Respiratory Flashcards
1
Q
How is the severity of pneumonia assessed?
A
CURB 65
2
Q
Other than a high CURB 65 (>2) what are signs of severe pneumonia?
A
1) Hypoxaemia
2) Lots of consolidation on CXR
3) Co-morbidities
4) Evidence of cavitation
3
Q
Remind me of CURB 65 criteria?
A
1) New confusion
2) Urea >7
3) RR >30
4) BP <90 or <60
4
Q
Management of CURB 0-2 ?
A
Community mainly
Amoxicillin 1g TDS PO for 5 days
(Doxy - 200mg loading dose then 100mg daily)
(Patients with CURB 1/ 2+ adverse prognostic factors may need hospital +/- IV)
5
Q
Management of patient with a CURB 65 of 3+ managed on ward 3?
A
Severe pneumonia
Co-amoxiclav 1.2g TDS IV
Doxycycline 100mg BD
(Penicillin allergy = 500mg BD)
6
Q
Management of patient with a CURB score of 1/2 who is penicillin allergic and needs IV therapy/
A
IV clarithromycin
(Doxycycline is not given IV)
IVOST to amoxicillin 1g TDS
7
Q
Management of a patient with CURB 4 in HDU?
A
Co-amoxiclav 1.2g TDS IV
Clarithromycin 500mg BD
7 days treatment
IVOST to doxycycline
8
Q
Management of a patient with CURB 65 of 4 who has a penicillin allergy?
A
Levofloxacin IV 500mg BD
Will need total 7 day treatment
IVOST to doxycycline
9
Q
What discharge advice should people with pneumonia be given?
A
1) Stop smoking
2) Follow up CXR at 6 week if smoker/ >50
10
Q
Adult with new diagnosed asthma. What regular therapy is first line?
A
1) SABA as required
2) ICS typically 400micrograms
11
Q
An asthmatic patient is on a SABA and 400 micrograms of ICS daily but is still symptomatic. Next step?
A
Add a LABA then assess control
Good = continue LABA
OK = continue LABA and increase ICS to 800mcg daily
No response = Stop LABA, increase ICS to 800mcg daily and consider trial e.g. LTRA or theophylline
12
Q
Asthmatic patient on SABA, 800mcg ICS and LABA. Control is still poor, next step?
A
Consider increasing steroid to 2000mcg daily
AND/OR add in a 4th agent e.g. LTRA or theophylline or oral B2 agonist such as terbutaline
13
Q
What is the final step in the asthma pathway?
A
Lowest dose of oral steroids to give good control
Refer to respiratory specialist
14
Q
What is a moderate asthma attack?
A
Worsening symptoms
PEFR 50-75% of predicted
15
Q
What is a severe asthma attack?
A
PEFR <50% of predicted
Inability to complete sentences
RR >25 or HR >110
16
Q
RR and HR that equate to a severe asthma attack
A
RR >25
HR >110
17
Q
Feature of a life threatening asthma attack?
A
PEFR <33% SP02 <92% PA02 <8 Silent chest Cyanosis Exhaustion Reduced conscious level Hypotnesion
18
Q
What defines a near fatal asthma attack?
A
Raised paCO2
Requiring ventilation!
19
Q
How many lobes do the lungs have?
A
Right = 3 Left = 2
20
Q
Name some accessory muscles of inspiration?
A
Scalene and SCM
21
Q
Which muscles are predominately involved in forced expiration?
A
Abdominal
22
Q
Tidal breathing is a balance between what 2 forces?
A
1) Chest wall - semi-rigid which wants to expand
2) Lung - which want to collapse inwards
E.g. Normal = stretching a neutral spring, Lung disease = stretching a spring already under tension
23
Q
What is lung compliance?
A
The change in lung volume brought about by a unit change in intra-pleural pressure e.g. the force needed to expand the lung
24
Q
At the lung bases perfusion exceeds ventilation
A
At the lung apices, ventilation exceeds perfusion
remember that vasoconstriction occurs in response to poor blood flow
25
What is the result of a fall in ventilation?
A rise in CO2 and a fall on O2
| E.g. type 2 respiratory failure
26
What is the result of a mismatch in V/Q?
Type 1 respiratory failure e.g hypoxia without hypercapnia
27
What are the main stimulants of ventilation?
Controlled by respiratory centre in the brain which is stimulated by pH and CO2 levels
Hypoxia is only a stimulant when PO2 <8kPA
28
What is the tidal volume?
Volume of air that enters and leaves lungs during normal breathing
29
What is the functional lung capacity?
