Respiratory

Question 1

Patient with asthma presents with acute breathlessness.
RR 20
Pulse 100
PEFR 65%

What severity is this?

Answer 1

Moderate

Question 2

Patient with asthma presents with acute breathlessness.
RR 28
Pulse 115
PEFR 40%
They are unable to speak in full sentences.

What severity is this?

Answer 2

Severe

Question 3

Patient with asthma presents with acute breathlessness.

They are becoming exhausted with reduced respiratory effort.

What is the PEFR?

Answer 3

< 33%

Question 4

Patient with asthma presents with acute breathlessness.

They are becoming exhausted with reduced respiratory effort.

What would you expect the heart rate and blood pressure to be?

Answer 4

Bradycardia (<60)

Hypotensive

Question 5

Patient is regularly using their Salbutamol inhaler. What is the next step in treatment?

Answer 5

Assess inhaler technique.

Add low dose ICS e.g. Beclometasone

Question 6

Asthma poorly controlled with Salbutamol and Beclometasone inhalers.
What is the next step in treatment?

Answer 6

Assess inhaler technique.

Add LABA e.g. Salmeterol (combined ICS + LABA inhaler)

Question 7

Asthma poorly controlled using Salbutamol and Beclometasone/Salmeterol inhalers.
Salmeterol has recently been added and has had no effect.
What is the next step in treatment?

Answer 7

Assess inhaler technique.
Stop Salmeterol
Increase dose of beclometasone

Question 8

Asthma poorly controlled using Salbutamol and Beclometasone/Salmeterol inhalers.
Salmeterol has improved symptoms but there are still problems.
What is the next step in treatment?

Answer 8

Assess inhaler technique.

Increase dose of beclometasone

Question 9

Asthma poorly controlled using Salbutamol and Beclometasone/Salmeterol inhalers.
Beclometasone has recently been increased.
What is the next step in treatment?

Answer 9

Assess inhaler technique.
Referral to specialist care.
Add a 4th drug e.g. LTRA such as Monteleukast

Question 10

When is oral steroid treatment indicated in management of asthma?

Answer 10

Addition of 4th drug such as Monteleukast has not sufficiently managed asthma.

Question 11

Management of Acute Asthma

Answer 11

15L O2 through non rebreather mask
Inhaled Salbutamol (Nebs if life threatening)
Steroids - PO Prednisolone or IV hydrocortisone

MgSO4 if ineffective

Question 12

Definition of Adult Respiratory Distress syndrome

Answer 12

Acute onset
CXR shows bilateral infiltrates
Pulmonary capillary wedge pressure < 19mmHg OR absence of congestive heart failure
Refractory hypoxaemia

Question 13

Presentation of ARDS

Answer 13

Acute dyspnoea + hypoxaemia 
Tachycardia 
Peripheral vasodilation 
Bilateral fine inspiratory crackles
Multiorgan failure

Question 14

Main infective organisms in bronchiectasis

Answer 14

Haemophilus Influenzae
Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas Aeruginosa

Question 15

Causes of Bronchiectasis

Answer 15

Cystic Fibrosis
Allergic Bronchopulmonary Aspergillosis
Post Infectious
Tuberculosis
Kartagener Syndrome - primary ciliary dyskinesia
Mounier Kuhn Syndrome (atrophy of elastic fibres and smooth muscle within the wall of the trachea and main bronchi)

Question 16

Presentation of Bronchiectasis

Answer 16

Chronic history of productive cough +/- haemoptysis
Coarse inspiratory crepitations
Obstructive picture on spirometry (reduced FEV1 and FVC/FEV1)

Question 17

Diagnostic Imaging in Bronchiectasis

Answer 17

High resolution CT - Signet ring sign due to thickening of bronchial walls

Question 18

Management of Bronchiectasis

Answer 18

Pulmonary physio - Airway clearance techniques
Pneumococcal & influenza vaccinations
Smoking cessation

Bronchodilators if comorbid resp disease (Nebuliser helps break up mucus)
Antibiotics - long term if > 3 exacerbations/yr
Mucolytic drugs

Surgery if localised disease

Question 19

Sail sign

Answer 19

Triangular opacity in posteromedial aspect of lower lobe on CXR
Seen in left lower lobe collapse

Question 20

Causes of primary pneumothorax

Answer 20

Young, tall, slim men
Marfan’s Syndrome 
Ehlers-Danlos Syndrome 
Alpha-1 antitrypsin Deficiency 
Homocystinuria

Question 21

Causes of secondary pneumothorax

Answer 21

Emphysema 
Asthma, COPD
Pneumocystis Jiroveci 
Interstitial Lung Disease
CF
Lung Abscess 
TB
Sarcoidosis
Carcinoma

Question 22

PC of pneumothorax

Answer 22

Asymptomatic if small

Sudden onset dyspnoea +/- chest pain

Question 23

Examination findings in pneumothorax

Answer 23

Reduced chest expansion
Hyperresonance to percussion
Reduced breath sounds on affected side
If tension pneumothorax: Deviated trachea, distended neck veins, cardiac arrest

Tachycardia and hypotension if severe

Question 24

Causes of upper zone pulmonary fibrosis

Answer 24

TEAR - TB, extrinsic allergic alveolitis, Ank spond, Radiation

Question 25

Causes of lower zone pulmonary fibrosis

Answer 25

CARDS - cryptogenic, asbestos, RA, Drugs, systemic sclerosis