Respiratory

Question 1

Lung Cancer

1. Signs and symptoms
2. Investigations
3. Extrapulmonary manifestations
4. SVC obstruction presentation
5. Features of Horner’s syndrome

Answer 1

1. SOB, cough, haemoptysis, weight loss, clubbing, recurrent pneumonia, lymphadenopathy
2. CXR, staging CT, PET-CT, EBUS, histological diagnosis
3. Recurrent laryngeal nerve palsy. Phrenic nerve palsy. SVC obstruction. Horner’s syndrome. SIADH, Cushing’s, hypercalcaemia, limbic encephalitis (anti-Hu antibodies), Lambert-Eaton myasthenic syndrome
4. facial swelling, difficulty breathing, distended veins in the neck and upper chest. Pemberton’s sign
5. Miosis, ptosis, anihidrosis.

Question 2

Pneumonia

1. Presentation
2. Signs
3. CURB-65
4. Most common cause
5. Presentation of Legionnaire’s disease
6. Presentation of mycoplasma pneumonia
7. Presentation of Q fever
8. Presentation of chlamydia psittaci
9. Treatment of PCP
10. Investigations
11. Treatment of mild CAP
12. treatment of moderate-severe CAP

Answer 2

1. SOB, cough, sputum, fever, haemoptysis, pleuritic chest pain, delirium, sepsis
2. tachypnoea, tachycardia, hypotension, hypoxia, fever, confusion. Bronchial breath sounds, focal coarse crackles, dullness to percussion
3. Confusion, Urea >7, RR 30 or more, BP <90/60, Age 65
4. S.pneumoniae
5. Infected water exposure/air conditioning, hyponatraemia
6. Erythema multiforme, neurological symptoms
7. Exposure to animals and bodily fluids. (Farmer)
8. Contact with infected birds -eg. parrot owner
9. Co-trimoxazole
10. FBC, U+Es, CRP, CXR, sputum and blood cultures, legionella and pneumococcal urinary antigens
11. 5 day course of amoxicillin or macrolide
12. 7-10 day course of dual antibiotics (amoxicillin and macrolide)

Question 3

Asthma

1. Triggers
2. Presentation
3. BTS Guidelines for Diagnosis
4. NICE Guidelines for Diagnosis
5. BTS Stepwise Ladder
6. NICE stepwise ladder

Answer 3

1. Cold weather, infection, night time/early morning, exercise, animals, strong emotions
2. Episodic symptoms, diurnal variability, atopic conditions, family history, bilateral widespread ‘polyphonic’ wheeze
3. High probability -> try treatment. Intermediate -> spirometry with reversibility testing. Low -> consider referral and investigating other causes
4. 1st line - FeNO, spirometry with reversibility testing. then if uncertainty -> peak flow variability testing, direct bronchial challenge
5. SABA. + ICS + LABA + trial of LTRA, oral beta-2 agonist, oral theophylline, inhaled LAMA + high dose ICS + referral + oral steroids
6. SABA + ICS +LTRA + LABA + MART + increase dose of ICS + increase to high dose, oral theophylline, or inhaled LAMA + referral

Question 4

Acute Asthma

1. Moderate
2. Severe
3. Life-threatening
4. Management
5. ABG in acute asthma
6. What else should be monitored?

Answer 4

1. PEFR 50-75% predicted
2. PEFR 33-50% predicted, HR >100, RR >25, unable to complete sentences
3. PEFR <33% predicted, sats <92%, becoming tired, no wheeze, haemodynamic instability
4. Oxygen (if needed), Help, Salbutamol nebs, Hydrocortisone IV or oral pred (continued for 5 days), Ipratropium bromide, Theophylline/aminophylline, Magnesium, Escalation
5. Respiratory alkalosis. Normal pCO2 - concerning!! Respiratory acidosis is a bad sign
6. Serum potassium

Question 5

COPD

1. Presentation
2. What scale can be used to assess dyspnoea?
3. Diagnosis of COPD
4. Other investigations to consider
5. Long term management
6. Investigations in exacerbation
7. Medical treatment of exacerbation

Answer 5

1. Smoker, cough, sputum, wheeze, recurrent infections
2. MRC dyspnoea scale
3. Clinical + spirometry (obstructive) with no reversibility to bronchodilators
4. CXR, FBC, BMI, sputum culture, ECG, echo, CT thorax, serum alpha-1 antitrypsin levels, TLCO (decreased in COPD)
5. yearly vaccines. smoking cessation. SABA or SAMA. iIf they do NOT have asthmatic/steroid-responsive features + LABA + LAMA. If they DO have asthmatic/steroid responsive features + LABA + ICS. LTOT in severe cases
6. CXR, ECG, sputum culture, FBC, U+Es, blood cultures
7. (if well enough at home) prednisolone 30mg for 7-14 days, regualr inhalers/nebulisers, antibiotics. (hospital) salbutamol and ipratropium nebs, steroids, antibiotics, physio

Question 6

NIV

1. When is Bipap used?
2. CI to BiPAP
3. When is CPAP used?

Answer 6

1. T2RF. Criteria for use is respiratory acidosis despite adequate medical treatment
2. untreated pneumothorax
3. OSA, congestive cardiac failure, acute pulmonary oedema

Question 7

Interstitial Lung Disease

1. Presentation of IPF
2. Medications used in IPF
3. Drugs that can induce PF
4. What type of hypersensitivity reaction is EAA?
5. Findings on BAL in EAA
6. Management of EAA

Answer 7

1. insidious onset of SOB, dry cough >3 months, bibasal fine inspiratory crackles, clubbing
2. Pirfenidone, nintedanib (targets tyrosine kinase)
3. Amiodarone, methotrexate, cyclophosphamide, nitrofurantoin
4. Type III
5. Mast cells, lymphocytosis
6. removal of the allergen, oxygen and steroids

Question 8

Pleural Effusion

1. Exudative vs Transudative
2. Causes of exudative effusion
3. Causes of transudative effusion
4. Presentation
5. Investigations
6. CXR findings
7. Management

Answer 8

1. exudative >3g/L protein, transudative low protein
2. Lung cancer, pneumonia, RA, tuberculosis
3. Heart failure, renal failure, hypoalbuminaemia, hypothyroidism, Meig’s syndrome
4. SOB, dullness to percussion, reduced breath sounds, tracheal deviation AWAY if big
5. CXR, pleural tap - protein count, cell count, LDH, glucose, pH, microbiology testing
6. Costophrenic angle blunting, fluid in lung fissures, meniscus, tracheal deviation
7. Conservative if small. Aspiration. Chest drain

Question 9

Pneumothorax

1. Causes
2. Investigations
3. Management
4. Signs of tension pneumothorax
5. Management of tension pneumothorax
6. Triangle of safety

Answer 9

1. Iatrogenic, spontaneous, lung pathology, trauma
2. CXR - measure horizontally from the lung edge to the inside of the chest wall at the level of the hilum. CT thorax if too small
3. if no SOB and <2cm - no treatment. If SOB and/or >2cm rim - aspiration. Unstable or bilateral or secondary - chest drain
4. Tracheal deviation AWAY. reduced air entry, increased resonance, tachycardia, hypotension
5. Large bore cannulae into the 2nd intercostal space, mid-clavicular line
6. 5th intercostal space, mid-axillary line (lateral edge of lat dorsi), anterior axillary line (lateral edge of pec major)