Respiratory Block Flashcards
(364 cards)
1
Q
What is PCP?
A
Pneumocystis pneumonia (PCP) is a serious infection caused by the fungus Pneumocystis jirovecii.
Affects people with weakened immune systems (I.e. HIV/AIDS, organ/stem cell transplant, autoimmune diseases, blood cancer)
Symptoms: Fever, cough, difficulty breathing, chest pain, chills, fatigue
- Develop over several weeks or a few days (in those who have a weakened immune system)
2
Q
What drug is used to prevent/treat pneumocystis jirovecii pneumonia?
A
Trimethoprim/sulfamethoxazole (co-trimoxazole)
Give for 3 weeks by mouth/IV
Side Effects: Rash, fever
3
Q
How is PCP diagnosed?
A
Sputum sample
Bronchoalveolar lovage
Lung biopsy
PCR to detect pneumocystis DNA
Blood test: b-D-glucan (part of the cell wall of many different types of fungi)
4
Q
What is wernicke-korsakoff syndrome?
A
The combined presence of Wernicke encephalopathy and alcoholic Korsakoff syndrome
Caused by thiamine (Vitamin B1) deficiency
5
Q
What disorders stem from thiamine deficiency?
A
- Beriberi
- Wernicke encephalopathy
- Alcoholic Korsakoff syndrome
6
Q
What is the difference between Wernicke encephalopathy and Korsakoff syndrome?
A
Wernicke encephalopathy (WE) is most commonly seen in people who are alcoholic. The failure to diagnose WE may lead to death or permanent brain damage associated with WKS
7
Q
What are the symptoms of wernicke encephalopathy?
A
- Ocular disturbances (nystagmus)
- Changes in mental state (confusion)
- Unsteady stance and gait (ataxia)
8
Q
What are the symptoms of Korsakoff syndrome?
A
- Anterograde amnesia
- Variable retrograde amnesia
- Aphasia
- Apraxia
- Agnostic
- Defect in executive functions
- Confabulation
9
Q
What is the treatment of Wernicke Syndrome?
A
IV thiamine to reverse it before it becomes irreversible Korsakoff syndrome
10
Q
What are the signs and symptoms of hypovolemia?
A
- Increased HR
- Low BP
- Pale/cold skin
- Altered mental status
- Oliguria
- Low JVP
- Headache
- Fatigue
- Weakness
- Thirst
- Dizziness
11
Q
What are causes of hyperkalemia?
A
- AKI
- CKI
- Addison’s Disease (adrenal insufficiency)
- Angiotensin II receptor blockers
- ACE inhibitors
- Beta blockers
- Dehydration
- Destruction of RBCs due to severe injury/burns
- Type 1 diabetes
12
Q
What is the treatment for active pulmonary TB?
A
- Isoniazid + rifampicin (6mo)
2. Pyrazinamide + ethambutol (first 2mo of 6mo treatment)
13
Q
How long after TB treatment is the patient no longer infectious?
A
After taking antibiotics for 2 weeks
14
Q
When can patients make their own decisions about their treatment (when do patients have capacity)?
A
Age 16
15
Q
How does the MCA set out a 2-stage test of capacity?
A
- Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
- Does the impairment mean the person is unable to make a specific decision when they need to?
16
Q
The MCA says a person is unable to make a decision if they can’t:
A
- Understand the information relevant to the decision
- Retain that information
- Use or weigh up that info as part of the process of making the decision
17
Q
Explain the WHO’s cancer pain ladder and name 1 drug for each step of the ladder
A
If pain occurs there should be a prompt oral administration of drugs in the following order:
- Nonopioids (aspirin, paracetamol)
- Mild opioids (codeine, co-codamol)
- Strong opioids (morphine, diamorphine, oxycodone)
18
Q
Describe what emphysema look like on a (1) x-ray (2) CT
A
(1) Lungs appear much larger than they should be
2) CT will show destruction of alveoli (air sacs
19
Q
How is one diagnosed with schizophrenia?
A
A person must have 2+ of the following symptoms occurring persistently in the context of reduced functioning:
- Delusions
- Hallucinations
- Disorganised speech
- Disorganised/catatonic behaviour
- Negative symptoms
20
Q
Identify the stages of AKI
A
I - Cr > 150-200% from baseline OR acute increase of Cr > 25uM/L/48hr OR urine output < 0.5ml/kg/hr for >6hrs
II - Cr > 200-300% from baseline OR urine output < 0.5ml/kg/hr >12hrs
III - Cr > 300% from baseline OR Cr > 350uM/L OR urine output <0.3ml/kg/hr for 24hrs or auric for 12hrs OR requires renal replacement therapy irrespective of Cr
21
Q
What are risk factors for AKI?
A
- Kidney disease
- Malignancy
- Heart failure
- Ischemic heart disease
- Liver disease
- Urological intervention
22
Q
What are the nephrotoxic drugs?
A
- Angiotensin-converting enzyme inhibitors/angiotensin-II receptor antagonists
- NSAIDs
- Antivirals/antifungals
- Vancomycin/gentamicin
- Chemotherapy/contrast
23
Q
How can an azygous lung lobe form?
A
When the R posterior cardinal vein, which is one of the precursors of the azygos vein penetrates the R lung apex, rather than migrating over it. The cardinal vein carries both pleural layers with it, resulting in entrapment of a portion of the R upper lobe.
24
Q
Which drugs can cause hyponatremia?
A
- Diuretics (thiazides, loop diuretics, indapamide, amiloride)
- Antidepressants (amitryptilline)
- Anti-epileptic drugs (carbamazepine)
- Anticancer agents
- NSAIDS
25
What is CPVT?
Catecholaminegic polymorphic ventricular tachycardia
- As the heart increases in response to physical activity or emotional stress, it can trigger an abnormally fast and irregular heartbeat called VT. May cause sudden death in young adults and children.
- Involve mutations in either RYR2 or CASQ2 genes that disrupt the handling of calcium within myocytes leading to VT.
26
What are signs/symptoms of type 2 respiratory failure?
- Drowsiness
- Peripheral cyanosis
- Confusion
- Headache
- Asterixis
- Shortness of breath
- Syncope
- Irregular heart rhythms
27
What are the top 4 most common causes of COPD?
1. Smoke exposure
2. Biomass exposure
3. Previous TB
4. Alpha-1 antitrypsin deficiency
28
How many units are in 1 pint of beer?
2 units
29
How do you calculate pack years of cigarettes?
(# of cigs/20 cigs in a pack) x # of years smoking
30
What is availability bias?
To diagnose conditions as being more likely due to frequency of occurrence and/or having had recent experience with the disease
31
What is search satisficing (premature closure)?
To stop investigating after 1 diagnosis is found
32
What is confirmation bias?
To look for supporting evidence for a diagnosis rather than seeking information to rule it out
33
What is posterior probability?
To be unduly influenced by the patient’s previous medical history
34
What is diagnosis momentum?
To accept without question a possible diagnosis as true because the label originally voiced gains momentum and “sticks” to the patient
35
What is fundamental attribution error?
To blame patients, especially psychiatric, minority, and marginalised groups, for their illness
36
What is ascertainment bias?
To be influenced by prior expectations (I.e. gender bias + stereotyping)
37
What is triage cueing?
To create bias at the initiation of triage that then influences the ultimate choice of patient management
38
What is playing the odds?
To assume that a vague presentation is a benign condition on the basis it is more likely than a serious one; opposite of the “rule out the worst case” scenario
39
What is psych-out?
To minimise or misdiagnose serious medical conditions in psychiatric patients
40
What is illusory correlation: superstition?
A perception that there is a causal relationship between conditions, events, and actions when no actual relationship exists
41
What is sarcoidosis?
Inflammation in the form of granulomatous tissue that can affect lymph nodes, lungs, eyes, joints, kidneys
42
What blood test can indicate sarcoidosis or TB?
Increased ACE levels
| - As ACE is found in macrophages (I.e. granulomas)
43
What is the treatment of sarcoidosis?
