards

1
Q

asthma:

  • risk factors? 6
  • three factors that contribute to airway narrowing?
A
  • PMH atopic disease
  • FH atopic disease
  • exposure to tobacco smoke (or other lung irritants)
  • social deprivation
  • low birth weight
  • obesity

1) bronchial muscle constriction (triggered by a variety of stimuli)
2) mucosal swelling/inflammation (dt mast cell + basophil degranulation)
3) increased mucus production

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2
Q

asthma:

  • symptoms? 3
  • common triggers? 8
  • drugs which exacerbate? 2
A
  • intermittent dyspnoea (diurnal variation)
  • wheeze
  • cough (often nocturnal) w sputum
  • cold air
  • exercise
  • emotions
  • allergens (dust mite, pollen, fur)
  • infection
  • smoking
  • passive smoking
  • pollution
  • NSAIDs
  • B blockers
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3
Q

asthma:

  • clinical signs?
  • conditions which often co-exist?
  • clinical testing/diagnosis?
A
  • symptomatic wheeze on auscultation
    (- can get hyper inflated chest, but only if severe)
  • other atopic (hayfever, eczema)
  • gastric reflux
  • peak flow

spirometry

  • FEV1/FVC ratio reduced (should be 90% in kids + 70% in adults)
  • FEV1 improves with salbutamol
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4
Q

asthma:

  • suggested lifestyle changes? 3
  • pharmacological treatment ladder? (5 steps)
A
  • stop smoking
  • avoid precipitants
  • weight loss (if overweight)

1) occasional SABA as required

(if used >1 a day or at night then go step 2)

2) add daily inhaled steroid (e.g. beclomethasone)

(before step 3, check inhaler technique, adherence + removal of triggers)

3) change to LABA/inhaled steroid dual inhaler (don’t take LABA alone)
- if no response, stop LABA + increase inhaled steroid dose

4) raise inhaled steroid dose or add other agents:
- oral theophylline
- oral B2-agonists
- LTRA
* refer to specialist at this point*

5) add daily steroid tablets

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5
Q

differential diagnosis for asthma:

  • resp? 5
  • cardiovascular? 3
A

resp:

  • COPD
  • bronchiectasis
  • large airway obstruction
  • pneumothorax
  • obliterative bronchiectasis (suspect in elderly)

cardiac:

  • pulmonary oedema (‘cardiac asthma’)
  • PE
  • SVC obstruction (e.g. by tumour)
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6
Q

acute severe asthma:

  • presentation?
  • signs of severe attack?
  • signs of life-threatening attack?
A
  • acute breathlessness + wheeze

severe:

  • unable to complete sentences in one breath
  • RR >25
  • pulse >110
  • PEF 33-50% of predicted (or best)

life threatening:

  • PEF <33% of predicted or best
  • silent chest, cyanosis, feeble respiratory effort
  • arrhythmia or hypotension
  • exhaustion, confusion, coma
  • poor ABG results
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7
Q

acute severe asthma:

  • management?
  • what to monitor? 3
A
  • stay calm!
  • nebuliser salbutamol (keep going, can’t really overdose)
  • oxygen
  • oral prednisalone
  • repeat salbutamol
  • continue reassessing
  • add ipratropium

GET HELP!!

  • RR
  • pulse
  • O2 sats
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8
Q

differential diagnosis for acute asthma attack? 5

A
  • acute infective exacerbation of COPD
  • pulmonary oedema
  • upper resp tract obstruction
  • PE
  • anaphylaxis
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9
Q

COPD:

  • definition?
  • definition of chronic bronchitis?
  • factors which make COPD more likely than asthma? 5
  • genetic risk factor?
A

progressive + prolonged airway obstruction

  • FEV1 <80% predicted
  • FEV1/FVC <0.7
  • with little or no reversibility
  • cough
  • sputum production on most days for 3 months of 2 successive years
  • symptoms improve if stop smoking
  • age of onset >35years
  • smoking (active or passive, or pollution related)
  • chronic dyspnoea
  • sputum production
  • minimal diurnal or day-to-day FEV1 variation
  • a1-antitrypsin deficiency
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10
Q

COPD:

- difference between a pink puffer and a blue bloater?