Volume in lungs at end of normal expiration
30
What is the total lung capacity?
Volume in lungs after maximal inspiration
31
Residual volume
Volume in lungs after maximal expiration
32
What is vital capacity?
Volume of air moved in full inspiration and expiration
33
Describe an obstructive pattern?
FVC is reduced but FEV1 is reduced more therefore FEV1: FVC = <70%
34
Describe a restrictive pattern?
Both FVC and FEV1 are reduced proportionately therefore FEV1:FVC ratio is normal e.g. >70%
35
What does FEF 25-75 measure?
Flow during middle half of forced expiration e.g. in the medium sized airways
36
What causes a lung collapse?
Obstruction of bronchus due to:
1) Tumour
2) Foreign body
3) Mucus plug
37
R upper lobe collapse?
Golden s sign
Increased density in RUL
Clear horizontal fissur e
38
R middle lobe collapse?
Poor definition of R heart border
| Horizontal fissure difficult to see
39
R lower lobe collapse
Increased opacity (triangle) at medial base of R lung
R hilum depressed
R hemidiaphragm elevated
40
L upper lobe collapse?
Falls inferiorly
| Hazy over the hilum, becomes less hazy inferiorly.
41
L lower lobe collapse
Triangular opacity at psteromedial aspect of left lung
Double cardiac contour
‘Sail sign’
42
What does the blood film of someone with EBV show?
Atypical mononuclear cells
| (Also do monospot/ heterophile anti-body +ve
43
Features of sinusitis?
Facial pain
Nasal obstruction
Nasal discharge
Fever
44
What is ephedrine?
A nasal decongestant
| sympathomimetic drug
45
Organism in whooping cough?
Bordetella pertussis
46
How do you diagnose flu?
Clinical features e.g. systemically unwell, URTI etc
| Immunofluorescent microscopy of nasal secretions/ serology
47
What is oseltamivir?
A drug that reduces the replication of influenza A and B virus - it is used to reduce duration of flu symptoms
(only by about 1 day)
48
The flu vaccine is CI to patients with severe egg allergy
The flu vaccine is CI to patients with severe egg allergy
| remember that even if you get flu after having the vaccine it is likely to be less severe with fewer complications
49
What is a Ghon focus?
The primary lesion of TB
Usually sub-pleural in the mid to lower zones - often in children
(a dot of consolidation
50
What is the difference between primary and post-primary TB?
Primary = first infection in patient without TB immunity
Post-primary = pattern of disease seen after specific immunity (can occur from progression, reactivation or re-infection)
51
Cavitating apical lesions on CXR
TB is most likely
Ask about cough, sputum, haemoptysis, weight loss and sweats
Diagnosis is with sputum culture for acid and alcohol fast bacilli
Caseating granuloma is characteristic of TB
52
What is the current treatment regime for TB?
6 months of rifampacin and isoniazid
With pyrazinamide and ethambutol for the first 2 months
Dispensed daily or with directly observed therapy
53
Side effects of rifampacin?
Hepatitis - check LFT at start
Enzyme inducer - reduces effect of warfarin and the pill etc
Makes pee red (good for checking compliance)
54
Side effect of isoniazid?
Peripheral neuropathy (pyridoxine is given to high risk groups e.g. DM)
Hepatitis
55
Side effect of pyrazinamide?
Increase in uric acid —> gout
56
Side effect of ethambutol?
Optic neuritis
| Check visual acuity before treatment and stop if any visual problems
57
Summarise the pathogenesis of bronchiectasis
Impaired mucociliary clearance > infection > inflammatory response > tissue damage > bronchial damage and dilatation
58
What is Kartagners syndrome?
Ciliary dyskinesia with situs invertus (appendix in LIF)
59
Give some causes of bronchiectasis?
Severe Infection - measles, pertussis, pneumonia, TB
Obstruction - foreign body/ carcinoma
CF
Ciliary dysfunction
60
Features of bronchiectasis
Chronic cough with copious sputum production
| Possibly haemoptysis and frequent infection
61
What is the best investigation for diagnosing bronchiectasis?
CT
| Consider cause e.g. check immunoglobulin, ciliary function, TB etc
62
Which drug should be used to treat Pseudomonas infection?
Ciprofloxacin
(2 week course)
Pseudomonas infection is a bad prognostic indicator
63
Management of bronchiectasis
1) Chest physio
2) Use mucolytics such as nebulised saline (with bronchodilator)
3) Antibiotics (to treat infections)
4) surgery (excision of particular lesion or transplant)
64
How common is CF?