Steroids for 1-2yrs
44
Name 2 anti-acids used to treat GORD and side effects?
Omeprazole + ranitidine
SE: increased risk of gastroenteritis
45
Name the antibiotic typically prescribed for bronchiectasis prophylaxis and its class and possible side effects
Azithromycin
Macrolide
SE: hearing loss + balance problems
46
What is the difference between an autologous and allogeneic transplant?
Autologous transplant = uses a person’s own stem cells
Allogeneic transplant = uses stem cells from a donor whose human leukocyte antigens (HLA) are acceptable matches to the patient’s
47
What is the effect of using voriconazole and azithromycin together?
Can increase the risk of an irregular heart rhythm + can stop proper metabolism of the azithromycin
48
What drug is used to treat aspergillosis?
Voriconazole (antifungal)
49
What is Anoro?
It’s a combination drug used in COPD that contains vilanterol (B2 agonist - ultra LABA) and umeclidinium (long-acting muscarinic antagonist)
50
What are side effects of excess steroid use?
1. Increased risk of infections
2. Cushing’s syndrome
3. Glaucoma
4. Indigestion
5. Increased appetite -> weight gain
6. Difficulty sleeping
7. Changes in mood/behaviour
8. High blood sugar/diabetes
9. Osteoporosis
10. High BP
11. Mental health problems
51
What are the 3 main causes of clubbing?
1. Infective endocarditis
2. Chronic lung infection
3. Bronchiectasis
52
Which drug is used to treat glaucoma?
Latanoprost
53
What is Barrett’s esophagus?
An abnormal (metaplastic) change in the mucosal cells lining the lower portion of the esophagus from normal stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the SI and LI.
Considered to be premalignant -> increased risk of esophageal adenocarcinoma
Thought to be due to chronic acid exposure from reflux esophagitis
54
What is a Schatzki ring?
A narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). Narrowing is caused by a ring of mucosal/muscular tissue
55
What is the progression of common infections in COPD?
1. Hemophilius
2. Influenza
3. Staph. Aureus
4. Pseudomonas
56
What lobes are affected by TB?
Upper lobes of lungs
57
What is bronchiectasis?
Chronic inflammation of bronchioles + bronchi leading to build-up of excess mucus that can make the lungs more vulnerable to infection
Permanent dilation + thinning of airways
58
What is typical of asthmatics that are SOB?
Diurnal variation of SOB (worse at night)
59
What is Bird Fancier’s lung?
Hypersensitivity pneumonitis triggered by exposure to avian proteins present in dry dust/feathers of birds
Symptoms: SOB, dry cough, flu-like symptoms, headache, aching joints, weight loss, 2-6hrs after contact with pigeons
60
What are the typical investigations performed in the respiratory department?
- Spirometry
- X-ray
- Sputum sample (I.e. TB need 3 samples in the morning)
- Post-nebuliser spirometry (to dx asthma)
- Blood tests (FBC -> asthma = increased eosinophils, increased serum IgE; CRP for infections)
61
What are the typical drugs prescribed for the respiratory system?
1. Bronchodilators (salbutamol + steroid to settle inflammation)
2. Antibiotics (for infections)
3. Mucolytics (to loosen up phlegm to more easily cough it up)
62
What would a patient be prescribed in addition to their salbutamol inhaler in a severe asthma attack?
A beclomethasone (steroid) inhaler
63
What are atypical organisms that can cause pneumonia?
Listeria, Mycoplasma, Legionella, Chlamydia
64
What is the treatment for atypical pneumonia?
Macrolides (i.e. clarithromycin) -> as these atypical organisms lack a cell wall
65
How do beta-lactams/penicillins work?
Destroy the cell wall of the organism
66
How do macrolides work?
Destroys the protein synthesis process within the organism
67
What condition should you think of when you hear a heart murmur?
Infective endocarditis
68
What murmur causes a collapsing pulse?
Aortic regurgitation
69
How many lobes does the R lung have?
3
70
How many lobes/features does the L lung have?
2 + cardiac notch + lingula
71
What is dyshemaglobinemia?
Hemoglobin molecule is functionally altered, and prevented from carrying O2
72
What is the equation for vital capacity in spirometry?
Tidal volume + Inspiratory reserve volume + Expiratory reserve volume
73
What is the equation for functional reserve capacity?
Expiratory reserve volume + residual volume
74
What is the equation for total lung capacity?
Residual volume + expiratory reserve volume + tidal volume + inspiratory reserve volume
75
What is the normal TLC for an adult male?
Approx 6L
76
What is FEV1
Forced expiratory volume in 1sec
77
What is a normal FEV1/FVC ratio?
~80%
78
Name 4 obstructive lung disorders
1. COPD
2. Asthma
3. Cystic fibrosis
4. Bronchiectasis
79
What occurs in obstructive lung disorders?
Reduction in airflow + air remains in lung at expiration + hyperinflation
80
What is the FEV1/FVC ratio in obstructive lung disease, and why?
< 70%
```
FVC = normal b/c decreased IRV + increased ERV
FRC = increased b/c increased ERV + RV
TLC = increased b/c increased FRC + RV
```
81
Name 5 restrictive lung disorders
1. Fibrosis
2. Sarcoidosis
3. Pneumonia
4. Connective tissue defects
5. Pleural effusion
82
What occurs in restrictive lung disease?
Reduction in lung volume
83
What is the FEV1/FVC ratio in restrictive lung disease, and why?
> 70% (normal or reduced, but not as low as in obstructive lung disease)
```
FVC = deceased
FRC = decreased
TLC = decreased
```
84
What is the best imaging for each of the following:
1. Pleural effusions + empyema
2. Pulmonary embolism
3. Bone metastases
4. Cancer/inflammation
5. Lung cancer, interstitial lung disease
1. Ultrasound
2. Radionucleotide scans
3. Bone scan
4. PET scan
5. CT scan
85
What are the 2 most common antibiotics used to treat pneumonia?
Amoxicillin + clarithromycin
86
What are the most common community-acquired organisms leading to pneumonia?
1. Strep. pneumoniae
2. H. influenzae
3. Moraxella catarrhalis
- 15% are viruses
87
What are the most common hospital-acquired organisms leading to pneumonia?
1. Gram negative enterobacteria
| 2. Staph. aureus
88
Name 3 clinical features of pneumonia?
1. Purulent sputum
2. Hemoptysis
3. Pleuritic pain
89
What are 5 signs of pneumonia?
1. Tachypnea
2. Tachycardia
3. Hypotension
4. Signs of consolidation (i.e. dull percussion)
5. Pleural rub
90
What is the most common bacteria to cause pneumonia?
Pneumococcal pneumonia
91
Name 6 complications of pneumonia
1. Hypotension
2. Type 1 respiratory failure
3. Atrial fibrillation
4. Pleural effusion
5. Empyema
6. Lung abscess (septicemia, jaundice, pericarditis/myocarditis)
92
What is cystic fibrosis?
Autosomal recessive disorder on chromosome 7
| Decreased Cl- secretion + increased Na+ absorption across airway epithelium
93
What 2 drugs target the cystic fibrosis transmembrane conductance receptor?
Ivacaftor + lumacaftor
94
What are signs of a lung tumour?
1. Cough
2. Hemoptysis
3. Chest pain
4. Recurrent pneumonia
5. Weight loss/anorexia
6. Lethargy
95
What is asthma and what are the 3 things that cause it?
Reversible airway obstruction caused by:
1. Bronchial muscle contraction
2. Mucosal swelling/inflammation (mast cell + basophil degradation)
3. Increased mucus production
96
What does the British Thoracic Society Prescribing Guidelines say about asthma medications? What are the 5 steps of prescribing for asthma?
1. Short-acting B2 agonist (salbutamol)
2. Inhaled steroid (beclomethasone)
3. Long-acting B2 agonist (salmeterol)
4. Leukotriene receptor antagonist (Theophylline)
5. Regular prednisolone
97
What is a side effect of B2 agonists?
Paradoxical bronchospasm
98
What is COPD?
