Respiratory

Question 1

Size of normal pneumothorax requiring management and what is management

Answer 1

More than 2 cm. First line aspiration then chest drain (often in secondary)

Question 2

Drug and conditions causing pulmonary fibrosis

Answer 2

Amiodarone, bleomycin, cyclophosphamide, methotrexate, nitrofurantoin. Alpha 1 antitrypsin, rheumatoid, systemic sclerosis, SLE.

Question 3

What is sarcoidosis

Answer 3

A disease characterised by granulomatous (granules with macrophage) inflammation causing mediastinal lymlhadenopathy and lung fibrosis.

Question 4

Signs of sarcoid and initial treatment.

Answer 4

Lupus pernio (raised purple colored skin lesions across nose or cheeks), lofgren syndrome (erythema nodosum, bilateral hilar lymphadenopathy, polyarthralgia) . In small amount of symptoms no treatment. Otherwise long term oral steroids

Question 5

Management of asthma

Answer 5

First line SABA (salbutamol) when required. Then SABA prn + inhaled corticosteroids.
Second line add LABA, then leukotriene receptor antagonist (montelukast)

Question 6

Management of acute asthma

Answer 6

If mild or moderate, start SABA every 20min + prednisone + O2.
If severe, nebulised salbutamol + nebulised ipratropium + IV steroids + consider magnesium sulfate

Question 7

Signs of acute exacerbation of asthma (RR, PEFR, speech, pulse )

Answer 7

Mild: 75-50% PEFR, RR<25, speech normal, pulse <110
Moderate: 50-33% PEFR, RR>25, pulse >110, unable to finish sentence in one breath
Severe: PEFR <33%, hypoxia, bradycardia, haemodynamic instability

Question 8

Characteristic feature of strep pneumonia and type of bacteria

Answer 8

Following a viral infection, rust coloured sputum. Gram + cocci

Question 9

Management of viral pneumonia and main cause

Answer 9

Main cause is influenza A + B. Management includes antivirals (aciclovir)

Question 10

Staph aureus pneumonia characteristics and management

Answer 10

Common post flu and IV drug use. Often associated with GI sx. With MRSA: vancomycin/linezoid/ teicolplanin. Without MRSA flucloxacillin and rifampicin

Question 11

Legionella pneumonia characteristics (way of infection and symptoms) and type of organism and treatment.

Answer 11

Often caught due to travel (contaminated water), ACs or humidifiers. Gram - bacteria. Causes Neuro and GI Sx. Fluoroquinolone main treatment

Question 12

What makes mycoplasma and chlamydophillia pneumonia atypical and main treatment.

Answer 12

Resistance to b lactam abx and difficulty to spot on normal gram staining. Follow a pattern of 4 year infection cycles. Mycoplasma has no cell wall.

Question 13

Nocardia pneumonia type of organism and management

Answer 13

Bacteria of the actinomycete order. Treated with trimethoprim/sulfamethoxazole (septrin)

Question 14

Pneumocystis jirovecii pneumonia type of organism common population and treatment.

Answer 14

Fungal organism, common in HIV positive patients (CD4 <200), treat with septrin. AIDS defining illness,

Question 15

Management of pulmonary embolism

Answer 15

If haemodynamically unstable, give unfractionated heparin and IV thrombolysis (altepase/streptokinase).
If haemodynamically stable, give DOAC (apixaban or rivaroxaban) or if not suitable low molecular weight heparin.

In patients with unprovoked PE, offer long term treatment with DOAC / VKA / LMWH.

Question 16

How to investigate a PE ( and ecg findings)

Answer 16

First perform wells score. If PE likely, perform CTPA. If PE unlikely, first perform D-diner then if positive CTPA. ECG signs are t-wave inversion in leads v1-4 and S1Q3T3 pattern (right heart strain) which is deep S wave in 1, q wave in III, inverted T wave in III.

Question 17

CURB56 score for Pneumonia

Answer 17

C: confusion?
U: urea (BUN) >7mmol/ L
R: RR > 30 
B: BP ( less than 90/60) 
65: age over 65 
If 1 or less, outpatient. If 2, inpatient, if 3 or more consider ICU admission.

Question 18

What is bronchiectasis, signs and x ray findings

Answer 18

Permanent dilation of the airways due to destruction of elastic and muscular component of bronchial wall. Chronic cough with sputum, high pitched inspiratory crackles, X-ray shows tramlines

Question 19

Spirometry and X-ray findings of COPD patient

Answer 19

Spirometry shows obstructive pattern: FEV/FVC ratio less than 70%, FEV1 reduced. Increased functional residual capacity.
X-ray may show lung hyperinflation with flatter diaphragm

Question 20

Management of COPD according to gold classification

Answer 20

GOLD 1 (FEV1 >80): SABA/ SAMA / LAMA / LABA 
GOLD 2/3 (80-50): LABA/ LAMA + inhaled salbutamol or ipratropium 
GOLD 4 (<30): LAMA or combined LABA/LAMA or combined LABA/ICS

Actually GOLD A-D depending on risk level

Question 21

Management of acute exacerbation of COPD

Answer 21

1. ABCDE controlled oxygen therapy via Venturi mask
2. Salbutamol
3. If does not work, ipratropium nebulized
4. If severe, give corticosteroids PO
5. If hypercapnia consider NIV

Question 22

Investigation of pulmonary TB

Answer 22

1. X-ray showing opacities in upper lobes +- cavitation
2. Smear test looking for alcohol acid fast bacilli. Do 3 sputums, at least 8h apart 1 of which in morning.
3. Culture and sensitivities. ( takes longer)
4. Nucleic acid amplification test (for confirmation of diagnosis following smear test, can get results within 8h).

Question 23

Main type of cancer and it’s main subtype

Answer 23

Non small cell carcinoma (80-85%) - adenocarcinoma most common

Question 24

Explain small cell carcinoma type of cell and affected population and prognosis

Answer 24

SCC can metastasise early and therefore has a low prognosis. It is believed to arise from neuroendocrine cells called feyrter cells and can lead to ectopic production of hormones like ADH and ACTH. Virtually all patients are smokers

Question 25

Most common causes of community acquired pneumonia

Answer 25

Strep. Pneumo (39%), viral and chlamydia pneumonia (13% each), mycoplasma 11%, h influenza 5%.

Question 26

Laboratory and biopsy findings in sarcoidosis

Answer 26

Elevated serum ACE and calcium, biopsy shows non-caseating granulomas with epitheloid cells