1 in 25 are carriers
| 1 in 2500 are affected
65
Why does CF cause abnormalities in the GI tract?
Abnormal ion transport causes the ducutules within the pancreas to become blocked —> enzymes not being able to pass —> malabsorption
There is increased risk of DM, gallstones and biliary cirrhosis
66
What is the main reason that kids with CF are not allowed to spend time together?
Risk of infection and transmission of Burholderia strains, especially Burholderia cenocepacia which can cause a rapid decline in lung function
67
If a diagnosis of meconium ileus is made, what is the most likely underlying cause?
CF
68
How is CF diagnosed?
Elevated Na in the sweat test (using pilocarpine)
| Then look for specific CF mutation on DNA analysis
69
Why are males with CF infertile?
Congenital absence of the vas deferns
70
The newborn screening test is used to test for CF. What are they testing for?
Increased immunoreactive trypsin activity
71
What are mucolytic medications?
Treatments which help aid mucus clearance
1) Dnase- cleaves DNA, give via nebuliser
2) Hypertonic saline - given with salbutamol
3) Mannitol - osmotic
72
What is the life expectancy for a patient with CF?
Median age of death is now 44 - this has improved hugely due to advances in all aspects of medicine
73
What is Ivacaftor?
```
A gene therapy drug used in the management of CF patients with a class 3 mutation
It increase the action of the CFTR channel and improves lung function and weight gain
```
74
Define asthma
Airway inflammation
Increased airway responsiveness
Reversibility
Variability
75
How are T cells linked to asthma?
Th2 cells produce pro-inflammatory cytokines
Th1 cells produce cytokines that down regulate the immune response
In asthma, Th2 cells are likely to predominate
76
Describe the pathology of asthma
```
Airway thickening and oedema
Increased smooth muscle mass
Thickened basement membrane
Remodelling of the airway
Mucus plugging (in acute, severe asthma)
```
77
What are the core symptoms of asthma?
Cough
Wheeze
SOB
Chest tightness
78
How does peak flow vary throughout the day?
Classically there is a ‘morning dip’
79
What are key features of the asthma history?
1) Symptoms - nocturnal wakening etc
2) Family History (and of atrophy)
3) Environmental history - smoking, pets
4) Work environment
5) Triggers
80
Spirometery diagnosis of asthma
1) Obstructive pattern (ratio <70%)
| 2) Reversibilty - give a bronchodilator drug and see if they improve
81
Total lung capacity is increased in asthma as a result of hyper-inflation
Residual volume is also increased as a result of gas trapping
82
Why is a normal CO2 worrying in an acute severe asthma attack?
```
Normally hypoxia will develop, associated with increased ventilation and a reduced CO2.
A normal (or rising) CO2 is a sign of a fatigued patient who is failing to maintain ventilation
```
83
What are the 2 types of stress test that can be used to diagnose asthma?
1) Exercise testing - does peak flow fall by >25% after exercise
2) Histamine challenge
84
Remember that SABAs are good for symptom control but they do NOTHING to address the underlying inflammation
Salbutamol and terbutaline have the side effects of tremor and palpitations at high doses
85
SABA have an onset of action within 15 minutes and are effective for 4-6 hours
LABAS have a slower onset of action but are effective for 12 hours
(normally green inhalers but combination inhalers are purple)
86
What is the mechanism of action of theophyllines?
Drugs such as aminophylline/ theophylline increase cAMP by inhibiting the metabolism of cAMP. Not used widely and are generally the ‘last resort’ for steroid sparing agents.
87
It’s really important when counselling patients to remind them that the blue inhaler will help with their symptoms
The brown inhaler will help reduce the inflammation and stop them getting symptoms
88
What is ‘resucue’ prednisolone?
A 7 day course of 30-40mg prednisolone PO which is given when asthma symptoms are increasing e.g. when PEFR <60% of expected
To be used infrequently
89
Who will benefit from treatment with Omalizumab?
Patients with severe allergic asthma
| It is a monoclonal antibody that binds to IgE
90
How do you use a pressurised metered dose inhaler?
1) remove cap and shake
2) Exhale
3) Place mouth on inhaler and fully inhale while pressing down on the canister
4) Hold breath for a few seconds
(remember that without a spacer, only about 10% of the drug reaches the lower airways
91
What should the nebuliser flow rate be set too?
6-8l/ min
92
Managment of acute severe asthma?