Chronic bronchitis + emphysema
99
What are signs/symptoms of COPD?
1. >35yrs of age
2. Smoking (active/passive)/pollutants
3. Chronic dyspnea
4. Sputum production
5. Minimal diurnal variation
100
How does one diagnose chronic bronchitis?
Cough, sputum production on most days for 3mo of 2 successive years. Symptoms decrease if smoking stops
101
What is emphysema?
Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls visible on CT
102
What are the signs of a "Pink Puffer" COPD patient?
1. Increased alveolar ventilation
2. Near normal PaO2
3. Normal/low PaCO2
4. Breathless
5. NOT cyanosed
6. At risk of type 1 respiratory failure
103
What are the signs of a "Blue Bloater" COPD patient?
1. Decreased alveolar ventilation
2. Low PaO2
3. High PaCO2
4. NOT breathless
5. Cyanosed
6. At risk of Cor Pulmonale (R sided heart failure)
104
What is important to note when giving oxygen to "Blue Bloaters"?
They are insensitive to CO2 and rely on hypoxic drive, thus supplemental oxygen should be given with care to maintain respiratory effort
105
How can hyperinflation be measured?
By the cricosternal distance (if more than 3cm = hyperinflation)
106
What is seen clinically on examination of a COPD patient?
1. Decreased expansion
2. Resonant/hyperresonant percussion
3. Decreased breath sounds
4. Wheeze
5. Cyanosis
6. Cor pulmonale
107
What blood test can lead towards a diagnosis of COPD?
Increased packed cell volume (PCV) because the patient is hypoxic so the body will produce more RBCs to compensate
108
What are the x-ray findings for COPD?
1. Increased bronchovascular markings
2. Cardiomegaly
3. Lung hyperinflation
4. Flattened hemidiaphragms
5. Small heart
6. Bullous changes
- Lateral view = barrel chest (widened AP diameter)
109
What would an ECG of COPD show?
R atrial + ventricular hypertrophy (cor pulmonale)
110
What would be present on the ABGs of a patient with COPD?
Decreased PaCO2 + hypercapnea
111
What is the treatment of an Acute exacerbation of COPD?
1. Nebulised bronchodilators salbutamol + ipratropium
2. Oxygen therapy if SaO2 < 88% (start with 24-28%; aim for PaO2 > 8kPa and PaCO2 not to rise > 1.5kPa
3. Steroids (prednisolone, hydrocortisone)
4. Antibiotics if infection
5. Physio for sputum expectoration
6. If no response to steroids/bronchodilators use IV aminophylline
7. Use non-invasive positive pressure ventilation (if reap rate > 30, pH < 7.35, PaCO2 increases despite tx)
112
What are 2 causes of acute respiratory distress syndrome?
1. Direct lung injury (primary)
| 2. Severe systemic illness (secondary)
113
What are the signs/symptoms of Acute respiratory distress syndrome?
Cyanosis, tachypnea, tachycardia, peripheral vasodilation, fine inspiratory crackles bilaterally
114
What is a normal PaO2/FiO2 ratio? What is it in Acute respiratory distress syndrome?
500
< 200 in ARDS
115
How is respiratory failure defined?
PaO2 < 8kPa
116
What is type 1 respiratory failure?
Decreased PaO2 and normal PaCO2
Due to ventilation/perfusion mismatch
E.g. pneumonia, PE, pulmonary oedema, asthma, emphysema, pulmonary fibrosis, ARDS
117
What is type 2 respiratory failure?
Decreased PaO2 + increased PaCO2
Due to alveolar hypoventilation with or without V/Q mismatch
E.g. pulmonary disease (asthma, COPD), decreased respiratory drive, neuromuscular disease, thoracic wall disease
118
What do the ABGs show if the cause is respiratory?
pH and PaCO2 in opposite directions
119
What do the ABGs show if the cause is metabolic?
pH and HCO3 change in the same direction
120
What is a normal anion gap?
10-18mmol/L
121
What O2 % should you start COPD patients on?
24-28%
122
What is a PE?
Typically venous thrombosis from legs/pelvis
Clot breaks off and passes thru veins to R side of heart, before lodging in pulmonary circulation
Rare causes = septic embolus, air, fat, amniotic fluid, neoplastic cells, parasites
123
What are 5 risk factors for PE?
1. Thrombophilia (hypercoag)
2. Recent surgery
3. Pregnancy, postpartum, combined OCP
4. Malignancy
5. Previous PE (assess family hx)
124
What are the symptoms of PE?
Breathlessness, pleuritic chest pain, hemoptysis, dizziness, syncope
125
What are the signs of PE?
Pyrexia, hypotension, cyanosis, tachypnea/cardia, raised JVP, pleural rub, pleural effusion
126
What is the classical ECG presentation of PE?
S1Q3T3
Large S wave in lead 1
Q wave in lead 3
T wave inverted in lead 3
Indicates Acute R heart strain
127
What tests do you order for PE investigation?
FBC, U&E, D-dimers, clotting baseline
ABG (decreased PaO2 & PaCO2)
CXR (linear atelectasis, dilated pulmonary artery, wedge-shaped opacities, small pleural effusions)
ECG (RBBB, RV strain (inverted T in V1-V4), S1Q3T3
128
What's the treatment for PE?
If hemodynamically unstable = thrombolyse for massive PE
-> Alteplase 10mg IV over 1min, then 90mg IV over 2hrs, max 1.5mg/kg if under 65kg
Hemodynamically stable = 1. LMWH or unfractioned heparin if underlying renal impairment for 5 days; 2. DOAC (rivaroxaban, apixaban, dabigatron) or warfarin; 3. Consider vena Cavaliers filter if contraindication for anticoagulant (3mo treatment)
129
What is the treatment to prevent PE?
Give all immobile patients heparin + stop HRT/combined OCP
130
What are DOACs?
Rapid onset + don't need continuous monitoring because of fixed dose. Antidotes for DOACs becoming available.
131
Who is at increased risk of pneumothorax?
Increased risk in young thin males due to rupture of suprapleural bulla
132
What are the signs of a pneumothorax?
Decreased chest expansion, hyper resonance, decreased breath sounds on affected side
i.e. tension pneumothorax = trachea deviated away from affected side
133
What is the management for a primary/secondary pneumothorax?
Aspiration + chest drain if unsuccessful
134
What is a pleural effusion?
Fluid in pleural spaces
135
How can pleural effusions be classed?
Based on their protein components:
1. Exudates = >35g/L
2. Transudates = <25g/L
136
What occurs in a pleural effusion with exudates and what conditions are at increased risk of having this?
Increased leakiness of capillaries
| Secondary to infection, malignancy, inflammation
137
What occurs in a pleural effusion with transudates and what conditions are at increased risk of having this?
Increased venous pressure
Cystic fibrosis, constrictive pericarditis, fluid overload or hypoproteinuria (cirrhosis, malabsorption, nephrotic syndrome)
138
```
Define the following:
Hemothorax
Empyema
Hemopneumothorax
Chylothorax
```
1. Blood in pleural space
2. Pus in pleural space
3. Blood + air in pleural space
4. Chyle (lymph with fat) in pleural space
139
What are the symptoms of a pleural effusion?
Asymptomatic or pleuritic pain + dyspnea
140
What are the signs of a pleural effusion?
1. Decreased expansion
2. Stony dull perussion
3. Decreased breath sounds on affected side
4. Vocal resonance decreased
5. Bronchial breathing above effusion
141
What are good investigations to confirm a pleural effusion diagnosis?
1. Chest x-ray -> blunted costophrenic angles
| 2. Ultrasound -> to guide aspiration treatment
142
What is obstructive sleep apnea syndrome?
Collapse/intermittent closure of pharyngeal airway. Terminated by partial arousal
143
Who is at risk of obstructive sleep apnea syndrome?
Typically obese, middle-aged men
144
What are the symptoms of obstructive sleep apnea?
Snoring + daytime somnolence
| Morning headache, decreased libido, nocturia
145
What are 3 complications of obstructive sleep apnea syndrome?
