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phase 2a clinical > respiratory > Flashcards

respiratory Flashcards

1
Q

chronic obstructive pulmonary disease

A

progressive airway obstruction with little or no reversibility
FEV1 <80%
FEV1/FVC <70%

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2
Q

COPD: chronic bronchitis

A

epithelial cell layer may ulcerate
when these heal, squamous epithelium may replace columnar
results in chronic cough and phlegm production
‘blue bloaters’

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3
Q

COPD: airway narrowing causes (in chronic bronchitis)

A

bronchial wall inflammation due to irritants- causes scarring
hypertrophy and hyperplasia of mucus secreting glands of bronchial tree- luminal occlusion
mucosal oedema

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4
Q

COPD: chronic bronchitis characteristics

A

submucosal bronchial gland enlargement
goblet cell metaplasia and mucus hypersecretion
airway oedema
inflamed bronchial tree
smooth muscle and connective tissue hypertrophy
airway epithelial squamous metaplasia
ciliary dysfunction

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5
Q

COPD: emphysema

A

dilation and destruction of lung tissue distal to terminal bronchioles
loss of elastic recoil- leads to airflow limitation and air trapping
‘pink puffers’

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6
Q

COPD: emphysema classification

A

centri-acinar emphysema
pan-acinar emphysema
irregular emphysema

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7
Q

COPD: centri-acinar emphysema

A

most common
upper lobe
more concentrated around resp bronchioles, more distal alveolar ducts and alveoli tend to be preserved

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8
Q

COPD: pan-acinar emphysema

A

lower lobe
emphysema affects whole acinus
associated with alpha-1-antitrypsin

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9
Q

COPD: small airway involvement

A

<2mm
involved early in COPD- obstructive bronchiolitis
major site of airway obstruction

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10
Q

COPD: pulmonary vascular changes

A

intimal thickening and endothelial destruction
collagen deposition and breakdown of collagen bed architecture
causes pulmonary hypertension and hypoxia

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11
Q

COPD: pink puffers

A

high alveolar ventilation (compensatory)
near normal PaO2 and normal or low PaCO2
breathless but not cyanosed
can progress to type 1 resp failure

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12
Q

COPD: blue bloaters

A

low alveolar ventilation, low PaO2 and high PaCO2
cyanosed but not breathless
can develop cor pulmonale

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13
Q

COPD: epidemiology

A

10-20% >40 y/o

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14
Q

COPD: causes

A 
cigarette smoke
alpha-1-antitrypsin
cystic fibrosis
industrial irritants
resp infections- cause exacerbations
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15
Q

COPD: smoking

A

> 90%
cause mucus gland hypertrophy and inflammation
inactivates major protease inhibitor alpha-1-antitrypsin

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16
Q

COPD: alpha 1 antitrypsin deficiency

A

cause of early-onset emphysema
tend to have liver disease
low acinar of lungs affected

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17
Q

COPD: risk factors

A 
smoking
pollution
occupational exposures
family history 
increasing age
poor lung development during gestation
severe childhood resp infection
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18
Q

COPD: symptoms

A 
cough
sputum
dyspnoea 
wheeze
lethargy
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19
Q

COPD: signs

A 
tachypnoea
use of accessory muscles of respiration
hyperinflation- barrel shaped chest
wheeze
cyanosis
ankle swelling- if causes heart failure
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20
Q

COPD: complications

A 
acute exacerbations
polycythaemia
resp failure
cor pulmonale- oedema, raised JVP
pneumothorax 
lung carcinoma
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21
Q

COPD investigations: spirometry

A

gold standard
obstruction and air trapping
FEV1 <80%
FEV1/FVC <70%

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22
Q

COPD investigations: CXR

A

hyperinflation
flat hemidiaphragms
large central pulmonary arteries

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23
Q

COPD investigations: FBC

A

increased PCV/haematocrit

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24
Q

COPD investigations: CT

A

bronchial wall thickening
scarring
air space enlargement

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25
Q

COPD investigations: ECG

A

right atrial and ventricular enlargement

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26
Q

COPD investigations: ABG

A

PaO2 high and normal PaCO2 in pink puffer

PaCO2 high and PaO2 low in blue bloater

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27
Q

COPD: lifestyle management

A 
information and support
smoking cessation
exercise
diet advice 
flu vaccination
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28
Q

COPD: stage 1 treatment

A

shot acting bronchodilator when needed (SABA= salbutamol) (SAMA= ipratropium bromide)

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29
Q

COPD: stage 2 treatment

A

regular LABA (salmeterol) or LAMA (tiotropium)
or LABA +LAMA
add pulmonary rehabilitation

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30
Q

COPD: stage 3 treatment

A

LABA+LAMA+ICS (budesonid or beclometasone)

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31
Q

COPD: stage 4 treatment

A

LABA+LAMA+ICS
add long term oxygen if in resp failure
consider surgery

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32
Q

COPD: treatment pathway

A

nebulised bronchodilators such as salbutamol
oxygen therapy if sats <88%- aim for 88-92
steroids- IV hydrocortisone or oral prednisolone
antibiotics if sign of infection

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33
Q

COPD: treatment for acute exacerbations

A

mild- short acting bronchodilators
moderate- SABA and antibiotics, maybe oral steroids
severe- hospitalisation

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34
Q

COPD: signs of life threatening resp failure

A 
resp rate >30/min
use accessory muscles
acute changes in mental status
persisting hypoxaemia
hypercapnia
acidosis
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35
Q

COPD: differentials

A 
congestive heart failure
bronchiectasis
allergic fibrosing alveolitis pneumoconiosis 
asbestosis
asthma
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36
Q

asthma

A

reversible chronic obstructive airway disease

hypersensitivity type 1 reaction

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37
Q

characteristics of asthma

A

airflow limitation
airway hyper-responsiveness
bronchial inflammation

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38
Q

non allergic asthma

A

intrinsic
exercise, cold air and stress
obesity associated

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39
Q

allergic asthma

A

atopic/eosinophilic
extrinsic
allergens

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40
Q

asthma: three characteristics that contribute to airway narrowing

A

bronchial muscle contraction
mucosal swelling/inflammation- mast cell and basophil degranulation
increased mucus production

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41
Q

asthma: immediate pathogenesis, IgE mediated type 1 hypersensitivity

A
  • APC phagocytoses allergen and presents on surface as antigen
  • T-helper binds to antigen and releases cytokines which cause B cells to become plasma cells
  • Plasma cells release IgE which binds to mast cells
  • next time allergen enters body it binds to IgE on mast cell which causes it to degranulate
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42
Q

asthma: immediate pathogenesis, mast cell degranulation

A

histamine
tryptase
prostaglandin 2
cytokines- TNF-alpha, IL-2/4/5_

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43
Q

asthma: immediate pathogenesis, histamine and cytokines release

A

cause:
bronchoconstriction
mucus production
inflammation

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44
Q

asthma: long term pathogenesis

A

airway remodelling:

  • repeated airway constriction causes smooth muscle hyperplasia and hypertrophy
  • increased goblet cells caused by mucus gland hyperplasia
  • thickening of basement membrane
  • reduced retractile forces
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45
Q

asthma: epidemiology

A

5-8% of population
1/11 children
common start is 3-5 y/o

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46
Q

asthma: allergic, genetic causes

A

atopy triad- asthma, hayfever, eczema

atopy= predisposition toward developing certain allergic hypersensitivity reactions

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47
Q

asthma: allergic, environmental stimuli

A

hygiene hypotheses= growing up in clean environment may predispose towards IgE response
maternal smoking
childhood exposure to allergens

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48
Q

asthma: non-allergic causes

A

stress
cold air
infection

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49
Q

asthma: precipitating factors

A 
inflammatory factors
irritants
smoking/passive smoking
drugs- NSAIDs, beta-blockers, ACE-i
pollution
obesity
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50
Q

asthma: inflammatory factors

A

infection

allergens- house dust mite, pollen, fur

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51
Q

asthma: irritants

A

cold air
exercise
emotion
stress

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52
Q

asthma: symptoms

A 
intermittent dyspnoea 
wheeze
cough
sputum
chest tightness
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53
Q

asthma: signs

A 
tachypnoea
audible wheeze
hyperinflated chest
hyper-resonant percussion
decreased air entry
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54
Q

asthma: severe attack

A

inability to complete sentences
pulse >110bpm
resp rate >25/min
PEF 33-50% predicted

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55
Q

asthma: life-threatening attack

A 
silent chest
confusion
exhaustion
cyanosis
bradycardia
PEF <33% predicted
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56
Q

asthma: presentation pattern

A

diurnal variation
worse in morning
night time cough

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57
Q

asthma treatment: lifestyle

A

stop smoking
avoid allergens
education on good inhaler technique and PEF monitoring

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58
Q

asthma treatment: step 1

A

occasional SABA for symptom relief e.g salbutamol

if used more than one daily then step 2

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59
Q

asthma treatment: step 2

A

SABA and inhaled corticosteroids e.g beclometasone

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60
Q

asthma treatment: step 3

A

SABA +ICS + LABA e.g. salmeterol

if still uncontrolled increase ICS dose

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61
Q

asthma treatment: step 4

A

high corticosteroids

consider leukotriene receptor agonist/ modified release theophylline/LAMA

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62
Q

asthma treatment: step 5

A

step 4 + daily oral corticosteroid e.g. prednisolone

refer to asthma clinic

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63
Q

asthma treatment: beta- 2-agonists

A

selective to lungs

relax bronchial smooth muscle by increase cAMP- causes bronchodilation

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64
Q

asthma treatment: short acting beta agonist

A

4 hours
salbuatomol
can cause tachyarrhythmias

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65
Q

asthma treatment: long acting beta agonist

A

12 hours
salmeterol
lipophilic so remain in tissue longer
same S/E as SABA

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66
Q

asthma treatment: corticosteroids

A

decreased mucosal inflammation

rinse mouth after inhaled to prevent oral candidiasis

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67
Q

asthma treatment: theophylline

A

inhibits phosphodiesterase, decreasing bronchoconstriction by increasing cAMP levels