1) High flow O2
2) Salbutamol nebuliser - 5mg
3) Hydrocortisoe 100mg IV or prednsiolone 40-50mg PO
If poor response consider adding the following:
4) Nebulised ipratroprium bromide - add 0.5mg to the nebulised salbutamol
5) Magensium/ aminophylline = only if agreed by senior medical staff
93
Describe COPD
Chronic, slowly progressing airflow obstruction
94
Define chronic bronchitis?
Cough productive of sputum on most days for at least 3 months of 2 successive years
95
Chronic bronchitis is a hypersecretory disorder
Emphysema is dilation of the terminal air spaces of the lung with destruction of their walls
96
What are the 2 main sub-sets of emphysema?
Centriacinar - bronchioles are predominately damaged, upper lobes more affected
Panacinar - the whole acinus is affected equally, lower lobes destroyed more ( the type in alpha 1 anti-trypsin deficiency)
97
Describe ‘pink puffers and blue bloaters
Pink puffers = well preserved ventilators drive - intense SOB but CO2 level remains normal. Normally cachetic with barrel chest and predominantly emphysema
Blue bloaters = poor respiratory drive, easily fall into type 2 respiratory failure with hypoxaemia, hypercapnia and right sided heart failure. Normally obese, with oedema and predominately bronchitis
98
Extra-pulmonary features of COPD?
1) RVH (due to pulmonary vasoconstriction - right axis deviation, tall R wave in 1)
2) Loss of muscle mass + cachexia
3) Osteoporosis
4) Depression and anxiety
99
What is the medical research dyspnoea scale?
```
Grade 1 - SOBOE
Grade 2 = SOB on uphill walking
Grade 3 = SOB on flat
Grade 4 = SOB on walking 100m
Grade 5 = SOB on dressing/ undressing
```
100
CXR features of COPD?
1) Hyperinflation
2) Flattened diaphragm
3) Narrow cardiac shadow
101
How many ribs should be present on a well inspired CXR?
Anterior (diagonal) = 5-7
| Posterior = 8-10
102
What is the only treatment that is disease modifying in COPD?
Smoking cessation
| Everything else is just symptom relief
103
What is the best way to stop smoking?
Nicotine replacement therapy (doubles chance of success)
Usually a transdermal patch e.g. 21mg patch daily for 4 weeks, reducing to 14mg then 7mg as cravings reduce
Nicotine gum etc can be used to relieve immediate cravings
104
Bupropion is an anti-depressant used to aid smoking cessation. What is the major side effect?
Seizures (1 in 1000) therefore it is CI in patients with epilepsy or CNS problems
105
What is ipratropium?
A short acting anti-cholingeric drug e.g. blocks the parasympathetic system and causes vasodilatation
106
What is tiotropium?
A long acting muscarinic antagonist
107
What is seratide?
A combination inhaler of fluticasone and salmeterol (ICS and LABA)
108
Treatment for SOB associated with mild COPD
SABA or SAMA (ipratropium)
109
Treatment for patient with COPD who is breathless on a SABA. FEV1 is 59%
As FEV1 >50% = LABA or LAMA
If you give a LAMA it is important to stop the SAMA
110
Treatment for patient with COPD who is breathless on a SABA. FEV1 is 40%
FEV1 <50% —>
Combination inhaler of LABA + ICS e.g. seretide
OR
LAMA
111
Treatment for patient with COPD who is breathless on 2 agent e.g, SABA + LAMA
LAMA + ICS + LABA
| This is the maximum treatment - a SABA can be used at any stage
112
All COPD patients should be aware of and offered pulmonary rehab
It improves SOB, QoL and reduces hospital admission
113
What is cor-pulmonale?
R heart failure secondary to lung disease
Pulmonary hypoxia leads to pulmonary vessel vasoconstriction which increases vascular resistance and puts the heart under strain. The heart tries to overcome this (hypertrophy) but will eventually fail.
114
What are the features of cor pulmonale?
Ankle oedema (first sign)
Raised JVP
Ascites
Fatigue
115
What are the indications for long term oxygen therapy? E.g. home therapy
Severe COPD (FEV1 <1.5L) and persistent hypoxia (po2 <7.3kPa)
To be beneficial they have to be receiving oxygen for 15 hours a day, usually through nasal cannula
Helps by preventing pulmonary vasoconstriction leading to cor pulmonalae NOT by reducing SOB
Cannot smoke around the o2 due to fire risk
116
What are normal blood gas results?
pH - 7.35-7.45
PaO2 = >10.6 kPa
PaCO2 = 4.7-6kPa
117
What investigations should a patient admitted to AMU with an exacerbation of COPD have?
1) FBC, UE, LFT
2) ABG
3) CXR
3) ECG
5) Pulse oximetry
118
Why can sats of 94-98% be dangerous for patients with COPD and type 2 respiratory failure?