1. Pulmonary HTN
2. T2 respiratory failure
3. Risk factor for HTN
146
What is cor pulmonale?
Right heart failure caused by chronic pulmonary arterial HTN
147
Name 6 causes of cor pulmonale
1. Lung disease (i.e. COPD, bronchiectasis)
2. Pulmonary vessel disease (i.e. pulmonary emboli, ARDS, sickle cell)
3. Thoracic cage abnormalities (i.e. kyphosis, scoliosis)
4. Neuromuscular disease (i.e. myesthenia gravis, MND, Polio)
5. Hypoventilation (i.e. sleep apnea, enlarged adenoids in kids)
6. Cerebrovascular disease (i.e. stroke)
148
What are the clinical features of cor pulmonale?
Dyspnea
Fatigue
Syncope
149
What are the clinical signs of cor pulmonale?
```
Cyanosis
Raised JVP
RV heave
Loud P2
Pansystolic murmur (tricuspid regurgitation)
Hepatomegaly
Oedema
```
150
What would bloods, ABGs, CXR, and ECG show for cor pulmonale?
Bloods: FBC = Hb + hematocrit elevated (2º polycythemia)
ABGs: Hypoxia +/- hypercapnia
CXR: Enlarged RA + RV; prominent pulmonary arteries
ECG: P pulmonale, right axis deviation, RV hypertrophy/strain
151
What is sarcoidosis? Who is at risk?
Multisystem granulomatous disorder of unknown cause
Higher prevalence in Northern Europe, Females, AfroCarribean, 20-40yr age group
152
What are the clinical features of sarcoidosis?
1. 20-40% asymptomatic
2. Erythema nodosum -> acute sarcoidosis
3. Polyarthralgia (joint pain)
4. Bilateral hilar lymphadenopathy (BHL)
153
What are the symptoms of sarcoidosis?
Dry cough, progressive dyspnea, decreased exercise tolerance, chest pain
154
List 6 causes of Bilateral Hilar Lymphadenopathy
1. Sarcoidosis
2. Malignancy
3. Infection
4. Organic dust disease
5. Hypersensitivity pneumonitis (i.e. Bird Fancier's Disease)
6. Histocytosis X (eosinophilic granuloma)
155
What is interstitial lung disease?
A condition that affects lung parenchyma and leads to chronic inflammation and interstitial fibrosis
156
What are the clinical features of interstitial lung disease?
1. Dyspnea on exertion
2. Non-productive paroxysmal cough
3. Abnormal breath sounds
4. Restricted pulmonary spirometry with decreased diffusion capacity of lung for CO2
157
What are the 3 steps of the pathophysiology of interstitial lung disease?
1. Fibrosis and remodelling of interstitium
2. Chronic inflammation
3. Hyperplasia of type II epithelial cells or pneumocytes
158
How can interstitial lung disease be broadly classified?
1. Those with known causes
2. Those associated with systemic disorders
3. Idiopathic
159
What is extrinsic allergic alveolitis?
Inhalation of allergens triggers a hypersensitivity reaction
160
What occurs in the acute phase of extrinsic allergic alveolitis?
Alveoli are infiltrated with inflammatory cells
161
What occurs with chronic exposure to the allergen in extrinsic allergic alveolitis?
granulomas and obliterative bronchiolitis occurs
162
What are the clinical features 1) 4-6h post-exposure and 2) chronically
1) Fever, riggers, myalgia, dry cough, dyspnea, fine bibasal crackles
2) Finger clubbing (50%), weight loss, type 1 respiratory failure, cor pulmonale, restrictive lung disorder
163
What cell types are present at increased levels in bilateral hilar lymphadenopathy?
Lymphocytes + mast cells
164
What is idiopathic pulmonary fibrosis and its signs?
Most common cause of interstitial lung disease
Signs:
- Fine end-inspiratory crackles
- Finger clubbing
- Cyanosis
- Bilateral lower zone shadows on chest x-ray
165
How is idiopathic pulmonary fibrosis treated?
1. Opiates
2. Oxygen
3. Pulmonary rehab
4. Palliative care (50% 5-yr survival)
5. Lung transplant
166
What is the DLCO transfer factor?
The DLCO measures the ability of the lungs to transfer gas from inhaled air to the red blood cells in pulmonary capillaries
167
What are the main causes of lung fibrosis?
Idiopathic pulmonary fibrosis, asbestos, drugs (methotrexate), systemic sclerosis + lupus, hypersensitivity pneumonitis, vasculitis
168
What is the prognosis for lung fibrosis?
3-5 years, there isn't a cure
169
What is a signet ring sign?
When the bronchi is bigger than the neighbouring blood vessel on a CT scan
Indicative of bronchiectasis
170
What are the 3 main causes of a cough?
1. GORD
2. Asthma
3. Post-nasal drip (tickling cough)
171
If someone has a cough for over 6 weeks what should you do and why?
Order chest X-ray to screen for lung cancer
172
What 4 conditions can rheumatoid arthritis cause?
1. Interstitial lung disease
2. Lung nodules
3. Bronchiectasis
4. Pleural effusion
173
What breath sounds are heard in idiopathic pulmonary fibrosis?
Fine end-inspiratory crackles ("walking on snow")
174
What is a possible treatment for interstitial lung disease?
Antifibrotics (i.e. Perfenidone)
175
What are 3 characteristic features of interstitial lung disease on a CT scan?
1. Subpleural reticulation worse in bases
2. Traction bronchiectasis (bronchi present at end of lung border)
3. Honeycombing (holes in the lung itself)
176
Raised Ca2+ can lead to what abnormality?
AKI
177
What is the medication used to treat alcohol withdrawal
Chlordiazepoxide
178
What is the treatment for sarcoidosis?
Prednisolone steroids
179
What tests can you perform to check for sarcoidosis? What test can diagnose sarcoidosis?
1. ACE, Ca2+ levels in bloods; ECG
| 2. Biopsy
180
What are 5 causes of hypercalcemia?
1. Cancers, especially lung cancer and breast cancer
Immobilization over a long period of time
2. Kidney failure
3. Overactive thyroid (hyperthyroidism) or excessive thyroid hormone intake
4. Use of certain medications such as the thiazide diuretics
Inherited kidney or metabolic conditions
5. Excessive vitamin D levels from vitamins, excessive dietary calcium, or from diseases that may result in excess vitamin D production
181
What CT view is best to see lymph nodes?
Mediastinal view
182
Outline sepsis 6
1. Give high flow O2
2. Take blood cultures
3. Give IV antibiotics
4. Give IV fluids
5. Measure lactate
6. Measure urine output
183
What are 2 causes of an increased ammonia on a blood test?
1. Encephalopathy
| 2. Sodium valproate (used as an anti-epileptic)
184
What is BiPAP and when is it used?
BiPAP (aka BPAP) = bilevel positive airway pressure
It is a non-invasive form of therapy to assist in inspiration and expiration
It is often used for patients with type 2 respiratory failure
NOTE: it is very similar to CPAP (continuous positive air pressure). The main difference is that BiPAP machines have 2 pressure settings: 1 pressure for inhalation + a lower pressure for exhalation. The dual settings allow the patient to get more air in and out of their lungs. CPAP only has 1 pressure setting. Thus BiPAP is more useful in T2 respiratory failure as there is CO2 retention in the lungs.
185
What is the antibiotic used to treat a pseudomonas aeruginosa (PA) chest infection?
Nebulised colomycin
For 1st infection: should start 2x/day + continue treatment at home for 3mo
For established/repeated infection: 2x/day for life
186
What drugs are used to treat TB?
*Think PRIEST*
| ```
Pyrazinamide
Rifampicin
Isoniazid
Ethambutol hydrochloride
Streptomycin
(TB drugs)
```
187
What are common side effect of TB drugs?
```
Liver damage (Check LFTs!)