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68
Q

asthma treatment: anticholinergics

A

decrease muscle spasm

e.g. ipratropium (short term) or tiotropium (long term)

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69
Q

asthma treatment: leukotriene receptor antagonist

A

block effects of cysteinyl leukotrienes in airways

e.g. montelukast

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70
Q

asthma: treatment summary

A

SABA
SABA+ICS
SABA+ICS+LABA
SABA+LABA+high dose ICS+biological therapy
SABA+LABA+ HD ICS+ BT+ oral corticosteroid

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71
Q

asthma: ABCDE O SHIT ME- acute management

A 
ABCDE checks
Oxygen- maintain sats 94-98%
Salbutamol nebulised 
Hydrocortisone IV
Ipratropium bromide- 4 to 6 hourly
Theophylline- usually in ICU
Magnesium sulphate- one off dose if life threatening, before doing theophylline 
Escalate care- intubation and ventilation
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72
Q

asthma: associated diseases

A

acid reflux 40-60%
polyarthritis nodosa
churg-strauss syndrome
allergic bronchopulmonary aspergillosis

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73
Q

asthma: differentials

A 
pulmonary oedema
COPD
large airway obstruction
pneumothorax
PE
bronchiectasis
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74
Q

asthma: distinguishing from COPD

A

COPD later disease- mainly in smokers
less day to day variation
winter symptoms and sputum production on COPD
overlap can occur

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75
Q

asthma investigations: RCP3 questions

A

daytime symptoms
effect on daily life
difficulty sleeping from cough

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76
Q

asthma investigations: initial diagnosis

A

spirometry, FEV1/FVC <70%
reversibility to distinguish from COPD
peak flow diary

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77
Q

asthma investigations: acute attack

A 
PEF
sputum culture
FBC, U&amp;E, CRP, cultures
ABG
CXR
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78
Q

chronic asthma investigations

A 
PEF monitoring
spirometry
CXR
skin prick tests to identify allergens
histamine challenge
aspergillus serology
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79
Q

bronchial carcinoma: small cell

A

20%, worse prognosis
arise from endocrine cells in central bronchus
often secrete polypeptide hormones in paraneoplastic syndrome
70% are disseminated at presentation

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80
Q

bronchial carcinoma: non small cell

A 
80%
squamous cell carcinoma 35%
adenocarcinoma 27%
large cell carcinoma 10%
adenocarcinoma in situ- rare, <1%
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81
Q

bronchial carcinoma: non small cell- squamous cell

A

most strongly associated lung cancer with smoking

arise from epithelial cells

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82
Q

bronchial carcinoma: non small cell- adenocarcinoma

A

most common type
most common for non-smokers
arise from mucus-secreting glandular cells

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83
Q

bronchial carcinoma: sites of metastatic spread

A 
liver
bone
adrenal glands
brain
pleura and ribs
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84
Q

bronchial carcinoma: epidemiology

A

second most common cancer in UK
third most common cause of death in UK
more common in men

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85
Q

bronchial carcinoma: cigarette smoke

A

causes 90% of lung carcinomas

passive smoking also causes carcinomas

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86
Q

bronchial carcinoma: occupational risk factors

A 
asbestos
chromium 
arsenic
iron oxides
coal, nickel, petroleum
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87
Q

bronchial carcinoma: environmental risk factors

A

ionising radiation

radon gas

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88
Q

bronchial carcinoma: host risk factors

A

cystic fibrosis

HIV infection

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89
Q

bronchial carcinoma: symptoms

A 
haemoptysis- red flag
cough
dyspnoea
chest pain
weight loss
lethargy
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90
Q

bronchial carcinoma: signs

A

cachexia- weakness/wasting of the body
anaemia
clubbing
supraclavicular or axillary lymph nodes

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91
Q

bronchial carcinoma: chest signs

A

may be none
consolidation
collapse
pleural effusion

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92
Q

bronchial carcinoma: metastatic signs

A

bone tenderness

hepatomegaly

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93
Q

bronchial carcinoma: non metastatic skeletal manifestations

A

clubbing

hypertrophic osteoarthropathy

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94
Q

bronchial carcinoma: non metastatic cutaneous manifestations

A

dermatomyositis
herpes zoster
acanthosis nigricans

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95
Q

bronchial carcinoma: non metastatic vascular manifestations

A

thrombophlebitis migrans
anaemia
disseminated intravascular coagulation

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96
Q

bronchial carcinoma: non metastatic neurological manifestations

A

cerebellar degeneration
myopathy
polyneuropathy

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97
Q

bronchial carcinoma: non metastatic endocrine manifestations

A

ectopic secretion:
ACTH-cushing’s
ADH- dilutional hyponatraemia
TH- hypercalcaemia

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98
Q

bronchial carcinoma: local complications

A 
recurrent laryngeal nerve palsy
phrenic nerve palsy
SVC obstruction
Rib erosion
pericarditis
AF
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99
Q

bronchial carcinoma: metastatic complications

A

brain
bone- anaemia, hypercalcaemia
liver
adrenals- addison’s

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100
Q

bronchial carcinoma: non-metastatic neurological complications

A 
confusion
fits
cerebellar syndrom
proximal myopathy
polymyositis
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101
Q

bronchial carcinoma: chest x ray

A 
peripheral nodule
hilar enlargement
consolidation
lung collapse
pleural effusion
bony secondaries
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102
Q

bronchial carcinoma: cytology

A

sputum and pleural fluid

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103
Q

bronchial carcinoma: CT scan

A

for Staging

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104
Q

bronchial carcinoma: bronchoscopy

A

give histology

assess operability

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105
Q

bronchial carcinoma: lung function test

A

assess suitability for lobectomy

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106
Q

bronchial carcinoma: bone scan

A

if suspected mets

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107
Q

bronchial carcinoma: PET scan

A

helps with staging

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108
Q

bronchial carcinoma: non-small cell treatment

A

surgical excision- lobectomy
radiotherapy for stages I-III
chemo and radio for more advanced

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109
Q

bronchial carcinoma: small cell, treatment

A

surgery
chemo and radio if well enough
pharmacological, palliative and treat complications

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110
Q

bronchial carcinoma: small cell, palliative care

A

radiotherapy- for bronchial obstruction, SVC obstruction, haemoptysis, bone pain and cerebral mets

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111
Q

bronchial carcinoma: small cell, treat complications

A

SVC obstruction- stent, RT and dexamethasone
endobronchial therapy- tracheal stenting, cryotherapy, laser brachytherapy
pleural effusion- drainage

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112
Q

bronchial carcinoma: small cell, pharmacological treatment

A 
analgesia
steroids
anti0emetics
cough linctus
bronchodilators
antidepressants
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113
Q

bronchial carcinoma: prevention

A

stop smoking

prevent occupational exposure

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114
Q

bronchial adenoma: pathology

A

rare
slow growing
90% carcinoid
10% cylindromas

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115
Q

bronchial adenoma: treatment

A

surgery

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116
Q

hamartoma: pathology

A

rare
benign
irregular proliferations of benign tissues that are not normally found in that pattern within lung tissue

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117
Q

hamartoma: investigation

A

CT- lobulated mass, potential flecks of calcification

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118
Q

hamartoma: treatment

A

excision to exclude malignancy

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119
Q

malignant mesothelioma: pathology

A

malignant tumour of mesothelial cells that usually occurs in the pleura

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120
Q

malignant mesothelioma: epidemiology

A

more common in men

presents 40-70 y/o

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121
Q

malignant mesothelioma: aetiology

A

asbestos is main cause- 90%

latent period can be up to 45 years

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122
Q

malignant mesothelioma: symptoms

A 
chest pain
dyspnoea
weight loss
fatigue
recurrent pleural effusions
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123
Q

malignant mesothelioma: signs

A

finger clubbing
signs of metastasis- lymphadenopathy, hepatomegaly, bone pain/tenderness
abdo pain

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124
Q

malignant mesothelioma: investigation

A

CXR/CT- pleural thickening/effusion
aspiration- bloody pleural fluid
thorascopy w/ biopsy= diagnostic

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125
Q

malignant mesothelioma: treatment

A

poor prognosis- presents late and progresses quickly, average survival is 8 months
chemo can improve survival

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126
Q

cancers that spread to the lung

A

breast
bowel
kidney
bladder

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127
Q

causes of nodule in the lung

A 
malignancy, primary or secondary 
abscess
granuloma
cyst
foreign body 
skin tumour
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128
Q

complications of resp viruses

A 
pharyngitis
sinusitis
otitis media
bronchitis
pneumonia
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129
Q

viral illnesses of resp tract

A

influenza
coronavirus
adenovirus
respiratory syncytial virus

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130
Q

emergency respiratory infections

A

severe acute respiratory syndrome

avian influenza

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131
Q

tonsillitis: pathology

A

pharyngitis and tonsillitis are infections in the throat that cause inflammation
either affecting pharynx or tonsils