1) They are used to hypercapnia so this no longer triggers their breathing centre
2) They rely on hypoxia to stimulate ventilation
3) High oxygen levels will prevent adequate ventilation so they will not blow off CO2 —>hypercapnia, acidosis, respiratory depression and death
119
What o2 therapy should be given in a patient with an acute exacerbation of COPD?
Aim for 88-92% with 24% Venturi mask
This is the ‘goldilocks zone’ - the patient will not die from hypoxia or hypercapnia
120
When should non-invasive ventilation be used in an acute exacerbation of COPD?
If after initial management the pH is < 7.35
121
15% of lung cancer is small cell (arising from neuroendocrine cells)
85% of lung cancer is non-small cell (most commonly squamous)
122
Which type of lung cancer is least likely to be caused by smoking?
Adenocarcinoma
| most likely to cause a peripheral lesion
123
Which type of lung cancer is associated with SIADH?
Small cell
| Low serum osmolality (low Na, K and urea) and high urine osmolality (>500)
124
Which type of lung cancer releases parathyroid hormone related protein that causes hypercalcaemia?
Squamous
125
Imaging for suspected lung cancer?
```
CXR
CT scan
Bronchoscopy +/- biopsy
PET scan - good for differentiating malignant and benign tumours
Percutaneous needle biopsy
```
126
Best treatment for lung cancer?
1) Small cell -> chemotherapy
2) Non small cell -> surgical resection (if not metastasised and fit for surgery which is only about 20%)
3) Radiotherapy is primarily used for symptom relief e.g. SVCO or chest wall pain
127
What is the WHO performance status?
Assessment of fitness, can be used to assess suitability of surgery
0 = fully active
1 = restricted on strenuous activity
2 = mobile for >50% of day, sell care OK but can’t work
3 = in bed >50% of day, cannot self care
4 = bed bond
128
Young man presents with haemoptysis and wheeze. At bronchoscopy a small, rounded tumour which appears ‘like a cherry’ is seen. Diagnosis?
Carcinoid tumour of the lungs
129
Facial swelling and distended neck veins?
Exclude SVCO, usually caused by lung cancer
| Do urgent CT, treat with dexamethasone
130
Interstitial lung disease describes a range of diseases that result in fibrosis and inflammation of the alveoli. What do people present with?
SOB
Dry cough
Crackles
Hypoxia with hypocapnia
131
What risk factors must be asked about when you suspect interstitial lung disease?
1) Allergens
2) Toxins
3) Occupational e.g. asbestos
4) Drugs e.g. methotrexate, sulfasalazine, azathioprine
132
CT shows fibrosis with honey combing and ground glass opacities. Diagnosis?
Idiopathic pulmonary fibrosis
| (restrictive pattern with clubbing and reduced lung volumes
133
What is Caplan’s syndrome?
RA in association with coal workers pneumoconiosis
134
What is hypersensitivity pneumoitis?
Immune mediated lung disease in which hypersensitivity occurs to an inhaled antigen
E.g. hay, birds, metal-working
135
Features of acute hypersensitivity pneumonitis?
Cough, dyspnoea and pyrexia and flu-like sensation about 4-8 hours after exposure to antigen e.g. pigeon
The chronic form is characterised by progressive dyspnoea and fibrosis (lymphocytic alveolitis)
136
Management of hypersensitivity pneumonitis?
1) Avoid allergen
| 2) Steroids to relieve acute attack
137
Features of sarcoidosis?
```
Acute = BHL, uveitis, erythema nodosum, BHL, arthritis
Chronic = progressive fibrosis, ocular disease and other complications including bone, skin and CNS
```
138
Which workers are at risk of berylliosis?
1) Aviation industry
2) nuclear weapons manufacturing
3) fluorescent lightbulbs
139
Difference between simple and complicated coal workers pneumoconiosis?
```
Simple = small accumulations within the lungs of coal particles, usually asymptomatic
Complicated = large black, fibrotic nodules typically in the upper lobes which often cavitate and are associated with dyspnoea, restrictive lung defect and impaired gas exchange. Consider if black sputum
```
140
CXR shows eggshell calcification of Hilary lives with pleural thickening...
Silicosis is the most likely diagnosis
| Increases risk of COPD and TB
141
Asbestosis is more prominent around the lung bases
The time lag is between 30-40 years
Asbestos bodies are usually present
There is a greatly increased risk of developing lung cancer
142
Holly leaf pattern on CXR
Pleural plaques
| The result of asbestos exposure - do not cause any lung symptoms
143
What is the main risk factor for mesothelioma, a malignant tumour of the pleura?