Peripheral neuropathy (isoniazid)
Nausea + vomiting
Thrombocytopenia (rifampicin)
Hyperuricemia
Nerve disorders
Visual impairment (ethambutol)
Joint pain
```
188
Outline the standard course of antibiotics for active TB
Ethambutol + pyrazinamide + rifampicin + isoniazid = 2mo
Rifampicin + isoniazid = for another 4mo
Total course of antibiotics = 6mo
189
What is the infectious agent that causes TB?
Mycobacterium tuberculosis
190
What are the systemic features of TB?
1. Low-grade fever
2. Anorexia
3. Weight loss
4. Malaise
5. Night sweats
6. Clubbing (bronchiectasis)
7. Erythema nodosum
191
What are the clinical features of pulmonary TB?
1. Cough (<2-3wks, dry then productive)
2. Pleurisy
3. Hempotysis (uncommon, seen with bronchiectasis, not always active disease)
4. Pleural effusion
An aspergillosis/my stomach may form in the cavities. Presentation varies and may be silent/atypical especially with immunosuppression
192
What are the clinical features of GI TB?
Most disease is ileocecal
Causes colicky abdo pain + vomiting
Bowel obstruction can occur due to bowel wall thickening, stricture formation, or inflammatory adhesions
Biopsy required for diagnosis
193
What are the clinical features of military TB?
Hematogenous dissemination leads to the formation of discrete foci of granulomatous tissue throughout the lung (‘millet’-seed appearance)
Untreated mortality close to 100% - don’t delay treatment while results are pending
194
What does active pulmonary TB look like on an X-ray?
1. Fibronodular/linear opacities in upper lobe, middle/lower lobes (atypical)
2. Cavitation
3. Calcification
4. Miliary disease
5. Effusion
6. Lymphadenopathy
195
What are diagnostic tests for TB?
1. Chest x-ray
2. Sputum smear (looking for acid-fast bacilli)
3. Sputum culture (more sensitive than smear; can assess drug sensitivity)
4. Nuclei acid amplification test (can detect drug resistance; <8hrs)
196
Which TB drugs can be toxic to the kidneys?
Pyrazinamide + ethambutol
197
Which TB drug inhibits formation of active pyridoxine and requires you to prescribe it prophylactically? What vitamin is pyridoxine?
Isoniazid
Vitamin B6
198
Which TB drug changes body secretion colours? What colour are the body secretions?
Rifampicin
Orange-red colour
199
What is an example of a Factor Xa inhibitor?
Rivaroxaban
200
What is an example of a Low-Molecular Weight Heparin (LMWH)?
Dalteparin
201
What are factor Xa inhibitors and heparins?
Anti-coagulates
202
What blood test abnormalities indicate TB?
1. Increased erythrocyte sedimentation rate (ESR)
2. Normocytic normochromic anemia
3. Decreased serum albumin
4. Hyponatremia
5. Abnormal LFTs
6. Leukocytosis
7. Hypocalcemia
203
Define “open” and “closed” TB
Open/pulmonary-positive = an inflammation developed inside the lungs that the immune system is not able to isolate/bring under control. This enables TB bacteria to be released thru the respiratory tract (I.e. thru coughing) and means that this type of TB infection is contagious.
Closed/pulmonary-negative = no risk of infection as the inflammation is on the lungs’ periphery and not inside
- Extra-pulmonary TB is not contagious (I.e. affecting lymph nodes, kidneys, brain, spine, joints + bones, intestines)
204
What is a paradoxical reaction in TB?
A clinical/radiological worsening of pre-existing TB lesions or the development of new lesions, in patients receiving anti-TB medication who initially improved on treatment (I.e. cervical lymph node inflammatory response)
205
How can paradoxical reactions to TB be treated?
1. Steroid treatment
| 2. Immunosuppression if severe
206
What are causes of microcytic anemia?
Think MICRO-T
```
Metal poisoning (I.e. copper, lead, zinc)
Iron deficiency
Chronic inflammation anemia
Ring sideroblastic anemia
Other hemoglobinopathies
Thalassemia
```
207
Explain drug-resistant TB
NAAT should be requested for all patients with risk factors for drug-resistance (previous TB treatment, contact with drug-resistant disease, birth or residence in a country where ≥5% new cases are drug resistant)
Multi drug-resistant TB = resistant to rifampicin + isoniazid
Extensively drug-resistant TB = resistant to rifampicin, isoniazid, one injectable agent (capreomycin, kanamycin, amikacin) + 1 fluoroquinolone
—> if rifampicin resistant treat with 6 agents
208
How do you treat long QT syndrome?
1. Removal/treatment of causative factors
| 2. B-blockers, lifestyle modifications, monitoring
209
Which TB drug can be responsible for long QT syndrome?
Rifampicin
210
Name an anti-anginal
Ranolazine
211
What is the treatment for drug-resistant TB?
High-dose isoniazid, pyrazinamide, and ethambutol
fluoroquinolones, high-dose levofloxacin.
Capreomycin, kanamycin, then amikacin.
Thioamides, cycloserine, then aminosalicylic acid.
Treatment typically lasts for 12mo
212
What is the treatment for HIV?
Highly Active Antiretroviral Therapy (HAART)
- Aim is to reduce HIV viral load to a level undetectable by standard labs, reduced clinical progression, reduced mortality
213
What is the mechanism of action of HAART?
1. CCR5 antagonists -> inhibit the entry of the virus into the cell by blocking the CCR5 co-receptor (I.e. Maraviroc)
2. Nucleoside + non-nucleoside reverse transcriptase inhibitors -> inhibit reverse transcriptase + conversion of viral RNA to DNA (I.e. Truvada - combo of tenofovir + emtricitabine; Kivexa - combo of abacavir + lamivudine)
3. Integrate strand transfer inhibitors -> inhibit integrate + prevent HIV DNA integrating into the nucleus (i.e. Dolutegravir, Elvitegravir, Raltegravir)
4. Protease Inhibitors -> inhibit protease, an enzyme involved in the maturation of virus particles (i.e. Atazanavir, darunavir)
5. Pharmacokinetic enhancers/boosters -> increase the effectiveness of antiretroviral drugs allowing lower doses (I.e. cobicistat, ritonavir)
214
What types of granulomas are found in TB?
Caseous/necrotising + non-caseous granulomas
215
What kind of bacteria is mycobacterium tuberculosis
Acid fast bacilli
TB doesn’t gram stain
216
What are the important things to check on a chest-X-ray before beginning analysis?
1. Patient, date, time, quality of x-ray
2. Orientation (PA/AP, R/L)
3. Penetration (if overexposed see retrocardial vertebral bodies)
4. Rotation (spinous processes + clavicles)
5. Inspiration (anteriorly - 6th rib; posteriorly - 10th rib)
217
What areas are you looking at systematically on a chest-X-ray?
Airway: trachea central
Breathing: Describe lungs in 3 zones (air moves to top, fluid to bottom)
Circulation: Heart should be < 50% of full chest (otherwise cardiomegaly); great vessels, lymph nodes + arteries in hilum of lungs
Diaphragm: Costophrenic angles, R hemidiaphragm should be 1 rib higher than L, calcification due to asbestos
Extras: Bones, behind the heart, apices of the lungs, below the diaphragm (any air)
218
What do prominent hilar areas indicate on a chest X-ray?
1. Pulmonary HTN
2. TB
3. Sarcoidosis
4. Lymphoma
219
What are the main causes of bilateral hilar lymphadenopathy?
1. TB
2. Sarcoid
3. Hodgkin’s Lymphoma
220
What is a Silhouette sign on x-ray?
Also known as Sail’s sign, its the loss of the border if next to a dense structure
Indicates collapse of the L lower lobe (usually)
221
How are lung zones divided?
Upper zone = above anterior 2nd rib
Middle zone = anterior 2nd - 4th rib
Lower zone = below anterior 4th rib
222
What would a dense, white shadow on a chest x-ray indicate?
Collapsed lung (atelectasis)
- No air in space = white
- Collapsed lung is thought to be cancer until proven otherwise via bronchoscopy
- Sometimes can be caused by mucus plugging
223
What does interstitial shadowing, upper lobe diversion of blood flow, cardiomegaly, blunting of costophrenic angles, and kerley B lines on chest x-ray indicate?
