Respiratory

Question 1

COPD

Answer 1

SOB on exertion
"winter bronchitis"
Wheeze
Chronic productive cough
Ix: spirometry

Question 2

Acute exacerbation of COPD

Answer 2

Productive cough
Green/yellow sputum
Increased SOB
Reduced exercise tolerance
O/E consolidation, reduced breath sounds, bronchial breathing over consolidation, dull percussion

Question 3

TB

Answer 3

Fever, night sweats
Chronic dry cough
Weight loss
Asian/recent travel
Red Ziehl-Nelson stain (acid-fast bacilli)
RIPE: rifampicin (orange urine), isoniazide (peripheral neuropathy), pyrazinamide (hepatitis), ethambutol (colour blind)

Question 4

Cystic fibrosis

Answer 4

Steatorrhoea, diabetes (failure of exocrine glands)
Clubbing
CT: signet rings, bronchiectasis, airway thickening
Sweat test: sodium >60mmol

Question 5

Mesothelioma

Answer 5

Shipyard/builder occupational hx (presents 50/60yrs)
\+/- haemoptysis
End-inspiratory crackles
Non-productive cough
Constitutional symptoms

Question 6

Hypersensitivity pneumonitis/Extrinsic Allergic Alveolitis

Answer 6

Non IgE-mediated inflammation
Farmers lung: mouldy hay
Bird fancier’s lung: birdkeeper
Malt worker’s lung: aspergillus fumigatus/clavatus

Question 7

Pancoast’s tumour

Answer 7

Horner's syndrome (ptosis, miosis, anyhdrosis)
Arm pain (T1/2 ulnar nerve compression)

Question 8

Squamous cell carcinoma

Answer 8

Centrally located
Late metastasis
Male > female
Smoking hx
PTHrp: hypercalcaemia (stones, bones, abdo groans, psychic moans)

Question 9

Small cell carcinoma

Answer 9

Smoking hx
Central location, aggressive metastasis
Paraneoplastic syndromes:
- SIADH (hyponatraemia)
- ATCH (Cushing's syndrome)
- Carcinoid (facial flushing, diarrhoea, +ve Pemberton's sign)
- Eaton Lambert syndrome
- SVC obstruction
- Dermatomyositis

Question 10

Adenocarcinoma

Answer 10

Middle-aged non-smoking women
Goblet cell origin
Peripheral cancers
Pulmonary osteoarthropathy: periosteal elevation on XR
Marantic endocarditis

Question 11

Large cell carcinoma

Answer 11

Men
ß-hCG = gynaecomastia
Peripheral cancers, late metastasis

Question 12

Pneumonia

Answer 12

Fever, SOB, productive cough
Bronchial breath sounds
Coarse crepitations, dull percussion
CURB-65 score (AMTS <8, urea >7, resp rate >30, SBP<90/DBP<60-aged >65yrs)

Question 13

Management of pneumonia

Answer 13

Mild: oral amoxicillin
Moderate: oral/IV amoxicillin + clarithromycin
Severe: IV co-amoxiclav + clarithromycin

Question 14

Management of atypical pneumonia

• aspiration
• Legionella
• mycoplasma
• Pneumocystis jiroveci
• HAPs
• Pseudomonas aeruginosum

Answer 14

Aspiration: ceftriaxone + metronidazole
Legionella: IV fluoroquinolones (ciprofloxacin) or macrolide
Mycoplasma: erythromycin/clarithromycin
Pneumocystis jiroveci: high dose co-trimoxazole
HAP: flucloxacillin
Pseudomonas aeruginosum: Tazocin

Question 15

Atypical pneumonia

• Aspiration
• Legionella
• Mycoplasma
• Pneumocystis jiroveci
• HAPs
• Pseudomonas aeruginosum

Answer 15

Aspiration: hx of stroke, oesophageal dysmotility (limited cutaneous systemic sclerosis, achalasia)
Legionella: water tanks, low Na+, air conditioning
Mycoplasma: adolescents, erythema nodosum, pericarditis, haemolytic anaemia, worse CXR than clinical presentation, low Na+
Pneumocystis jiroveci: HIV +ve/AIDS, widespread infiltrations, desaturation on exertion
HAPs: been in hospital for a while
Pseudomonas aeruginosum: CF or bronchiectasis

Question 16

Asthma

Answer 16

Night cough
Intermittent wheeze
Eczema/hayfever (atophy) 
Stepwise management
Diurnal variation
IgE mediated

Question 17

ARDS

Answer 17

Acute onset (within 1 week)
Bilateral opacities on CXR indicative of pulmonary oedema
Non-cardiac cause (PCWP <18 mmHg)

Question 18

Management of pneumothorax

Answer 18

Primary:
<2cm high flow O2 and review with CXR
>2cm aspiration (then chest drain if failed)
Secondary: <1cm high flow O2 (aspiration) 1-2cm aspiration (chest drain) >2cm chest drain and assessment

Question 19

Community acquired pneumonia

Answer 19

Streptococcus pneumoniae

Haemophilus influenzae

Question 20

Hospital acquired pneumonia

Answer 20

Pseudomonas aeruginosa (CF, bronchiectasis)
Staphylococcus aureus (MRSA)
Klebsiella pneumoniae (redcurrent jelly, alcoholics, diabetes, bilateral upper lobes)
E. coli

Question 21

Moderate asthma exacerbation

Answer 21

Increasing symptoms
PEF 50-75%
No features of acute asthma

Question 22

Acute asthma exacerbation

Answer 22

PEF 33-50%
RR >25
HR >110
Inability to complete sentences

Question 23

Life-threatening

Answer 23

Type I respiratory failure
Silent chest
PEF <33%
Cyanosis
Exhaustion

Question 24

Near fatal

Answer 24

Type II respiratory

Requires artificial ventilation