Prolonged exposure to blue asbestos, 20 -40 year time lag
Features chest pain, SOB, weight loss and features of pleural effusion
Diagnose with CT scan and pleural biopsy
144
What does a positive Homan’s sign mean?
Pain on ankle dorsiflexion is suggestive of a DVT
145
What are the 3 cardinal features of a PE?
Pleuritic pain
Tachypnoea (>20)
SOB
146
What do ABGs usually show in a PE?
Due to reduced perfusion and ventilation there will be hypoxia and hypocapnia
147
What is the significance in a D-dimer test in suspected PE?
A normal level can exclude a PE, a raised level is not diagnostic
148
Management of confirmed PE?
1) LMWH e.g. dalteparin (fragmin) 200 units/kg
2) Oral anticoagulant e.g. rivaroxaban 15mg BD for 21 days or warfarin
Combined treatment is required for at least 5 days
149
How long is treatment with an oral anti-coagulant continued after a PE?
3-6 months (6 months if active cancer)
150
Give an example of a drug that increases and decreases the effect of warfarin
1) Increase —> bleed more —> NSAIDs, alcohol, ciprofloxacin
| 2) Descrease —> clot more —> carbamazepine and rifampacin
151
Define pulmonary hypertension?
The mean pulmonary arterial pressure is >25mmHg at rest
| usually secondary to lung disease or may be idiopathic
152
Features of pulmonary hypertension
```
Ankle oedema
Ascites
Raised JVP
Hepatomegaly
Tricuspid regurgitation (pansystolic)
```
153
Asthma and eosinophilia vasculitis
Churg Strauss
154
Glomerulonephritis + alveolar haemorrhage....
Goodpastures syndrome
| confirm with anti-glomerular basement membrane
155
What is a ‘small’ and ‘large’ pneumothorax?
```
Small = rim of air <2cm
Large = rim of air >2cm
```
156
Management of 3cm primary pneumothorax that is not causing respiratory distress?
Use local anaesthetic e.g. 10ml of 1% lignocaine
Aspirate using a 16G cannula in the 2nd intercostal space, MCL
Connect to a 3 way tap and aspirate air
157
Where is the safe triangle for insertion of chest drain?
4th ICS MAL
| Borders = lateral edge of pec major, lateral edge of latissmus dorsi and axilla
158
Features of pleural effusion?
Dsypnoea
Stony dullness
Reduced expansion
159
Aspiration of pleural fluid shows a milky liquid. Most likely diagnosis?
Chylothorax
| lymphatic fluid e.g. due to lymphoma or trauma to thoracic duct
160
Transudates have low protein content (<30g/L) and low LDH. Possible diagnosis?
```
All the failures
HF
Renal failure
Liver cirrhosis
Ascites
```
161
Exudate have a high protein content (>30g/L) and a high LDH. Likely diagnosis?
Malignancy - mets, mesothelioma (predominantly lymphocytes on cytology)
Infection - TB, empyema (predominantly neutrophils on cytology)
Inflammation - SLE, RA etc
162
Most likely diagnosis in a male who has been vomiting and develops sudden onset pleuritic chest pain and SOB. Several hours later he notices air under his skin.....
Boerhaave’s syndrome
| oesophageal rupture
163
What is bupropion?
A norephinephrine and dopamine reuptake inhibitor and nicotinic antagonist
Used in smoking cessation - small risk of seizure
164
Which antibody is associated with Churg Strauss?
pANCA
Allergy -> nasal polyps -> eosinophilia-> vasculitis e.g. skin and kidney damage
Wegners is cANCA +ve
165
Talk though the AMTS? Abbreviated mental test score. A score of 6 or less suggests dementia/ delirium
1) DOB
2) Recognise doctor and nurse
3) Repeat and address
4) Time to neared hour
5) Count from 20-1
6) Prime minister
7) Date of WWI
8) Where are you?
9) Year
10) Age
166
Raised purple plaque of indurated skin on nose in a rheumatology patient.
Most likely lupus pernicious - the cutaneous manisfestation of sarcoidosis
167
Patient with right testicle hanging lower than left
Kartagners syndrome = due to situs inversus
| Often dextrocardia too
168
What is the TLCO?
Total gas transfer
Measure of gas transfer - reflects how much O2 is taken up by red cells
Reduced in kyphosis as chest restriction reduces ventilation
169
What is KCO?