Congestive heart failure
224
What would absence of lung markings and blackness indicate on chest x-ray?
Pneumothorax
| If trachea/mediastinum deviated = tension pneumothorax
225
When would you see spherical shadowing/opacity + diffuse shadowing on chest X-ray?
TB + aspergillosis (fungal infection)
226
What do multiple spherical opacities on a chest x-ray indicate?
Metastases in the lungs
227
What does diffuse shadowing throughout entirety of the lung on chest x-ray indicate?
Pulmonary fibrosis
228
What does air under the diaphragm indicate on chest x-ray?
Perforation
229
When ensuring proper insertion of nasogastric tubes, where should they be located on chest x-ray?
Should be under the diaphragm
230
Identify 3 causes of weight loss with normal eating
1. Diabetes
2. Hyperthyroidism
3. Malabsorption
231
Name the 4 most common causes of hypoalbuminemia
1. Nephrotic syndrome
2. Hepatic cirrhosis
3. Heart failure
4. Malnutrition
232
What is the pathophysiology behind hypoalbuminemia?
Hypoalbuminemia is largely a function of increased vascular permeability and increased interstitial volume.
233
Smoking decreases the risk of which 3 conditions?
1. Type 3 hypersensitivity reactions (i.e. Bird Fancier's lung b/c alveolar macrophages aren't able to gobble up allergens)
2. Crohn's Disease
3. Ulcerative Colitis
234
What drug class is Trimolol a part of, and which condition is it used to treat?
Beta blocker
Used to treat increased ocular pressure in glaucoma
235
What occurs if you give an asthmatic a beta blocker?
Severe bronchospasm
Bronchoconstriction occurs because sympathetic nerves innervating the bronchioles normally activate β2-adrenoceptors that promote bronchodilation
236
Name 4 risk factors for developing Dupuytren's Contracture
1. Alcoholism
2. Manual labour
3. Diabetes
4. Smoking
237
What is the biggest risk factor for mesothelioma?
Asbestos exposure (75% go on to develop mesothelioma)
238
What sign is observed on a chest x-ray indicative of mesothelioma?
Calcification in the hemi-diaphragm
239
Explain the signs present on physical examination of someone with a pleural effusion
- Decreased expansion on affected side
- Dull percussion on affected side
- Decreased breath sounds
- Decreased vocal resonance/tactile vocal fremitus
- Trachea pushed away from the affected side
(Note: Physical signs are the same as tumour clogging of the R main bronchus + collapse of the lung)
240
Which murmurs get louder on expiration? inspiration?
L-sided murmurs
R-sided murmurs
241
What does the pulse feel like in aortic stenosis?
Weak, plateau pulse
242
What does the pulse feel like in aortic regurgitation?
Collapsing pulse (very strong)
243
What is an indwelling pleural catheter and when is it used?
An IPC is a specially designed small tube used to drain pleural fluid from around your lungs easily and painlessly, whenever needed. It avoids the need for repeated uncomfortable injections and chest tubes every time the fluid needs to be drained.
Used in pleural effusion where fluid has accumulated in the pleural cavity making the patient breathless
244
Name 3 causes of PE
1. Stasis
2. Vessel injury
3. Coagulopathy
245
What is the use for a PET scan?
Looks at metabolically active sites where cell division is more rapid than normal. Useful in cancer diagnosis.
246
What occurs in systole?
Closure of the tricuspid/mitral valve
| Opening of aortic/pulmonary valve
247
What occurs in diastole?
Closure of aortic/pulmonary valves
| Opening of mitral/tricuspid valves
248
What are the 3 questions to ask to determine the type of murmur?
1. Where is it loudest?
2. Does it radiate?
3. Is it systolic or diastolic?
249
Where does aortic stenosis radiate to?
Carotids
250
Where does mitral regurgitation radiate to?
Axilla
251
What in the heart causes pulmonary oedema?
Backlog of blood and buildup of pressure from the L atrium
252
What is the benefit to using controlled humidified oxygen over unhumidified oxygen?
Generally more comfortable for the patient and lower risk of nose bleeds
253
What is the main side effect for COPD patients on steroids?
Increased bleeding risk
254
What is emphysema?
Lung tissue (alveoli) breakdown with exposure to smoke
255
What are the 3 commonest presentations of asthmatics to hospital?
1. Acute exacerbation
2. Pneumothorax
3. Infection
256
What is the use of levetiracetam?
Used for seizures
257
What can cause a seizure?
1. Epilepsy
2. Infection
3. Hyper/hypothyroidism
258
What are 2 signs of consolidation?
1. Coarse crackles at bases
| 2. Bronchial breathing
259
What are 2 signs of pulmonary oedema?
1. Fine crackles
| 2. Pink sputum
260
What are 4 causes of microcytic anemia?
1. Sideroblastic anemia (lead poisoning)
2. Iron deficiency anemia
3. Chronic diseases
4. Thalessemia
261
What are 3 causes of macrocytic anemia?
1. Alcohol
2. Folate deficiency
3. B12 deficiency
262
What are 2 causes of normocytic anemia?
1. Anemia of chronic disease
| 2. Acute blood loss
263
What are 4 main signs of aortic regurgitation?
1. Collapsing pulse (Corrigan's pulse)
2. Head bobbing (De Musset's sign)
3. Audible murmur heard with bell over femoral artery (Duroziez sign)
4. Pulating fingernail capillaries (Quinke's sign)
264
What is an Austin Flint murmur?
Backflow of regurgitation hitting the mitral valve in aortic regurgitation
265
What is the normal amount of Na, K, and fluid a healthy person needs in a day?
Na: 60mM
K: 100mM
Fluid: 2-2.5L
266
What time of day should statins be given?
Night time; work by blocking HMG-CoA Reductase enzyme in the liver which produces cholesterol
267
How is a hospital-acquired pneumonia (HAP) defined?
1. Inpatient stay > 2wks then developing pneumonia
| 2. Pneumonias in a nursing home
268
What is a safe example amount of fluid to give a patient?
1 bag 0.9% saline + 2 bags 5% dextrose over 8h + 20mM KCl in each fluid bag
269
What are the scores used for:
1. CAP
2. DVT/PE
3. GI bleeds (before endoscopy)
4. GI bleeds (after endoscopy)
1. CURB-65
2. Well's Criteria
3. Glasgow Blatchford Score
4. Rockall Score
270
How is pH detected in the body?
By baroreceptors and chemoreceptors in the carotids + aortic arch
271
What is the primary and secondary drive to breath?
```
Primary = hypercapnia
Secondary = hypoxia
```
272
What are the 2 types of COPD patients and how can you distinguish them?
1. Retainers
2. Non-retainers
Distinguish by performing blood gases
273
Why do COPD Retainers need SpO2 between 88-92%?
They have a chronically raised pCO2 level which means they lose their hypercapnia drive to breath and rely on hypoxic drive. If their oxygen levels are high, they'll lose their respiratory drive to breath. Therefore, the need a degree of hypoxia to survive.
274
Name a mucolytic
Carbocisteine
275
What heart condition are patients with COPD at risk of developing?
Right heart failure
This occurs when low oxygen levels due to COPD cause a rise in blood pressure in the arteries of the lungs, a condition known as pulmonary hypertension.
276
Name 3 speech disturbances
1. Dysarthria -> knows what their saying but its not articulating
2. Dysphasia -> sensory (cant understand what’s being asked); motor (cant find words)
3. Aphasia -> Inability to use spoken language
277
Name stroke investigations
1. Non-invasive angiogram
2. Angiogram
3. Ultrasound
Coronary/carotid arteries need to be > 75% blocked on ultrasound before intervention is used
278
What is the intervention for stroke?
Carotid endarterectomy or balloon stent
Fibrinolytic (tPa)
279
What is the likely visual abnormality if a patient is looking away from their stroke arm?
L homonymous hemianopia
280
What are the side effects of amiodarone (used for AF reversal as a last resort treatment option)?