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132
Q

tonsillitis: viral causes

A

adenovirus= most common cause
rhinovirus
epstein barr virus
acute HIV infection

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133
Q

tonsillitis: bacterial causes

A

lancefield group A beta-haemolytic streptococci

strep pyogenes

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134
Q

tonsillitis: symptoms

A

sore throat

fever

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135
Q

tonsillitis: signs

A

oropharynx and soft palate are red
tonsil inflammation and swelling
lymph nodes enlarge

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136
Q

tonsillitis: viral presentation

A

red swollen tonsils

throat redness

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137
Q

tonsillitis: bacterial presentation

A

white pus filled spots
grey furry tongue
swollen uvula
red swollen tonsils and throat

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138
Q

tonsillitis: investigations

A

clinical diagnosis

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139
Q

self limiting tonsillitis: treatment

A

symptomatic treatment- pain relief

no antibiotics required

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140
Q

persistent tonsillitis: treatment

A

phenoxymethylpenicillin

cefaclor

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141
Q

sinusitis: pathology

A

infection of paranasal sinuses

mostly bacterial but can be fungal

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142
Q

sinusitis: causes

A

streptococci pneumoniae= 40%

haemophilus influenzae= 30-35%

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143
Q

sinusitis: symptoms

A

purulent rhinorrhoea
facial pain, unilateral with tenderness
fever
frontal headache

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144
Q

sinusitis: signs

A

past medical history of upper resp tract infection- cold

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145
Q

sinusitis: complications

A

brain abscesses
sinus vein thrombosis
orbital cellulitis

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146
Q

sinusitis: investigations

A

clinical diagnosis

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147
Q

sinusitis: treatment

A

nasal decongestants- xylometazoline

broad spectrum antibiotics- co-amoxiclav

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148
Q

acute epiglottitis: pathology

A

inflammation of epiglottis

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149
Q

acute epiglottitis: causes

A

haemophilus influenzae= most severe

causes of pharyngitis

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150
Q

acute epiglottitis: symptoms

A

high fever
severe airway obstruction
odynophagia- pain when swallowing

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151
Q

acute epiglottitis: signs

A

inspiratory stridor- high pitch wheezing when breathing in

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152
Q

acute epiglottitis: complications

A

meningitis
septic arthritis
osteomyelitis

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153
Q

acute epiglottitis: investigations

A

clinical diagnosis

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154
Q

acute epiglottitis: treatment

A

IV antibiotics- ceftazidime

may require emergency endotracheal intubation

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155
Q

whooping cough: pathology

A

caused by bordatella pertussis- gram -ve coccobacillus
highly contagious
spread via droplets

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156
Q

whooping cough: epidemiology

A

mainly occurs in childhood

90% <5 y/o

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157
Q

whooping cough: catarrhal phase presentation

A 
highly infectious, 1-2 weeks
malaise
anorexia
rhinorrhoea
conjunctivitis
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158
Q

whooping cough: paroxysmal phase presentation

A

chronic cough >14 days
coughing spasms which may end in vomiting
classic whoop= breath through partially closed vocal cords

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159
Q

whooping cough: complications

A

pneumonia
encephalopathy
sub-conjunctival haemorrhage

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160
Q

whooping cough: investigations

A

PCR- nasal/throat swab

culture sensitivity

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161
Q

whooping cough: treatment

A

macrolides- clarithromycin

vaccination in pregnancy

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162
Q

croup: pathology

A

aka acute laryngotracheobronchitis

complication of URTI- particularly from parainfluenza virus and measles

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163
Q

croup: pathogenesis

A

inflammatory oedema extends to vocal cords and epiglottis
causes narrowing of airway
associated tracheobronchitis
progressive airway obstruction

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164
Q

croup: symptoms

A

barking cough- croup

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165
Q

croup: signs

A

hoarse voice
audible stridor- high pitch wheeze breathing in
tachypnoea
cyanosis

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166
Q

croup: investigation

A

clinical diagnosis

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167
Q

croup: treatment

A

nebulised adrenaline
oral corticosteroids- dexamethasone
oxygen
IV fluids

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168
Q

pneumonia

A

acute lower resp tract infection associated with fever, symptoms and signs in the chest and abnormalities on CXR

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169
Q

pneumonia: methods of spread

A

inhalation of airborne particles
aspiration of gastric contents or nasopharyngeal flora
haematogenous spread- septic arthritis

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170
Q

pneumonia: pathogenesis

A

bacteria translocate in normally sterile distal airway
multiply in lung- overwhelm host defence
alveolar macrophages release chemicals resulting in inflammation and entry of neutrophils

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171
Q

community acquired pneumonia

A

pneumonia occurs in person with no underlying immunosuppression or malignancy

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172
Q

community acquired pneumonia: epidemiology

A

occurs in all ages but commoner in extremes of age

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173
Q

community acquired pneumonia causes: typical

A

streptococcus pneumonia= most common

haemophilus influenzae

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174
Q

community acquired pneumonia causes: atypical

A 
water cooler/air conditioner
mycoplasma pneumonia
staph. aureus 
legionella
chlamydia
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175
Q

community acquired pneumonia causes: viral

A

account for 15%
CMV
VZV
SARS

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176
Q

hospital acquired pneumonia

A

defined as >48 hours after hospital admission

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177
Q

hospital acquired pneumonia: epidemiology

A

mostly in elderly, ventilated and post-op

2nd most common Hospital acquired infection

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178
Q

hospital acquired pneumonia causes: common

A

gram -ve enterobacteria
(E.coli, pseudomonas aeruginosa)
Staph. aureus

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179
Q

hospital acquired pneumonia causes: less common

A

bacteriodes

clostridia

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180
Q

pneumonia causes: aspiration

A

acute aspiration of gastric contents into lungs

stroke, myasthenia, bulbar palsies, loss of consciousness, poor dental hygiene

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181
Q

pneumonia causes: immunocompromised patients

A 
pneumocystis jiroveci- HIV 
strep. pneumonia 
haemophilus influenzae
staph. aureus 
gram -ve bacilli 
fungi
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182
Q

pneumonia: risk factors

A 
infants and elderly 
COPD
cystic fibrosis 
immunocompromised 
smoking
excess alcohol 
diabetes
impaired swallowing 
CVD
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183
Q

pneumonia: symptoms

A 
fever
dyspnoea
productive cough
purulent sputum
pleuritic chest pain 
haemoptysis
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184
Q

pneumonia: signs

A 
confusion
tachypnoea
tachycardia
hypotension
pyrexia
cyanosis
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185
Q

pneumonia: signs of consolidation

A

reduced expansion
dull percussion
increased tactile vocal resonance
bronchial breathing

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186
Q

pneumonia investigations: examination

A

dull percussion

reduced breath sounds

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187
Q

pneumonia investigations: chest x ray

A

gold standard
lobar or multilobar infiltrates
pleural effusion

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188
Q

pneumonia investigations: microbiology

A

sputum sample
serology
pleural fluid aspiration

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189
Q

pneumonia investigations: CURB 65

A 
Confusion
Urea >7mmol/L
Resp rate >30/min
Bp<90  systolic
65y/o or higher
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190
Q

pneumonia investigations: CURB 65 implications

A

0-1=mild, oral antibiotic, home treatment
2= moderate- admit to hospital
3-5= severe=admit and closely monitor
4-5= consider admission to CCU

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191
Q

pneumonia treatment: mild community acquired

A

oral amoxicillin or clarithromycin

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192
Q

pneumonia treatment: moderate community acquired

A

oral amoxicillin or clarithromycin

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193
Q

pneumonia treatment: severe community acquired

A

oral co-amoxiclav or clarithromycin

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194
Q

pneumonia treatment: atypical community acquired

A

legionella- fluoroquinolone and clarithromycin

chlamydia- tetracycline

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195
Q

pneumonia treatment: hospital acquired patients

A

IV aminoglycoside and IV antipseudomonal penicillin

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196
Q

pneumonia treatment: aspiration patients

A

IV cephalosporin and IV metronidazole

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197
Q

pneumonia treatment: neutropenic patients

A

IV aminoglycoside and IV antipseudomonal penicillin

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198
Q

pneumonia treatment: supportive therapy

A

oxygen- keep sats >94% (if COPD, 88-92%)

IV fluids- for anorexia, dehydration and shock

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199
Q

pneumonia treatment: analgesia

A

paracetamol for pleuritic chest pain

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200
Q

pneumonia: prevention

A

smoking cessation
influenza vaccine
pneumococcal vaccine for at risk groups

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201
Q

pneumonia: complications

A 
pleural effusion
empyema 
resp failure
hypotension
AF
lung abscess
jaundice
septicaemia
pericarditis
brain abscess
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202
Q

pneumonia complications: pleural effusion

A

inflammation of pleura by adjacent pneumonia
may cause fluid exudation into pleural space
if small then no consequences
if large or infected then drainage required

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203
Q

pneumonia complications: empyema

A

pus in pleural space
should be suspected if a pt. with resolving pneumonia develops a recurrent fever
should be drained

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204
Q

pneumonia complications: resp failure

A

type 1 is relatively common

treat with high flow oxygen, aim for normal sats

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205
Q

pneumonia complications: hypotension

A

may be due to combination of dehydration and vasodilation from sepsis
treat with IV fluids

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206
Q

pneumonia complications: atrial fibrilation

A

common in elderly
usually resolves with treatment of pneumonia
beta-blocker or digoxin can be used short term

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207
Q

pneumonia complications: septicaemia

A

may occur as result of bacteria spread from lung into blood stream
treat with IV antibiotics according to sensitivities