TLCO divided by alveolar volume e.g. how efficient gas exchange is in relation to volume
This is increased in kyphosis
170
Causes of raised and lowered TLCO
Raised = asthma and pulmonary haemorrhage
| Low - fibrosis, pneumonia, pe, emphysema etc
171
What is Lofrgren’s syndrome?
Acute form of sarcoidosis
| Recovery is typically complete with a low risk of recurrence
172
Define ARDS?
Bilateral pulmonary infiltrates + severe hypoxaemia usually seeen with acute dyspnoea + multi-organ failure
Loads of causes e.g, sepsis, pancreatitis, trauma etc
173
What is the commonest cause of an infective exacerbation of COPD?
Haemophilus influenzae
174
Spirometery result in COPD
FEV1 - very reduced
FVC - normal/ reduced
FEV1 % - RECUED
175
Opacity with rim of air in lungs?
Aspergillosis
176
Old lady presents with dyspnoea, haemoptysis, new AF and a diastolic murmur?
Mitral stenosis
| The murmur is mid-diastolic and is usually caused by rheumatic fever
177
Causes of upper zone fibrosis?
CHARTS
```
Coal workers pneumoconiosis
Hypersensitivty pneumonitis
Ank spon
Radiation
TB
Silicosis/ sarcoid
```
178
Cavitating, upper lobe pneumonia
Klebsiella, associated with diabetic and alcoholic patients
179
What is the typical blood gas pattern on someone with opiate overdose?
Respiratory acidosis due to hypoventilation
180
What blood results would you expect in a patient with Klinefelters
Low/ normal testosterone with high LH/ FSH
Affects 1 in 660 men, 47 XXY
Testosterone replacement is useful
181
Which condition would you find epitheliod histiocytes in?
These are macrophages which have become elongated to look like epithelial cells
They are a common finding in granulomas e.g. those found in TB
182
How do you know if an NG tube has been positioned correctly?
1) It must pass vertically inn the midline and below the level of the carina
2) Must not follow the course of the R/L bronchus
3) Must pass through the gastro-oesophageal junction
4) Tip of the tube must be visible below the diaphragm, on the left side of abdomen and >10cm beyond GO junction
183
What is the investigation of choice in idiopathic pulmonary fibrosis?
CT scan
| ‘Ground glass appearance —> honey combing’
184
How does military TB spread in the lungs?
Through the pulmonary venous system
185
Where is the ‘safe triangle’ for chest drain insertion?
5th intercostal space, MAL
186
What is the differential for post op dyspnoea?
Atelectasis - basal alveolar collapse due to airways becoming blocked by respiratory secretions
Pneumonia
PE
187
Children <2 with bilateral otitis media or children with otitis media and otorrhoea need antibiotics
Antibiotics are not indicated for acute sinusitis
188
Asthma + eosinophilia + mononeuritis multiplex?
Churn-Strauss Vasculitis
| pANCA +ve
189
Acute asthma - on salbutamol and ipratropium nebuliser and oral prednisolone. What treatment should you include if life-threatening?
Magnesium sulphate 2g
190
Typical blood gas in patient with acute asthma
Initially respiratory alkalosis as blowing off too much CO2
Progresses to respiratory acidosis - type 2 respiratory failure
191
ECG changes of COPD
Peaked p waves
RVH
Right axis deviation
192
Remember after SABA/ SAMA in COPD you give a LABA or LAMA if FEV1 >50% and a LABA + ICS or LAMA if <50%
Step 3 = LABA + ICS (ipratropium) + LAMA (tiotropium)
193
Which drug should be given if patient not responding to nebulisers in COPD exacerbation?
Aminophylline
194
What ABG pattern will be seen in ILD?
Type 1 failure
| Hypoxia without hypercapnia
195
Lady with COPD who has a 2cm pneumothorax. Managment?
If asymptomatic -> aspiration —> chest drain
If asymptomatic —> chest drain
196
Diagnosis and treatment of an atypical pneumonia. The patient also has erythema multiforme?
Mycoplasma pneumonia
Often complicated by haemolytic anaemia + skin complaints such as erythema nodosum or erythema multiforme
Treat with a macrolide e.g. clarithromycin or azithromycin
197
Commonest pneumonia after influenza A
Staph aureus
198
How do you treat PCP?
Co-trimoxazole
199
What paraneoplastic syndromes are associated with Small cell lung cancer?
Cushing’s
Lambert Eatons
SIADH
200
What paraneoplastic syndrome is associated with squamous cell carcinoma?
Release of PTH —> hypercalcaemia
201
Investigation of PE in pregnancy?