Thyrotoxicosis
Photosensitivity of skin
Myxoedema
Slate-grey skin appearance
281
What are the commonest causes of AF?
Heart disease
| Thyrotoxicosis
282
What are 3 signs of tricuspid valve incompetence (regurgitation)?
1. Flicking v wave of JVP
2. Enlarged liver
3. Oedema
283
What pulse pressure is present in aortic regurgitation and what condition can cause this pulse pressure?
Weak pulse pressure
Aortic dissection can cause weak pulse pressure and radio-radial/femoral delay
284
What extra manoeuvre is used to accentuate the sound of aortic regurgitation? Mitral stenosis?
Aortic regurgitation -> sit forward breath in, out, and stop with diaphragm
Mitral stenosis -> roll to L side and listen in axilla with bell
285
What are the 2 murmurs where you can see flicking v waves of the JVP in the neck?
Aortic regurgitation
Tricuspid regurgitation
286
What is a nutmeg liver and when does this occur?
A liver appearing mottled like a nutmeg when cut because of congestion and associated with impaired circulation.
This occurs due to heart/lung disease
287
What are 3 complications of aortic stenosis?
1. L ventricular failure
2. Angina
3. Exertional syncope
288
What is the CHADS-VASc score and what criteria are used in it?
Used for AF and stroke risk, and to determine whether the patient should be on anticoagulation.
- Age (65-74 = +1; ≥75 = +2)
- Sex (F = +1)
- CHF history (+1)
- HTN history (+1)
- Stroke/TIA/thromboembolism history (+2)
- Vascular disease history (+1)
- Diabetes history (+1)
289
What is the HAS-BLED score and what are its parameters?
Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in AF care
- HTN (+1)
- Renal disease (+1)
- Liver disease (+1)
- Stroke history (+1)
- Prior major bleeding/predisposition to bleeding (+1)
- High/unstable INR (+1)
- Age > 65 (+1)
- Medication usage predisposing to bleeding - aspirin, clopidogrel, NSAIDs (+1)
- Alcohol use ≥ 8 drinks/week (+1)
290
What is the most common side effect of isoniazid?
Peripheral neuropathy
291
What questions should you ask someone with thrombocytopenia?
Look for active bleeding sites:
- Coughing up/vomiting blood
- Blood in urine/stool
- Abnormal vaginal bleeding
- Nose bleeds
- Gums bleeding
292
What breath sounds would you hear in someone with TB?
Bronchial breathing + crackles
293
What are the common side effects of rifampicin?
N+V, thrombocytopenia, changes in bodily fluid colour to orange/red
294
What are common side effects of ethambutol hydrochloride?
Hyperuricemia, nerve disorders, visual impairment
295
What does detection of Bence Jones protein suggest?
Multiple myeloma or Waldenström’s macroglobulinemia
296
What is the TLCO? KCO?
TLCO = transfer factor of the lung for carbon monoxide. It’s the extent to which oxygen passes from the air sacs of the lungs into the blood.
KCO = transfer coefficient - the value of the transfer factor divided by the alveolar volume. This value is an expression of the gas transfer ability per unit volume of lung.
297
What are the 4 most common interstitial lung diseases?
1. Idiopathic pulmonary fibrosis: mostly affects women, 50-70y, rarely familial. Gradual progressive breathlessness over 2-4y before death. Predominantly basal + peripheral changes of the lung on CT. 2/3 of ILD is of this type. Drugs hold things stable but not curable (Pirfenidone + Nintedanib)
2. Sarcoidosis: Granulomatous inflammation. Mediastinal lymph nodes are affected first, then other systems (I.e. eyes, lungs, kidneys). Responds to steroids. Sometimes gets better without medication.
3. Hypersensitivity pneumonitis: Exposure to antigen (mostly fungus) causes fibrosis after initial inflammation. Fibrosis seen throughout the lung on CT.
4. Asbestosis: Similar CT presentation as hypersensitivity pneumonitis but asbestos exposure in patient history
298
What are the 2 benefits of using fixed-flow oxygen masks?
1. Obtain a more accurate PO2 on blood gases
| 2. Cannot give too much O2 as the rate is always fixed
299
What PaO2 calls for long-term oxygen therapy for patients normally?
PaO2 ≤ 7.3kPa
300
In what 3 conditions should the PaO2 ≤ 8kPa for long-term oxygen therapy?
1. Peripheral oedema
2. Polycythemia (hematocrit ≥ 55%)
3. Pulmonary hypertension (cor pulmonale)
301
How is an esophagectomy performed for esophageal cancer treatment?
Removes part of the esophagus that is affected by the cancer and rebuilds it using part of the stomach or large intestine
302
What hormone will increase with the development or worsening of heart failure?
BNP - B-type natriuretic hormone
303
What drug is used to help people stop smoking?
Varenicline
304
Name 3 commonly used LMWH/factor 10a inhibitors and when each is used
Enoxaparin: in renal impairment (eGFR < 30)
Dalteparin: first line for normal patients
Tinzaparin: in pregnancy
305
Other than LMWH, what other treatment is used to prevent clot formation?
1. TEDS/GECS stockings —> used in post-surgical patients
| 2. Flow Trons —> used in stroke patients
306
What is the acute treatment regimen for ACS? After acute treatment what medications do you give?
Acute:
- 300mg aspirin
- 300mg clopidogrel
- 2.5mg SC fondaparinux
Afterwards:
- Morphine
- Oxygen
- Nitrates SL 1-2 puffs
- 75mg Aspirin
- 300mg Clopidogrel
- B-blockers after 1-2 days
307
What is the mechanism of action of aspirin + clopidogrel?
Work on platelets + arteries (not venous)
308
What is the mechanism of action of nitrates?
Cause cerebral vasoconstriction + peripheral vasodilation -> hypotension
SE = dizziness, headache
309
Name a drug that can be used for acid reflux and its drug class
Rabeprazole
Proton Pump Inhibitor (PPI). Works by inhibiting gastric acid secretion by blocking the hydrogen-potassium adenosine triphosphatase enzyme system of the gastric parietal cell.
310
What are the differences between aortic stenosis and aortic sclerosis?
Aortic valve thickening (sclerosis) without stenosis is common in elderly adults. It is often detected either as a systolic murmur on physical examination or on echocardiography or computed tomography performed for some other reason. Aortic valve sclerosis is important clinically because it can progress to aortic stenosis and is a marker for increased cardiovascular risk.
Aortic stenosis radiates to the neck
311
What values are high from a blood test in myxoedema (other than thyroid function tests)?
High cholesterol + creatine kinase
312
What are the 2 true tests to determine if the liver is working properly?
1. Clotting factors
| 2. Albumin
313
What is the progression of liver disease?
1. Normal liver
2. Fatty liver
3. Acute hepatitis
4. Cirrhosis
314
What can appear on a chest X-ray in a patient with hypoalbuminemia?
Pleural effusion
315
What is a patient's liver like in cirrhosis?
Shrunken liver (not palpable)
316
Name an example of a drug to control blood pressure and its class
Ramipril
Angiotensin-converting enzyme (ACE) inhibitor. Works by blocking ACE in the lungs from converting angiotensin I to angiotensin II. Thus ACE inhibitors cause vasodilation of blood vessels leading to the reduction of blood pressure.
317
Name an example of a b-blocker and its use
Propranolol
Used in heart failure, hypertension, and heart arrhythmias. These drugs slow the heart rate and lower blood pressure by blocking the effects of epinephrine/adrenaline. They also vasodilate veins and arteries.
318
Name the coronary arteries and the areas of the heart that they supply
Left anterior descending artery: R ventricle, L ventricle, intraventricular septum
L marginal artery: L ventricle
R coronary artery: R atrium + R ventricle
L circumflex artery: L atrium + L ventricle
319
Name the ECG changes in the different MIs and the coronary arteries that are occluded
Inferior MI = II, III, aVF = Right coronary artery
Anteroseptal MI = V1-V4 = LAD
Anterolateral MI = I, aVL, V5-V6 = Circumflex artery
Extensive anterior = I, aVL, V2-V6 = LCA
True posterior = tall R in V1 = RCA
320
Give an example when you would use Resuscitations fluids. What fluid would you give and at what rate?