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208
Q

pneumonia complications: Jaundice

A

usually cholestatic and may be due to sepsis or secondary to antibiotic therapy- especially flucloxacillin and co-amoxiclav

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209
Q

pneumonia complications: lung abscess

A

cavitating area of localised, suppurative infection within the lung

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210
Q

pneumonia complications: lung abscess causes

A

inadequate treat pneumonia
aspiration
bronchial obstruction
septic emboli

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211
Q

pneumonia complications: lung abscess presentation

A 
swinging fever
cough
purulent, foul selling sputum
malaise
finger clubbing 
anaemia
weight loss
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212
Q

pneumonia complications: lung abscess CXR

A

walled cavity

often with a fluid level

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213
Q

pneumonia complications: lung abscess CT scan

A

exclude construction

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214
Q

pneumonia complications: lung abscess bronchoscopy

A

obtain diagnostic samples

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215
Q

pneumonia complications: lung abscess treatment

A

antibiotics
postural drainage
repeated aspiration

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216
Q

pneumonia differential diagnosis

A

TB

lung cancer

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217
Q

pneumococcal pneumonia

A

most common cause of bacterial pneumonia

affects all ages but common in elderly, alcoholics, immunocompromised and chronic heart failure

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218
Q

pneumococcal pneumonia: treatment

A

amoxicillin

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219
Q

staphylococcal pneumonia

A

may complicate influenza infection
occurs in young, elderly or those with underlying disease
causes bilateral cavitating bronchopneumonia

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220
Q

staphylococcal pneumonia: treatment

A

flucloxacillin

if MRSA- vancomycin

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221
Q

klebsiella pneumonia

A

rare

occurs in elderly, diabetic and alcoholics

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222
Q

klebsiella pneumonia: treatment

A

cefotaxime

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223
Q

pseudomonas treatment

A

antipseudomonal penicillin and aminoglycoside

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224
Q

mycoplasma pneumonia treatment

A

clarithromycin or doxycycline

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225
Q

legionella pneumophilia

A

colonises water tanks kept at 65 degrees

treat with clarithromycin or fluoroquinolone

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226
Q

chlamydia pneumonia treatment

A

clarithromycin or doxycycline

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227
Q

viral pneumonia causes

A 
influenza= most common
swine flu
measles
CMV
varicella zoster
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228
Q

pneumocystis pneumonia treatment

A

high dose co-trimoxazole

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229
Q

TB: causes

A

mycobacterium tuberculosis
mycobacterium bovis
mycobacterium africanum
mycobacterium microti

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230
Q

TB: bacteria features

A

M. tuberculosis:

  • intracellular bacteria
  • aerobic, non-motile, non-spore forming, slightly curved
  • slow growing
  • cell wall contains mycolic acid (phagocytosis resistant)
  • acid fast bacteria (ziehl-neelsen stain)
231
Q

TB: active infection

A

occurs when containment by immune system (t cells/macrophages) is inadequate
it can arise from primary infection or re-activation of previously latent disease
-transmission is via inhalation of aerosol droplets

232
Q

TB: latent pathophysiology

A
  • infection without disease
  • granuloma forms, preventing bacteria growth and spread
  • lifetime risk of reactivation is 5-10%
  • asymptomatic, non-infectious
  • normal sputum/CXR
  • positive skin test
233
Q

TB: risk factors for reactivation

A 
new infection, <2yrs
HIV
organ transplant
immunosuppression
silicosis 
illicit drug use
malnutrition 
haemodialysis
234
Q

TB: risk factors

A 
immunocompromised
HIV
diabetes mellitus
IV drug use
homeless
alcoholic 
viral hepatitis
235
Q

TB presentation: systemic features

A 
low grade fever
anorexia
weight loss
malaise
night sweats
erythema nodosum
236
Q

pulmonary TB presentation:

A

productive cough
haemoptysis
pleurisy
pleural effusion

237
Q

extra-pulmonary TB presentation: lymph

A

tuberculous lymphadenitis

painless enlargement of cervical or supraclavicular lymph nodes

238
Q

extra-pulmonary TB presentation: GI

A 
most disease is ileocaecal
colicky abdo pain
vomiting
bowel obstruction from wall thickening
ascites
239
Q

extra-pulmonary TB presentation: spinal/bone

A

local bone pain and tenderness
bone destruction
vertebral collapse

240
Q

extra-pulmonary TB presentation: milliary

A

haematogenous dissemination

discrete foci throughout lung (millet appearance)

241
Q

extra-pulmonary TB presentation: CNS

A

haematogenous spread
meningism
raised ICP

242
Q

extra-pulmonary TB presentation: GU

A

dysuria
frequency
loin pain
granulomas can cause infertility, ulceration and strictures

243
Q

extra-pulmonary TB presentation: cardiac

A

pericardial involvement- pericarditis, pericardial effusion, constrictive pericarditis

244
Q

extra-pulmonary TB presentation: skin

A

lupus vulgaris- persistent, progressive, cutaneous TB (red brown nodules)

245
Q

latent TB investigations: tuberculin skin testing

A

intradermal injection of purified protein derivative tuberculin
size of skin induration is used to determine positivity

246
Q

latent TB investigations: interferon-gamma release assays

A

diagnose exposure to TB by measuring the release of interferon-gamma from T-cells reacting to TB antigen

247
Q

active TB investigations: CXR

A 
fibronodular, linear opacities  in upper lobe
cavitation
calcification
miliary disease
effusion
248
Q

active TB investigations: sputum smear

A

Ziehl-neelsen for acid fast bacilli

three specimens are needed

249
Q

active TB investigations: sputum culture

A

cultured with lowenstein-jensen medium

ziehl-neelsen stain

250
Q

active TB investigations: NAAT

A

direct detection of M. tuberculosis

251
Q

active TB investigations: histology

A

caesating granuloma

252
Q

extra-pulmonary TB investigations: aspiration or biopsy

A

lymph node, pleura, bone, synovium, GI/GU
AFB staining
histology
culture

253
Q

extra-pulmonary TB investigations: NAAT

A

any sterile fluids- CSF, pericardial

lumbar puncture

254
Q

TB treatment: 1st line treatment RIPE

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

255
Q

TB treatment: rifampicin

A

6 months
bactericidal
blocks protein synthesis

256
Q

TB treatment: isoniazid

A

6 months
bactericidal for rapidly growing bacilli
block cell wall synthesis
inhibits formation of active vitamin B6 which causes peripheral neuropathy

257
Q

TB treatment: pyrazinamide

A

2 months

bactericidal

258
Q

TB treatment: ethambutol

A

2 months

bactericidal

259
Q

TB treatment: rifampicin side effects

A

Red/orange bodily fluids- urine, sweat, tears
renal failure
rash
hepatitis

260
Q

TB treatment: isoniazid side effects

A

peripheral neuropathy

tingling, numb feet/hands

261
Q

TB treatment: pyrazinamide side effects

A

hepatitis

hyperuricaemia/gout

262
Q

TB treatment: ethambutol side effects

A

Eye problems

optic neuritis

263
Q

TB treatment: side effect management

A

prophylactic vitamin B6

eye and liver screening

264
Q

TB: 2nd line treatment

A

fluoroquinolones- ciprofloxacin
augmentin
clarithromycin

265
Q

TB: prevention

A

active case finding

vaccination- BCG

266
Q

respiratory failure

A

occurs when gas exchange is inadequate, resulting in hypoxia

PaO2 <8kPa

267
Q

type 1 respiratory failure

A

hypoxia with normal or low PaCO2

ventilation/perfusion mismatch

268
Q

type 1 respiratory failure causes

A

V/Q mismatch= pneumonia, pulmonary oedema, pulmonary embolism, asthma, emphysema
Hypoventilation
Abnormal diffusion

269
Q

type 2 respiratory failure

A

hypoxia with hypercapnia

caused by hypoventilation w/ or w/o V/Q mismatch

270
Q

type 2 respiratory failure causes: pulmonary disease

A

asthma
COPD
pneumonia
end stage pulmonary fibrosis

271
Q

type 2 respiratory failure causes: reduced respiratory drive

A

sedative drugs
CNS tumour
trauma

272
Q

type 2 respiratory failure causes: neuromuscular disease

A

cervical cord lesion
diaphragmatic paralysis
myasthenia gravis
guillain-barre syndrome

273
Q

type 2 respiratory failure causes: thoracic wall disease

A

flail chest

kyphoscoliosis

274
Q

causes of respiratory failure: perfusion

A

PE
cardiac failure
shunt
pulmonary hypertension

275
Q

causes of respiratory failure: diffusion

A

IPF

emphysema

276
Q

causes of respiratory failure: hypoventilation

A

COPD
neuromuscular weakness
obesity
chest wall deformity

277
Q

causes of respiratory failure: obstructive

A

asthma
COPD
OSA
pneumonia

278
Q

hypoxia: symptoms

A 
dyspnoea
restlessness
agitation
confusion
central cyanosis
279
Q

hypoxia: signs

A

polycythaemia
pulmonary hypertension
cor pulmonale

280
Q

hypercapnia: symptoms

A 
headache
peripheral vasodilation
tremor
confusion
drowsiness
281
Q

hypercapnia: signs

A

bounding pulse
tachycardia
papilloedema

282
Q

respiratory failure investigations

A 
aimed at finding cause
ABG
CXR
sputum culture
spirometry
283
Q

type 1 resp failure treatment

A

treat underlying cause
oxygen by facemask
assisted ventilation if sats remain low