Perfusion only V/Q
202
Provoked PE = 3 months of rivaroxaban
Unprovoked = 6 month of rivaroxaban
| LMWH for 6 months if active cancer
203
For BP >140/90 but stage 1 HT you normally give lifestyle advice. Who needs treatment?
End organ damage
CVS/ DM/ renal disease
10 year CVS risk >10%
204
First line for <55/ black = ACEI
First line for >55 = CCB
Second line is add in the other
What is third line?
Add in a diuretic such as indapamide
4th stage depends on K
If < 4.5 = spironolactone
If >4.5 - thiazide
205
Fibrinoid necrosis
Malignant hypertension
If seizure/ severe —> IV labetolol
206
Don’t forget LMNOP for the management of heart failure
```
Loop diuretic
Morphine
Nitrate
O2
Postural - sit up
```
207
After bloods and ECG, what is the key investigation for diagnosing HF?
ECHO
208
Tachycardia with regular broad complex QRS
Amiodarone (K channel blocker)
209
Tachycardia with narrow QRS
Probably SVT
Vagal manoeuvres —>
Adenosine (6mg>12mg>12mg)
210
How to treat bradycardia if risk of/ features of asystole?
Atropine 500 micrograms
E.g. shock, syncope, mobitz 11 etc
211
Rate control of AF is with beta blocker or diltiazem
When would you do rhythm control?
First onset AF
HF
Reversible cause
212
What do you get a point for on CHA2DS2VS?
- Female
- >74 (2)
- 65-74 = 1
- DM
- BP > 140/90
- Previous stroke/ TIA =2
- Heart failure
- Vascular disease
213
FEV1: FVC <0.7 = obstructive e.g. asthma
FEV1: FVC >0.8 = obstructive
214
What are the 4 causes of hypoxaemia?
Hypoventilation
V/Q mismatch
Shunting
Reduced inspired partial pressure of O2
215
Always remember when thinking about respiratory failure that there are loads of possible causes e.g.
```
Airway —> asthma, COPD
Alveoli —> pneumonia
Nervous —> stroke, overdose
Musculature —> MG, GMB
Vasculature —> PE, shunt
```
216
Remember asthma is severe if RR >25, pulse >110, PEFR 33-50% predicted or unable to complete sentences
An ABG should be performed ONLY if sats <92%
Life threatening = PEFR <33%, silent chest, bradycardia, hypotension, confusion etc
217
What vaccinations should new COPD patient be given?
One off pneumococcal
| Annual influenza
218
Which COPD patients may benefit from long term oxygen therapy?
Pa02 <7.3 kPa
OR
PaO2 between 7.3 and 8 if other feature such as secondary polycythameia, peripheral oedema and pulmonary HT
Need to use at least 15 hours per day —> ALWAYS check if still smoking
219
Don’t forget to do extra tests in an atypical or severe pneumonia (CURB >3)e.g.
Legionella urinary antigen
Blood and sputum culture
Throat swab for culture
220
What antibiotic would you give a patient with CURB of 2 and pencilling allergy?
Oral doxycycline OR
IV clarithromycin
Remember that you cannot give IV doxycycline
221
For CURB 0-2 total treatment duration = 5 days
For CURB 3 or more total treatment duration = 7 days
222
Key investigation for suspected pulmonary TB
Sputum microscopy and culture for acid fast bacilli
223
Treatment regime for TB?
2 RIPE 4 IR
```
2 months of:
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
```
Then four months of Rifampicin and isoniazid
224
Why is pyridoxine given in patient with TB?
To prevent the peripheral neuropathy of isoniazid
225
What is a pulmonary bleb?
A thin walled air containing space which can rupture to cause a spontaneous pneumothorax
226
Give 5 causes of lung fibrosis?
1) Occupation e.g. extrinsic allergic alveolitis
2) Previous radiotherpy
3) Drugs e.g. amiodarone and methotrexate
4) Connective tissue disease e.g. RA, SLE
5) Systemic e.g. Wegner’s/ Churg Strauss
227
What are the 2 major complications of bronchiectasis?
1) Massive haemoptysis
| 2) Cerebral abscesses
228
Management of confirmed DVT/PE
Give LMWH for at least 5 days
Warfarin is also started LMWH cannot be stopped until INR is > 2 for 24 hours
229
Give an example of a lung condition causing increased compliance
Emphysema
| Destruction means that lungs are stretchy —> easy to get air in but difficult to get air out —> hyperinflation
230
Give an example of a lung condition with decreased lung compliance?
Fibrosis
| The lungs are scarred and stiff therefore it is difficult to get air in