A

blue bloater

  • mainly bronchitis
  • earlier
  • near normal PaO2
  • cyanosed
  • wheezing
  • overweight

pink puffer

  • mainly emphysema
  • later
  • low PaO2 and high CO2
  • severe breathless
  • quiet chest (hyper inflated lungs on x-ray)
  • cachexic
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11
Q

COPD:

  • symptoms? 4
  • signs? 4
A
  • cough
  • sputum
  • dyspnoea
  • wheeze
  • tachypnoea
  • use of accessory muscles
  • hyperinflation (barrel chest)
  • wheeze
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12
Q

COPD:

  • main investigation?
  • signs on x-ray? 2
A
  • spirometry

nb CXR may be normal if early/well-controlled

  • hyperinflation
  • flat hemidiaphragms
    (- may see bullae)
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13
Q

COPD:

  • non-pharm treatment? 3
  • what is the general progression of inhalers? 3
  • end-stage treatment?
A
  • stop smoking
  • exercise
  • pneumococcal + flu vaccine

1) SABA or SAMA (short-acting muscarinic antagonist)
2) add LABA or LAMA
3) add inhaled steroid

  • long term oxygen therapy (LTOT)
    ^contraindicated in smokers

nb can also consider surgery to remove bullae but rarely done

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14
Q

complications of COPD:

  • exacerbations? 2
  • other? 5
A
  • infective
  • non-infective
  • polycythaemia (dt prolonged hypoxia)
  • resp failure (1 or 2)
  • cor pulmonale
  • pneumothorax (ruptured bullae)
  • lung cancer
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15
Q

bronchial carcinoma

  • 4 types?
  • risk factors?
A

small cell

  • aka oat cell
  • worse prognosis
  • often have paraneoplastic syndromes (ACTH or ADH secretion)

non-small cell

  • squamous
  • adenocarcinoma (commonest in non-smokers + asbestos)
  • large cell
  • tobacco smoking (90%)
  • passive smoking
  • asbestos
  • chromium
  • arsenic
  • iron oxides
  • radiation
  • pollution
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16
Q

bronchial carcinoma:

  • local symptoms? 4
  • systemic symptoms? 3
  • signs? 3
A
  • persistent cough (80%)
  • haemoptysis (70%)
  • dyspnoea (60%)
  • chest pain (40%)
  • lethargy
  • anorexia
  • weight loss
  • cachexia
  • anaemia
  • clubbing

nb can get other signs if mets or paraneoplastic syndromes
- may auscultate an unresolved ‘pneumonia’ but not always

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17
Q

bronchial carcinoma:

  • imaging?
  • other tests?
A 
CXR
(nb if clear but smoker with haemoptysis send for CT as mediastinum may hide it)
- peripheral nodule
- hilar enlargement
- (lung collapse or pleural effusion)
  • fine needle aspiration or biopsy to identify + stage tumour
  • can send sputum or pleural fluid as well
  • bronchoscopy, to assess eligibility for surgery
  • PET CT for staging/mets
18
Q

bronchial carcinoma:

  • ideal treatment?
  • other treatments?
A
  • lobectomy
  • radical radiotherapy
  • radiotherapy + chemo (for advanced)

very poor prognosis! (especially small cell)

19
Q

differential diagnoses for nodules on the lung on a CXR:

  • respiratory? 8
  • other? 3
A
  • primary lung cancer
  • secondary lung cancer
  • carcinoid (neuroendocrine) tumours
  • abscess
  • granuloma
  • cyst
  • pulmonary hamartoma
  • encysted effusion (fluid, pus, blood)
  • Arterovenous malformation
  • foreign body
  • skin tumour (e.g. seborrheic wart)
20
Q

differential diagnosis for haemoptysis:

  • commonest? 4
  • others? 4
A
  • bronchitis (26%)
  • neoplastic (23%)
  • pneumonia (10%)
  • TB (8%)
  • PE
  • foreign body
  • rare vasculitisis
  • bronchiectasis
21
Q

pneumothorax:

  • commonest cause?
  • other causes?
A
  • spontaneous (in tall, young men)

chronic lung disease

  • asthma
  • COPD
  • CF
  • lung fibrosis
  • sarcoidosis

infection

  • TB
  • pneumonia
  • lung abscess

traumatic

  • trauma (incl rib fracture)
  • iatrogenic (e.g. lung biopsy, mechanical ventilation)

carcinoma

connective tissue disorder (e.g. marfans)

basically anything that affects the lung can cause a pneumothorax…

22
Q

pneumothorax:

  • symptoms? 2
  • signs? 3
  • signs of a tension pneumothorax? 3
A
  • often asymptomatic in tall, young men

sudden onset
- dyspnoea
- pleuritic chest pain
(sudden deterioration in asthma/COPD patients)

on affected side:

  • reduced expansion
  • hyper resonant to percussion
  • diminished breath sounds

tension:

  • trachea deviation (away from pneumothorax)
  • hypotension
  • rapid deterioration/resp distress
23
Q

pneumothorax:

  • imaging? 1
  • bloods? 1
A

CXR
- NOT in tension pneumothorax!!

  • ABG (if hypoxic or chronic lung disease)
24
Q

pneumothorax:

  • management? 2
  • future advice? 2
  • treatment for recurrent? 1
A
  • aspiration
  • if unsuccessful (do CXR), or patient ill: intercostal chest drain
  • no air travel for 6 weeks after normal CXR
  • avoid diving permanently
  • pleurodesis
25
Q

pleural effusion:

  • commonest causes of transudates? 2
  • rare causes of transudates? 2
  • causes of exudates? 3
A
  • heart failure
  • hypoalbuminaemia (liver failure)
    (- hypothyroidism)
    (- meig’s syndrome - ovarian fibroma)

infection

  • pneumonia
  • TB

inflammation

  • RS
  • SLE

malignancy

  • bronchial carcinoma
  • mets
  • lymphoma
  • mesothelioma
26
Q

pleural effusion:

  • symptoms? 2
  • commonest signs? 3
  • other signs? 3
A

asymptomatic if small

  • dyspnoea
  • pleuritic chest pain

on affected side:

  • decreased expansion
  • stony dull to percussion
  • decreased breath sounds
  • bronchial breathing (above effusion dt compression)
  • tracheal deviation away from effusion, if large
  • signs of underlying cause (liver disease, clubbing, SLE rash etc)
27
Q

pleural effusion:

  • imaging? 1
  • other investigation? 1
A
  • CXR (blunted costophrenic angles is first sign)

- USS guided pleural fluid aspiration (unless obvious it’s heart failure)

28
Q

pleural effusion:

  • treatment of transudates? 1
  • treatment of exudates? 1
  • treatment of recurrent pleural effusions? 1
A
  • treat underlying cause in transudates
  • drain in exudates (or if symptomatic) - nb also treat underlying cause!!
  • pleurodesis
29
Q

pneumonia:

- definition?

A

an acute LRTI associated with fever, symptoms + signs in the chest AND abnormalities on the CXR

30
Q

pneumonia:

  • commonest organism in CAP?
  • other typical CAP organisms?
  • atypical CAP organisms?
A

strep pneumoniae (commonest)

typical

  • Haemophilus influenzae (common w COPD)
  • moraxella catarrhalis

atypical

  • mycoplasma pneumoniae
  • staph aureus (IVDU)
  • legionella (water borne)
  • chlamydia

nb 15% are caused by viruses

31
Q

hospital acquired pneumonia:

  • definition?
  • 2 most common causative organisms?
  • 4 rarer ones?
A

> 48hours after hospital admission

+ gram negative enterobacteria
+ staph aureus

  • pseudomonas
  • kleibsiella
  • bacteroides
  • clostridia
32
Q

pneumonia:

  • resp symptoms? 4
  • other symptoms? 4
A
  • productive cough (w green sputum)
  • dyspnoea
  • pleuritic pain
  • haemoptysis
  • fever
  • rigors
  • anorexia
  • malaise
33
Q

pneumonia:

  • sign most commonly seen in elderly?
  • score used to assess severity?
A

confusion (can be only sign in elderly)

CURB-65

C - confusion
U - urea (in blood)
R - RR
B - BP
65 - over the age of 65

score 1 for each! determines whether treatment as outpatient or admitted

34
Q

pneumonia:

  • imaging?
  • bloods? 4
  • other bedside tests? 2
A

CXR

  • FBC (raised WBCs)
  • U+E (look for urea)
  • LFTs (just cos)
  • CRP (severity)
  • O2 sats
  • BP (see if getting septic)
35
Q

pneumonia Abx treatment:

  • first line if CAP with low CURB?
  • first line if CAP with high CURB?
  • first line if CAP with penicillin allergy?
  • if caused by MRSA?
A

low CURB
- amoxicillin (initially 5 days)

high CURB
- co-amoxiclav (initially 7 days)
(- add clarithromycin if not clearing!)

penicillin allergy
- clarithromycin

nb always consult trust guidelines

nb above are for typical organisms - atypicals use other things (check guidelines)

  • vancomycin

if hospital acquired, culture + treat organism

36
Q

Pneumonia:

  • non-Abx medication? 3
  • follow up required?
A
  • analgesia
  • fluids
  • oxygen (to keep up sats)
    ^all depend on severity

also physio to help cough

CXR in 6 weeks

37
Q

pneumonia:

- main resp DDx? 3

A
  • PE
  • pulmonary oedema
  • bronchial carcinoma
38
Q

PE:

  • commonest cause?
  • rare causes? 4
A

emboli from DVT in legs or pelvis

  • RV thrombus (post-MI)
  • septic emboli (R infective endocarditis)
  • fat, air or amniotic fluid emboli
  • neoplastic cells
39
Q

PE:

  • risk factors which increase hypercoaguability? 5
  • risk factors which increase stasis? 2
  • risk factors which damage blood vessels? 2
A

hypercoaguable

  • pregnancy (+ 6 wks postpartum)
  • COCP (HRT, but less so)
  • cancer
  • thrombophilia (e.g. antiphospholipid syndrome)
  • previous PE

stasis

  • prolonged bed rest/reduced mobility (incl air travel)
  • recent surgery (esp pelvic, hip or knee)

damaged blood vessels

  • obesity
  • over 60

also FH

40
Q

PE:

  • symptoms? 5
  • signs? 6
A

nb small emboli may be asymptomatic

  • acute breathlessness
  • pleuritic chest pain
  • haemoptysis
  • dizziness
  • syncope
  • tachypnoea
  • tachycardia (see on ECG)
  • hypotension
  • raised JVP
  • pleural rub
  • SIGNS OF DVT
41
Q

PE:

  • score used to work out likelihood of PE?
  • investigation if this is low?
  • investigation if this is high?
  • other investigations? (incl bloods) 3
A

WELLS score
- uses clinical signs as well as risk factors

low WELLS score
= do D-Dimer
- if negative, consider alternative diagnosis
- if positive, do CTPA (or empirical LMWH treatment if delay)

high WELLS score
= do CTPA or treat empirically with LMWH if delay

  • bloods, incl clotting
  • ECG (rule out ACS)
  • CXR (rule out other DDx)
42
Q

PE:

  • treatment if haemodynamically unstable?
  • treatment if haemodynamically stable?
  • investigations needed if unprovoked PE (i.e. no real risk factors)?
A

unstable
- thrombolyse (alteplase)

stable
- LMWH (unfractioned if renal probs) then introduce NOACs or warfarin (target INR = 2-3)

investigate for possible underlying malignancy

  • full Hx + exam
  • CXR, Ca2+, LFTs

if over 40, consider abdominal-pelvic CT + mammography for women

consider antiphospholipid + thrombophilia testing if FH positive

* year 3 core conditions (detailed) (12 decks)

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