284
Q

type 2 resp failure treatment

A

resp centre may be insensitive to CO2 and resp drive is usually because of hypoxia
treat cause
controlled oxygen therapy- aim for 88-92% sats
recheck ABG after 20 mins

285
Q

ABG result of metabolic alkalosis:

A 
pH= high 
PaCO2= normal, high when compensated
HCO3-= high
286
Q

ABG result of metabolic acidosis:

A

pH= low
PaCO2=normal, low when compensated
HCO3-=low

287
Q

ABG result of resp alkalosis:

A

pH= high
PaCO2= low
HCO3-=normal, low when compensated

288
Q

ABG result of resp acidosis:

A 
pH= low
PaCO2= high
HCO3-= normal/high when compensated
289
Q

interstitial lung disease pathology

A

generic term to describe conditions affecting mainly ling parenchyma in a diffuse manner
chronic inflammation and/or progressive interstitial fibrosis

290
Q

interstitial lung disease clinical features

A

dyspnoea on excretion
non-productive cough
abnormal breathing sounds
abnormal chest x ray or CT

291
Q

interstitial lung disease pathological features

A

fibrosis and remodelling of interstitium
chronic inflammation
hyperplasia of type II pneumocytes

292
Q

interstitial lung disease with known cause

A 
occupational/environmental- asbestos, cotton worker lung etc.
drugs
hypersensitivity reactions
infections- TB
gastro-oesophageal reflux
293
Q

interstitial lung disease associated with systemic disorders

A

sarcoidosis
RA
SLE

294
Q

idiopathic interstitial lung disease

A

idiopathic pulmonary fibrosis

non-specific interstitial pneumonitis

295
Q

causes of fibrotic shadowing on CXR: upper zone

A

TB
hypersensitivity pneumonitis
ankylosing spondylitis
Radiotherapy

296
Q

causes of fibrotic shadowing on CXR: mid zone

A

sarcoidosis

histoplasmosis

297
Q

causes of fibrotic shadowing on CXR: lower zone

A

idiopathic pulmonary fibrosis

asbestosis

298
Q

hypersensitivity pneumonitis

A

hypersensitivity reaction to inhaled allergens- affecting small airways and alveoli.
Type 3 hypersensitivity reaction due to immune complex deposition

299
Q

hypersensitivity pneumonitis: pathogenesis

A

in sensitised individuals, repetitive inhalation of allergens provokes a hypersensitivity reaction. This varies in intensity and clinical course depending on the allergen

300
Q

hypersensitivity pneumonitis: acute phase

A

alveoli are infiltrated with acute inflammatory cells

results in pneumonitis

301
Q

hypersensitivity pneumonitis: chronic phase

A

granuloma formas and obliterative bronchiolitis

results in fibrosis, emphysema, and permanent lung damage

302
Q

hypersensitivity pneumonitis causes: farmer’s/ mushroom worker’s lung

A

due to exposure of mouldy hay

bacteria= micropolyspora faeni, thermoactinomyces vulgaris

303
Q

hypersensitivity pneumonitis causes: pigeon-fancier’s lung

A

due to exposure of avian proteins in bird droppings

304
Q

hypersensitivity pneumonitis causes: malt worker’s lung

A

due to exposure of aspergillus clavatus

305
Q

hypersensitivity pneumonitis causes: bagassosis or sugar worker’s lung

A

due to exposure of thermoactinomyces sacchari

306
Q

hypersensitivity pneumonitis causes: cheese worker’s lung

A

due to exposure of mouldy cheese- penicillium casei

307
Q

hypersensitivity pneumonitis: risk factors

A

pre-existing lung disease
specific occupations
bird keeping
regular hot tub use

308
Q

acute hypersensitivity pneumonitis: presentation

A 
4-6 hr post exposure
fever
rigors
myalgia
dry cough
dyspnoea
fine bilateral crackles
309
Q

chronic hypersensitivity pneumonitis: symptoms

A

increasing dyspnoea
weight loss
exertional dyspnoea

310
Q

chronic hypersensitivity pneumonitis: signs

A

finger clubbing
type 1 resp failure
cor pulmonale

311
Q

acute hypersensitivity pneumonitis investigations: bloods

A

serum antibodies- may indicated exposure and previous sensitisation rather than disease

312
Q

acute hypersensitivity pneumonitis investigations: CXR

A

upper zone mottling/consolidation

313
Q

acute hypersensitivity pneumonitis investigations: lung function tests

A

reversible restrictive defect

reduced gas transfer during attack

314
Q

chronic hypersensitivity pneumonitis investigations: bloods

A

serum antibodies

315
Q

chronic hypersensitivity pneumonitis investigations: CXR

A

upper zone fibrosis

honey comb lung

316
Q

chronic hypersensitivity pneumonitis investigations: CT chest

A

nodules
ground glass appearance
fibrosis

317
Q

chronic hypersensitivity pneumonitis investigations: lung function test

A

restrictive defect

318
Q

chronic hypersensitivity pneumonitis investigations: bronchoalveolar lavage

A

fluid shows an increase in lymphocytes and plasma cells

319
Q

acute hypersensitivity pneumonitis: treatment

A

remove allergen
give oxygen
oral prednisolone

320
Q

chronic hypersensitivity pneumonitis: treatment

A

allergen avoidance

long term steroids

321
Q

hypersensitivity pneumonitis: differentials

A

infection
connective tissue disorder
pulmonary fibrosis
asthma

322
Q

occupational lung disorders

A

response to inhalation of fumes, dust, gas or vapour at work

323
Q

occupational lung disorders: acute bronchitis

A

from irritants such as sulphur dioxide, chlorine, ammonia, oxides of nitrogen

324
Q

occupational lung disorders: pulmonary fibrosis

A

from inhalation of inorganic dust- coal, silica, asbestos, iron, tin

325
Q

occupational lung disorders: occupational asthma

A

most common industrial lung disease in developed world

326
Q

occupational lung disorders: bronchial carcinoma

A

due to asbestos, polycyclic hydrocarbons, radon mines

327
Q

coal workers pneumoconiosis

A

pneumoconiosis is accumulation of dust in the lungs and reaction of the tissue

328
Q

coal workers pneumoconiosis: pathology

A

most common dust disease in countries with coal mines
results in inhalation of coal dust over 15-20 years
these are ingested by macrophages which die, releasing enzymes that cause fibrosis

329
Q

coal workers pneumoconiosis: presentation

A

asymptomatic

co-existing bronchitis is common

330
Q

coal workers pneumoconiosis: investigations

A

chest x ray- round opacities, especially upper lobe

331
Q

coal workers pneumoconiosis: treatment

A

avoid coal dust exposure

treat chronic bronchitis

332
Q

progressive massive fibrosis

A

due to progression of coal workers pneumoconiosis

333
Q

progressive massive fibrosis: presentation

A

progressive dyspnoea
fibrosis
cor pulmonale

334
Q

progressive massive fibrosis: investigations

A

CXR- bilateral, upper-mid zone fibrotic masses

develop from periphery to hilum

335
Q

progressive massive fibrosis: treatment

A

avoid coal dust exposure

336
Q

silicosis

A

caused by inhalation of silica particles which are very fibrogenic
jobs include- metal mining, stone quarrying, sand blasting, pottery

337
Q

silicosis: presentation

A

progressive dyspnoea

high incidence of TB

338
Q

silicosis: investigations

A

CXR- diffuse miliary/nodular pattern in upper-mid zones, egg shell calcification of hilar nodules
Spirometry- restrictive ventilatory defect

339
Q

silicosis: treatment

A

avoid silica exposure

340
Q

asbestosis

A

inhalation of asbestos fibres
the degree of roofing exposure related to degree of fibrosis
high risk of bronchial adenocarcinoma and mesothelioma

341
Q

asbestosis: presentation

A 
similar to other fibrotic lung diseases
progressive dyspnoea
clubbing
fine end-inspiratory crackles
pleural plaques
342
Q

asbestosis: treatment

A

symptomatic treatment- corticosteroids

343
Q

berylliosis

A

caused by inhalation of beryllium

copper alloy used in aerospace industry, atomic reactors and electrical devices

344
Q

byssinosis

A

caused by prolonged inhalation of textile fibre dust- cotton

chest tightness, cough, dyspnoea

345
Q

idiopathic pulmonary fibrosis

A

progressive chronic pulmonary fibrosis of unknown aetiology

most common cause of interstitial lung disease

346
Q

idiopathic pulmonary fibrosis: pathogenesis

A

thought to develop from repetitive injury to alveolar epithelium
wound healing mechanisms become uncontrolled leading to overproduction of fibroblasts
patchy fibrosis occurs in interstitium
structural integrity of parenchyma is lost as well as elasticity

347
Q

idiopathic pulmonary fibrosis: risk factors

A

factors that trigger aberrant wound healing:

cigarette smoke, infectious agents (hep C), occupational dust exposure, drugs (methotrexate) GORD

348
Q

idiopathic pulmonary fibrosis: symptoms

A

dry cough
exertional dyspnoea
malaise
weight loss

349
Q

idiopathic pulmonary fibrosis: signs

A

cyanosis
finger clubbing
fine end-inspiratory crepitation

350
Q

idiopathic pulmonary fibrosis: complications

A

resp failure

increased risk of lung cancer

351
Q

idiopathic pulmonary fibrosis: bloods

A

high CRP
high immunoglobulins
ABG- low PaO2

352
Q

idiopathic pulmonary fibrosis: CXR

A

bilateral lower zone reticulo-nodular shadows

honeycomb lung

353
Q

idiopathic pulmonary fibrosis: Chest CT

A

similar to XR but more sensitive and essential for diagnosis

354
Q

idiopathic pulmonary fibrosis: spirometry

A

restrictive

355
Q

idiopathic pulmonary fibrosis: bronchoalveolar lavage

A

high lymphocytes- good prognosis

high neutrophils and eosinophils- poor prognosis

356
Q

idiopathic pulmonary fibrosis: lung biopsy

A

may be needed for diagnosis

357
Q

idiopathic pulmonary fibrosis: supportive care

A

oxygen
pulmonary rehab
opiates
palliative care

358
Q

idiopathic pulmonary fibrosis: treatment

A

lung transplant

DO NOT give high dose steroids

359
Q

idiopathic pulmonary fibrosis: differentials

A 
COPD
asthma
congestive heart failure
pneumonia
lung cancer
asbestosis  
hypersensitivity pneumonitis
360
Q

sarcoidosis

A

multisystem granulomatous disorder of unknown cause

361
Q

sarcoidosis: pathogenesis

A

typical sarcoid granulomas consist of focal accumulations of epitheloid cells, macrophages and lymphocytes
affects any organ system

362
Q

sarcoidosis: histology

A

non-caseating granuloma (aggregation of epitheloid histiocytes)

363
Q

sarcoidosis: epidemiology

A

affects adults, 20-40 y/o
more common in women
afro-caribbeans are more affected

364
Q

acute sarcoidosis: presentation

A 
usually resolves spontaneously 
fever
erythema nodosum
polyarthralgia
bilateral hilar lymphadenopathy
365
Q

sarcoidosis: pulmonary symptoms

A 
dry cough
progressive dyspnoea
decreased exercise intolerance
chest pain
abnormal CXR
366
Q

sarcoidosis: non-pulmonary signs

A 
lymphadenopathy
hepatomegaly
splenomegaly
uveitis
conjunctivitis
neuropathy
space occupying lesions
arrhythmia 
renal stones
367
Q

sarcoidosis presentation: SARCOID

A

Skin- erythema nodosum
Arthritis- hands and feet
Respiratory- BHL
Cardiac- heart block, heart failure
Ocular- anterior uveitis
Intracranial- chronic meningitis, seizures
Derangement of liver and renal function- hypercalcaemia

368
Q

sarcoidosis investigations: bloods

A 
high ESR
lymphopenia
high LFT
high serum ACE
high calcium
369
Q

stage 0 sarcoidosis investigations: CXR

A

normal

370
Q

stage 1 sarcoidosis investigations: CXR

A

BHL

371
Q

stage 2 sarcoidosis investigations: CXR

A

BHL and peripheral pulmonary infiltrates

372
Q

stage 3 sarcoidosis investigations: CXR

A

peripheral pulmonary infiltrates

373
Q

stage 4 sarcoidosis investigations: CXR

A

progressive pulmonary fibrosis
bulla formation
pleural involvement

374
Q

sarcoidosis investigations: ECG

A

arrhythmias

BBB

375
Q

sarcoidosis investigations: lung function tests

A

may be normal
potential reduced lung volumes
impaired gas transfer and a restrictive ventilatory impairment

376
Q

sarcoidosis investigations: bronchoalveolar lavage

A

shows increase in lymphocytes in active disease

increase in neutrophils in pulmonary fibrosis

377
Q

sarcoidosis investigations: ultrasound

A

may show nephrocalcinosis or hepatosplenomegaly

378
Q

sarcoidosis investigations: bone X ray

A

punched out lesions in terminal phalanges

379
Q

sarcoidosis investigations: CT/MRI

A

may be useful in assessing severity of pulmonary disease or diagnosing neuro-sarcoidosis

380
Q

acute sarcoidosis: treatment

A

bed rest

NSAIDS

381
Q

stages I-III sarcoidosis: treatment

A

remission likely

382
Q

stage IV sarcoidosis: treatment

A

corticosteroids- prednisolone

if parenchymal lung disease/uveitis/hypercalcaemia/neuro or cardio involvement

383
Q

severe sarcoidosis: treatment

A

IV methylprednisolone
immunosuppressants- methotrexate
anti-TNF-alpha
lung transplant

384
Q

differentials for sarcoidosis

A 
RA
lymphoma
metastatic malignancy
TB
lung cancer
SLE
idiopathic pulmonary fibrosis
multiple myeloma
385
Q

differentials for granulomatous disease: infections

A

bacterial- TB, leprosy, syphilis
fungi- cryptococcus neoformans
protozoa

386
Q

differentials for granulomatous disease: autoimmune

A

primary biliary cholangitis

granulomatous orchitis

387
Q

differentials for granulomatous disease: vasculitis

A

giant cell arteritis

polyarteritis nodosa

388
Q

differentials for granulomatous disease: idiopathic

A

crohn’s disease

sarcoidosis

389
Q

causes of bilateral hilar lymphadenopathy

A 
sarcoidosis
infection- TB
malignancy- lymphoma
organic dust disease- silicosis
hypersensitivity pneumonitis
390
Q

bronchiectasis

A

chronic inflammation of the bronchi and bronchioles, leading to permanent dilation and thinning of these airways

391
Q

bronchiectasis: characteristics

A

irreversible dilation of the bronchioles- due to recurrent damage and inflammation
build-up of mucus increasing risk of infection
ciliary dysfunction

392
Q

bronchiectasis: pathogenesis

A 
damage to bronchi and bronchioles
widening due to scarring and inflammation
increased mucus production
stagnant bacteria cause infection
damage to the tract
widening
cycle continues
393
Q

bronchiectasis: main organisms

A

H. influenzae
pseudomonas aeruginosa
strep. pneumoniae
staph. aureus

394
Q

bronchiectasis: epidemiology

A

more common in women

395
Q

bronchiectasis: post-infection causes

A 
most common
previous pneumonia
TB
measles
whooping cough
bronchiolitis
HIV
396
Q

bronchiectasis: congenital causes

A

CF

young’s syndrome

397
Q

bronchiectasis: other causes

A 
bronchial obstruction- tumour, foreign body
allergic bronchopulmonary aspergillosis
RA
Ulcerative colitis
idiopathic
398
Q

bronchiectasis: symptoms

A

persistent cough
copious purulent sputum
intermittent haemoptysis
dyspnoea

399
Q

bronchiectasis: signs

A

finger clubbing
coarse inspiratory crepitations
wheeze

400
Q

bronchiectasis: complications

A

pneumonia
pleural effusion
pneumothorax
amyloidosis

401
Q

bronchiectasis: high resolution CT

A

gold standard
asses extent and distribution of disease
thickened, dilated bronchi (larger than associated blood vessels) and cysts at end of bronchioles

402
Q

bronchiectasis: sputum culture

A

look for infectious agents

403
Q

bronchiectasis: CXR

A

cystic shadows

thickened bronchial walls

404
Q

bronchiectasis: spirometry

A

often shows an obstructive pattern

reversibility should be assessed

405
Q

bronchiectasis: bronchoscopy

A

locate site of haemoptysis

exclude obstruction and obtain samples for culture

406
Q

bronchiectasis: non-pharmacological treatment

A

can’t be cured.
stop smoking
vaccinations for infections
airway clearance techniques- physio, flutter valves

407
Q

bronchiectasis: pharmacological treatment

A

bronchodilators- nebulised salbutamol
corticosteroids- prednisolone
antibiotics- according to sensitivities (amoxicillin for H. influenzae, flucloxacillin for s. aureus)

408
Q

bronchiectasis: surgery

A

may be indicated in localised disease or to control severe haemoptysis

409
Q

bronchiectasis: differentials

A 
COPD
asthma
TB
cough due to acid reflux
pneumonia
cancer
inhalation of foreign body
410
Q

cystic fibrosis (CF)

A

chronic disease resulting in thickened and sticky mucus

411
Q

CF: genetics

A

autosomal recessive

mutation in CF transmembrane conductance regulator (CFTR) gene on chromosome 7

412
Q

CF: pathogenesis

A

mutation in CFTR Cl- channel protein
Cl- cannot be transported into lumen
water does not move out by osmosis

413
Q

CF: characteristics

A

thick and sticky mucus which blocks ducts
affects all ducts that produce mucus
predisposes lung to chronic infections

414
Q

CF: epidemiology

A

one of the most common life-threatening autosomal recessive conditions
presents in childhood

415
Q

CF: aetiology

A

mutation in CFTR gene on chromosome 7

F508 deletion is most common- 70%

416
Q

CF: risk factors

A

family history

caucasian

417
Q

CF: neonate presentation

A

failure to thrive
meconium ileus
rectal prolapse

418
Q

CF: resp symptoms

A 
cough
wheeze
recurrent infections
bronchiectasis 
pneumothorax
resp failure
419
Q

CF: GI symptoms

A

pancreatic insufficiency- diabetes, steatorrhoea

distal intestinal obstruction syndrome

420
Q

CF: other symptoms

A 
male infertility
osteoporosis
arthritis
vasculitis
nasal polyps
421
Q

CF: signs

A

cyanosis
finger clubbing
bilateral coarse crackles

422
Q

CF complications

A

infertility
pancreatitis
resp infections
bronchiectasis

423
Q

CF investigations: sweat test

A

diagnostic
sweat sodium and chloride >60mmol/L
abnormal NaCl collected as it can’t be pumped into lumen so removed via skin

424
Q

CF investigations: genetic testing

A

diagnostic

screen for common CF mutations

425
Q

CF investigations: faecal elastase

A

screening test in newborns

low or no levels of elastase- marker for exocrine pancreatic dysfunction

426
Q

CF treatment

A

no cure
symptomatic management
life expectancy of about 50 years

427
Q

CF non-pharmacological treatment

A

physiotherapy- postural drainage, airway clearance techniques

428
Q

CF pharmacological treatment

A 
antibiotics
mucolytics
bronchodilators
pancreatic enzyme replacement
fat soluble vitamin supplements- A,D,E,K
ursodeoxycholic acid
429
Q

CF pharmacological treatment: antibiotics

A

for acute infective exacerbations
prophylactically
flucloxacillin for s. aureus
amoxicillin for H. influenzae

430
Q

CF pharmacological treatment: mucolytics

A

clear airways of mucus

DNase e.g. dornase alpha

431
Q

CF pharmacological treatment: bronchodilators

A

salbutamol and beclometasone

symptom relief

432
Q

CF pharmacological treatment: treat complications

A

CF related diabetes- insulin
osteoporosis- bisphosphonates
malabsorption, GORD, fertility

433
Q

CF surgery

A

lung transplant

434
Q

CF monitoring

A

annual chest x ray

screening for osteoporosis- DEXA scan

435
Q

CF, advanced lung disease: treatment

A

oxygen
diuretic
non-invasive ventilation
lung and heart transplants

436
Q

pleural effusion: haemothorax

A

blood in pleural space

437
Q

pleural effusion: empyema

A

pus in pleural space

438
Q

pleural effusion: chylothorax

A

chyle (lymph with fat) in pleural space

439
Q

pleural effusion: haemopneumothorax

A

both blood and air in pleural space

440
Q

pleural effusion: exudate

A

protein conc. >35g/L

441
Q

pleural effusion: transudate

A

protein conc. <25g/L

442
Q

pleural effusion: transudate pathogenesis

A

excessive production of pleural fluid or resorption of the fluid is reduced
mostly due to fluid being pushed out of the vessels and into the space

443
Q

pleural effusion: exudate pathogenesis

A

results from damaged pleura

mostly due to increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy

444
Q

pleural effusion: increased venous pressure, transudate causes

A

heart failure
constrictive pericarditis
fluid overload

445
Q

pleural effusion: hypoproteinaemia transudate causes

A

cirrhosis
nephrotic syndrome
malabsorption

446
Q

pleural effusion: other transudate causes

A

hypothyroidism

meig’s syndrome- R pleural effusion and ovarian fibrom

447
Q

pleural effusion: exudate causes

A 
pneumonia
TB
PE
lung cancer
SLE
RA
448
Q

pleural effusion: risk factors

A

previous lung damage

asbestos exposure

449
Q

pleural effusion: symptoms

A

can be asymptotic
dyspnoea
pleuritic chest pain

450
Q

pleural effusion: signs

A

decreased expansion
stony dull percussion notes
diminished breath sounds

451
Q

pleural effusion: signs of associated disease

A 
malignancy- clubbing, lymphadenopathy
stigmata of chronic liver disease
cardiac failure
hypothyroidism
RA
SLE- butterfly rash
452
Q

pleural effusion investigation: CXR

A

white fluid
small effusions blunt the costophrenic angles
larger effusions are seen as water-dense shadows with concave upper borders

453
Q

pleural effusion investigation: ultrasound

A

useful in identifying the presence of pleural fluid and guiding diagnostic or therapeutic aspiration

454
Q

pleural effusion investigation: diagnostic aspiration

A

clinical chemistry (protein, glucose, pH), bacteriology (TB culture, MC&C), cytology, immunology

455
Q

pleural effusion investigation: pleural biopsy

A

if pleural fluid analysis is inconclusive

456
Q

pleural effusion treatment

A 
treat cause
drainage
pleurodesis
intra-pleural alteplase and dornase alpha
surgery
457
Q

pleural effusion treatment: drainage

A

small needle or tube inserted and draws out the fluid

458
Q

pleural effusion treatment: pleurodesis

A

recurrent effusions for more severe cases

injection of ‘glue’, the two pleural surfaces stick together so no more fluid can come in between

459
Q

pleural effusion treatment: intra-pleural alteplase and dornase alpha

A

IPA= thrombolytic, DA= mucolytic

may help empyema

460
Q

pleural effusion treatment: surgery

A

persistent collections and increasing pleural thickness on USS requires surgery

461
Q

pneumothorax

A

air in pleural space

causes lung on affected side to collapse and is unable to inflate

462
Q

simple pneumothorax

A

no communication with atmosphere
no mediastinal shift
non-expanding
pleural cavity pressure less than atmosphere

463
Q

tension pneumothorax

A

progressive build up of air in pleural space from each inspiration
mediastinum is pushed over into contralateral hemithorax
can lead to cardiorespiratory arrest

464
Q

communicating pneumothorax

A

loss of integrity of a chest wall, secondary to penetrating chest trauma
causes collapse of affected lung on inspiration

465
Q

pneumothorax: primary spontaneous causes

A

young thin men- connective tissue disorders, marfan’s, elhers-danlos
due to rupture of subpleural bulla- thing walled air containing spaces
usually apical- due to congenital defects

466
Q

pneumothorax: secondary spontaneous causes

A

chronic lung disease- asthma, COPD, FC, sarcoidosis
infection- TB, pneumonia
carcinoma

467
Q

pneumothorax: traumatic causes

A

traumatic- fractured rib, stab wound, gunshot

iatrogenic- CVP line insertion, pleural aspiration

468
Q

pneumothorax: risk factors

A 
male
smoking
tall
underweight
use of mechanical ventilation
469
Q

pneumothorax: symptoms

A 
can be asymptomatic
sudden onset of dyspnoea
pleuritic chest pain
sudden deterioration
hypoxic
470
Q

pneumothorax: signs

A

reduced expansion
hyper-resonance to percussion
diminished breath sounds

471
Q

tension pneumothorax: signs

A 
respiratory distress
tachycardia
hypotension
distended neck veins
trachea deviation away from side of pneumothorax
472
Q

pneumothorax: CXR

A

should not be performed if suspected tension as it delays treatment
look for an area devoid of lung markings, peripheral to edge of collapsed lung

473
Q

pneumothorax: ABG

A

if dyspnoeic/chronic lung disease

hypoxia

474
Q

small spontaneous pneumothorax: treatment

A

heal on their own

475
Q

pneumothorax due to trauma or medical intervention: treatment

A

chest drain

476
Q

tension pneumothorax: treatment

A

needle aspiration then chest drain

477
Q

pneumothorax: surgery

A

if:
bilateral
lung fails to expand in 48 hours of drain insertion
persistent air leak

478
Q

pneumothorax: differentials

A

pleural effusion
chest pain
pulmonary embolism

479
Q

pulmonary embolism

A

blockage of pulmonary artery or one of its branches in the lung by a venous thromboembolism

480
Q

pulmonary embolism: pathogenesis

A

PEs usually arise from a venous thrombosis in pelvis or legs

clots break off and pass through the veins and right side of heart before lodging in pulmonary circulation

481
Q

pulmonary embolism: risk factors and causes

A 
deep vein thrombosis
septic emboli
fat
air
recent surgery
leg fracture
malignancy
old age
obesity
combined pill
482
Q

pulmonary embolism: symptoms

A

acute dyspnoea
pleuritic chest pain
haemoptysis
syncope

483
Q

pulmonary embolism: signs

A 
cyanosis
tachypnoea
tachycardia
hypotension
pleural effusion
484
Q

pulmonary embolism: bloods

A

FBC
U&E
baseline clotting

485
Q

pulmonary embolism: D-dimer

A

non-specific fibrin degradation product
normal excludes diagnosis
positive does not confirm

486
Q

pulmonary embolism: ABG

A

may show type 1 resp failure, low O2 and low Co2

487
Q

pulmonary embolism: CXR

A

may be normal or show dilated pulmonary artery, or pleural effusion

488
Q

pulmonary embolism: CT pulmonary angiography

A

sensitive and specific

test of choice in high risk or those with positive D-dimer

489
Q

pulmonary embolism: ECG

A

may be normal or show tachycardia, RBBB, RV strain

490
Q

pulmonary embolism: treatment

A 
LMHW
thrombolysis
anticoagulants
oxygen
morphine
IV fluids
491
Q

pulmonary embolism: LMWH

A

short term anticoagulation

fondaparinux

492
Q

pulmonary embolism: thrombolysis

A

if haemodynamically unstable

alteplase

493
Q

pulmonary embolism: long term anticoagulants

A

DOAC- rivaroxaban- inhibit factor Xa

warfarin

494
Q

pulmonary embolism: length of treatment

A

pregnancy- LMWH until delivery
malignancy- LMWH for 6 months or until cure of cancer
unprovoked- continue for > 3 months
provoked- 3 months then reassess risk

495
Q

pulmonary embolism: prevention

A

LMWH to all immobilised patients
stop HRT and combined pill
hydration
early mobilisation

496
Q

wegener’s granulomatosis

A

multisystem disorder of unknown cause characterised by necrotising granulomatous inflammation and vasculitis of small and medium vessels

497
Q

wegener’s granulomatosis: pathogenesis

A

anti-neutrophil cytoplasmic antibody (ANCA) attaches to neutrophils and activated them before then enter the tissue
this results in recruitment of more neutrophils and so more activation
reactive oxygen species produced and neutrophil degranulation occurs
this generates microabscesses, recruits monocytes and produces granulomas by macrophages

498
Q

wegener’s granulomatosis: upper airway disease presentation

A

nasal obstruction
ulcers
nose bleed
destruction of nasal septum

499
Q

wegener’s granulomatosis: renal disease presentation

A

rapidly progressive glomerulonephritis
proteinuria
haematuria

500
Q

wegener’s granulomatosis: pulmonary involvement presentation

A

cough
haemoptysis
pleuritic chest pain

501
Q

wegener’s granulomatosis: general presentation

A

skin purpura
peripheral neuropathy
arthritis

502
Q

wegener’s granulomatosis: bloods

A

cANCA positive

high ESR/CRP

503
Q

wegener’s granulomatosis: urinalysis

A

look for proteinuria and haematuria

504
Q

wegener’s granulomatosis: CXR

A

nodules present

possible fluffy infiltrate of pulmonary hemorrhage

505
Q

wegener’s granulomatosis: CT

A

diffuse alveolar haemorrhage

506
Q

wegener’s granulomatosis: treating severe disease

A

corticosteroids- prednisolone- induces remission

methotrexate for maintenance

507
Q

wegener’s granulomatosis treatment: plasma exchange

A

severe renal disease or pulmonary haemorrhage

508
Q

wegener’s granulomatosis treatment: co-trimoxazole

A

prophylaxis against pneumocystis jiroveci and staph colonisation

509
Q

wegener’s granulomatosis: differentials

A

churg-strauss syndrome:

  • affects small arteries
  • males in 40s
  • rhinitis, eosinophilia and vasculitis
  • high eosinophil count
  • ANCA +ve
510
Q

goodpasture’s syndrome: epidemiology

A

more common in males

usually presents >16 yrs

511
Q

goodpasture’s syndrome: lung disease presentation

A 
pulmonary haemorrhage
sneezing, nasal discharge, fever
cough
dyspnoea
anaemia
512
Q

goodpasture’s syndrome: acute glomerulonephritis presentation

A

nephritic glomerulonephritis
haematuria
proteinuria
hypertension

513
Q

goodpasture’s syndrome: autoantibodies

A

diagnostic test

anti-GBM

514
Q

goodpasture’s syndrome: CXR

A

infiltrates due to pulmonary haemorrhage- often in lower zones

515
Q

goodpasture’s syndrome: kigney biopsy

A

crescent glomerulonephritis

516
Q

goodpasture’s syndrome: treatment

A

vigorous immunosuppressants
treat shock
plasma exchange

517
Q

goodpasture’s syndrome treatment: vigorous immunosuppressants

A

corticosteroids- prednisolone

cyclophosphamide

518
Q

goodpasture’s syndrome: differentials

A

SLE
RA
idiopathic pulmonary haemosiderosis

519
Q

goodpasture’s syndrome

A

acute glomerulonephritis and lung symptoms caused by antiglomerular basement membrane antibodies
type 2 hypersensitivity
autoimmune disease

520
Q

acute respiratory distress syndrome

A

caused by direct lung injury or occur secondary to severe systemic illness
lung damage and release of inflammatory mediators cause increased capillary permeability and non-cariogenic pulmonary oedema

521
Q

acute respiratory distress syndrome: pulmonary causes

A 
pneumonia
gastric aspiration
inhalation
injury
vasculitis
522
Q

acute respiratory distress syndrome: other causes

A 
shock
septicaemia
haemorrhage
multiple transfusions
acute liver failure
trauma
burns
523
Q

acute respiratory distress syndrome: risk factors

A 
sepsis
trauma
pneumonia
gastric aspirin
pregnancy
drugs
burns
smoke inhalation
head injury
raised ICP
malaria
524
Q

acute respiratory distress syndrome: symptoms

A

cyanosis

peripheral vasodilation

525
Q

acute respiratory distress syndrome: signs

A

tachypnoea
tachycardia
bilateral fine inspiratory crackles

526
Q

acute respiratory distress syndrome: investigations

A

blood test
ABG
CXR
pulmonary artery catheter

527
Q

acute respiratory distress syndrome: CXR

A

bilateral pulmonary infiltrates

528
Q

acute respiratory distress syndrome: pulmonary artery catheter

A

measure pulmonary capillary wedge pressure- normal

529
Q

acute respiratory distress syndrome: diagnostic criteria

A

the following:

  • acute onset
  • CXR- bilateral infiltrates
  • PCWP normal
  • refractory hypoxaemia with PaO2:FiO2 <200
530
Q

acute respiratory distress syndrome: treatment

A 
admit to ITU
supportive therapy
treat cause
nutritional support
resp and circulatory support
treat sepsis
531
Q

acute respiratory distress syndrome treatment: respiratory support

A

1st line- continuous positive airway pressure with 40-60% O2

2nd line- mechanical ventilation

532
Q

acute respiratory distress syndrome treatment: circulatory support

A

conservative fluid management
inotropes, vasodilators, blood transfusions
low dose NO to treat hypertension

533
Q

acute respiratory distress syndrome treatment: sepsis

A

identify organism

give appropriate antibiotics

534
Q

pulmonary hypertension

A

mean pulmonary artery pressure above 25mmHg

occurs due to increased pulmonary vascular resistance or increased pulmonary blood flow

535
Q

pulmonary hypertension: pathogenesis

A

hypoxic vasoconstriction, inflammation or cell proliferation results in narrower vessels increasing right ventricular pressure causing hypertension.
leads to development of RV hypertrophy, dilation and eventually failure

536
Q

pulmonary hypertension: pulmonary vascular disorders causes

A

pulmonary embolism

primary pulmonary hypertension

537
Q

pulmonary hypertension: disease of lung parenchyma causes

A

COPD

chronic lung disorders

538
Q

pulmonary hypertension: MSK disorders causes

A

poliomyelitis

myasthenia gravis

539
Q

pulmonary hypertension: disturbance of resp drive causes

A

obstructive sleep apnoea
morbid obesity
cerebrovascular disease

540
Q

pulmonary hypertension: cardiac causes

A

mitral stenosis
LV failure
congenital heart failure

541
Q

pulmonary hypertension: symptoms

A 
exertional dyspnoea
lethargy
fatigue
ankle swelling
chest pain
542
Q

pulmonary hypertension: signs

A

loud pulmonary second sound

right parasternal heave

543
Q

pulmonary hypertension investigations: CXR

A

enlarged proximal pulmonary arteries which taper distally

544
Q

pulmonary hypertension investigations: ECG

A

RVH and P pulmonale

right axis deviation

545
Q

pulmonary hypertension investigations: echo

A

RV dilation

546
Q

pulmonary hypertension investigations

A 
LFT detects portal hypertension
autoimmune screen
Echo
ECG
CXR
547
Q

pulmonary hypertension: treatment

A 
treat cause
oxygen
warfarin
diuretics for oedema
pulmonary vasodilators
548
Q

pulmonary hypertension: differentials

A 
cor pulmonale
cardiomyopathies
primary right ventricular heart failure
congestive cardiac failure
portal hypertension
549
Q

cor pulmonale

A

right heart failure and abnormal enlargement

caused by chronic pulmonary arterial hypertension

550
Q

cor pulmonale: caused by lung disease

A

COPD
bronchiectasis
pulmonary fibrosis
lung resection

551
Q

cor pulmonale: caused by pulmonary vascular disease

A

pulmonary emboli
pulmonary vasculitis
ARDS
sickle cell

552
Q

cor pulmonale: caused by thoracic cage abnormality

A

hyphosis
scoliosis
thoracoplasty

553
Q

cor pulmonale: neuromsuclar disease

A

myasthenia gravis
poliomyelitis
motor neuron disease

554
Q

cor pulmonale: hypoventilation

A

sleep apnoea

enlarged adenoids

555
Q

cor pulmonale: symptoms

A

dyspnoea
fatigue
syncope

556
Q

cor pulmonale: signs

A 
cyanosis
tachycardia
raised JVP
loud P2
pansystolic murmur
557
Q

cor pulmonale: bloods

A

FBC- high haematocrit, secondary polycythaemia

558
Q

cor pulmonale: ABG

A

hypoxia

hypercapnia

559
Q

cor pulmonale: CXR

A

enlarged right atrium and ventricle, prominent pulmonary arteries

560
Q

cor pulmonale: ECG

A

P pulmonale
right axis deviation
right ventricular hypertrophy

561
Q

cor pulmonale: treat cause

A

COPD

pulmonary infections

562
Q

cor pulmonale: treating resp failure

A

in acute situation

give 24% oxygen

563
Q

cor pulmonale: treating cardiac failure

A

diuretics- furosemide

564
Q

cor pulmonale: venesection treatment

A

if haematocrit >55%

565
Q

cor pulmonale: surgery

A

if the patient is young

heart-lung transplant

566
Q

beta 2 agonists: indications

A

COPD asthma

567
Q

beta 2 agonists: examples

A

salbutamol- SABA

salmeterol- LABA

568
Q

beta 2 agonists: route of administration

A

inhaler

nebuliser

569
Q

beta 2 agonists: mechanism

A

bind to B2 receptor which causes smooth muscle relaxation and bronchodilation
B@R’s found in the smooth muscle of the bronchi, GI tract, uterus and blood vessels

570
Q

beta 2 agonists: types

A

short acting

long acting- take longer to act but last longer

571
Q

beta 2 agonists: adverse effects

A

hypokalaemia
tremor
palpitations

572
Q

corticosteroids: examples

A

prednisolone
methylprednisolone
dexamethasone

573
Q

corticosteroids: mechanisms

A

supress multiple inflammatory genes

leads to reduced inflammation

574
Q

corticosteroids: adverse effects

A

osteoporosis
increased risk of infection
weight gain

phase 2a clinical (8 decks)

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