- Sepsis
- N/S (normal saline - NaCl 0.9%) or Hartmann's (more biologically similar and includes K+)
- 500mL/5min (STAT rate)
321
Give an example when you would use Maintenance fluids. What fluid would you give and at what rate?
- Nil by mouth before a surgery
- N/S + KCl
- Hartmann's
- Dextrose 5%
- 500mL + 20mmol KCl/6h
322
Give an example when you would use Replacement fluids. What fluid would you give and at what rate?
- Fluid losses (i.e. vomit, stoma)
- Hartmann's
- On top of maintenance requirements, measure the amount of fluid losses
323
What is the normal PaO2 on a blood gas?
10.5 - 13.5kPa
324
What is the normal PaCO2 on a blood gas?
4.5-6kPa
325
What are the possible percentages of oxygen available through a Venturi mask?
24, 28, 31, 35, 40, 60%
326
How do you determine the normal PaO2 of a patient who is not on room air?
Subtract 10 to determine their normal O2 on air. If 65%+ oxygen used, then take 2/3 of that number to determine their normal
327
What is the difference between hypoxia and hypoxemia?
Hypoxia < 8kPa
Hypoxemia = relative hypoxia. Less than what the oxygen levels should be.
328
What value on an ABG will tell you if the acidosis/alkalosis is RESPIRATORY in origin?
PaCO2
PaCO2 > 6kPa = respiratory acidosis
PaCO2 < 4.5kPa = respiratory alkalosis
329
What is the normal base excess range? What does it show?
-2 to +2
Lower than -2 = metabolic acidosis
Higher than +2 = metabolic alkalosis
330
What value on an ABG will tell you if the issue is metabolic?
HCO3- levels
331
What are the normal levels of HCO3-?
22-26kPa
332
How do you know if compensation has occurred?
Complete compensation = normal pH (I.e. look at HCO3- would expect to be high if low PaCO2)
Partial compensation = pH remains abnormal
333
Give common examples of all acidosis/alkalosis conditions
Metabolic Alkalosis = vomiting (getting rid of stomach acid)
Metabolic Acidosis = Sepsis, DKA
Respiratory Alkalosis = Hyperventilation
Respiratory Acidosis = Acute exacerbation of COPD
334
What does lactate indicate on an ABG?
Anaerobic breakdown
This value would be high in METABOLIC disease (I.e. MI, ischemia bowel, seizures, sepsis)
335
When will you get a large anion gap in metabolic acidosis?
MUDPILES!
```
Methanol
Uremia (chronic renal failure)
Diabetic Ketoacidosis
Propylene glycol
Infection, isoniazid, Inborn errors of metabolism
Lactic Acidosis
Ethanol
Salicylates
```
336
Name a condition that would cause a small anion gap
Hypoalbuminemia (i.e. in CLD, nephrotic syndrome)
337
Name some conditions that would have a normal anion gap
Renal Tubular Acidosis, Diarrhea/vomiting, Addison’s Disease, Pancreatic fistula, Acetazolamide
338
What is the relationship between the direction of change in the pH and the direction of change in the PaCO2? HCO-?
In primary RESPIRATORY disorders, the pH and PaCO2 change in OPPOSITE directions
In METABOLIC disorders the pH and HCO3- change in the SAME direction
339
How do you know if compensation is occurring in respiratory/metabolic disturbances?
Respiratory: HCO3- will increase in acidosis or decrease in alkalosis
Metabolic: PaCO2 will decrease in acidosis or increase in alkalosis
340
What are the surgical options for COPD treatment?
1. Lung volume reduction surgery (chop off top of lungs)
- Can put valves/coils in to do this
2. Transplant (end-stage; not allowed to smoke 6-12mo beforehand; no improvement in life expectancy)
341
Name 2 types of inhalers
1. Metered-Dose Inhaler
| 2. Dry Powder Inhaler (DPI)
342
What is the treatment for gout?
Colchicine 500micrograms QDS + Naproxen 750mg STAT then regular dose
343
What drug class does allopurinol belong to and how does it work?
Xanthine Oxidase Inhibitor
It works by reducing the production of Uric acid in the body. High levels of uric acid may cause gout attacks or kidney stones
344
When should diuretics be given to patients?
Morning and at lunch time (so the patient wont have to urinate in the night)
345
If TLCO is low and is corrected by KCO (KCO is normal) where is the problem?
Outside of the lungs (I.e. caused by obesity)
346
What is the treatment for aspiration pneumonia?
If Gram positive:
- Amoxicillin + clavulanic acid (co-amoxiclav)
If Gram negative:
- Piperacillin/Tazobactam
If Either:
- Ceftriaxone
If Anaerobes:
- Clindamycin
- Metronidazole
347
What is bulbar palsy and name 2 causes
A LMN lesion affecting CN7-12
- Flaccid paralysis of pharynx and larynx
Causes:
- Guillain-Barré syndrome
- Brainstem lesions (i.e. Malignancy)
348
Name 4 main causes of high calcium levels in the blood
1. Primary hyperparathyroidism
2. Malignancy (i.e. bone metastases)
3. Thiazide diuretics
4. Chronic Kidney disease
349
Name 4 main causes of hyponatremia
1. Kidney failure
2. Heart failure
3. Cirrhosis
4. Diuretic use
350
What is the definition of consolidation?
Infectious material in the alveoli of the lungs. As a result you should still be able to see the airways
351
What is base excess?
Amount of base added/taken away from serum to get back to normal pH in a situation where CO2 is normal
352
What are the 2 types of lactic acidosis and why do they occur?
Type 1: Inadequate oxygen delivery (O2 levels are low)
- anaerobic muscular activity (sprinting, generalised convulsions)
- tissue hypoperfusion (shock, cardiac arrest, regional hypoperfusion -> mesenteric ischaemia)
- reduced tissue oxygen delivery (hypoxaemia, anaemia) or utilisation (CO poisoning)
Type 2: No evidence of inadequate oxygen delivery
(a) associated with underlying diseases:
LUKE: leukaemia, lymphoma
TIPS: thiamine deficiency, infection, pancreatitis, short bowel syndrome
FAILURES: hepatic, renal, diabetic failures
```
(b) associated with drugs & toxins:
phenformin
cyanide
beta-agonists
methanol
adrenaline
salicylates
nitroprusside infusion
ethanol intoxication in chronic alcoholics
anti-retroviral drugs
paracetamol
salbutamol
biguanides
fructose
sorbitol
xylitol
isoniazid
lactate-based dialysate in RRT
congenital forms of lactic acidosis with various enzyme defects — e.g. pyruvate carboxylase deficiency, glucose-6-phosphatase and fructose-1,6-bisphosphatase deficiencies, oxidative phosphorylation enzyme defects)
```
(c) associated with inborn errors of metabolism
353
In simple terms why are lactate levels increased?
1. Increased production by the liver
| 2. Decreased clearance by the liver
354
What 2 blood tests indicate acute systemic illness (i.e. sepsis, pancreatitis)?
1. Increased CRP
| 2. Decreased albumin
355
What is Guillain-Barré Syndrome?
Guillain–Barré syndrome (GBS) is a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system. The initial symptoms are typically changes in sensation or pain along with muscle weakness, beginning in the feet and hands.
- LMN disorder
356
What is the treatment of Guillain-Barré syndrome?
Intravenous immunoglobulin
357
What murmur is likely to cause exercise syncope?
Aortic stenosis
358
What is the most likely cause of SVC obstruction and what is a physical sign?
Bronchial tumour.
Physical sign = visible chest veins
359
Define Corrigan's Sign
Powerful pulsations of the carotid arteries causing ear movement and/or head nodding
Sign of aortic regurgitation
360
Name a drug that treats hypertension but also potentially causes peripheral oedema as a side effect. How would you treat this?
Amlodipine
DO NOT treat with furosemide (loop diuretic) as this can cause hypokalemia and AKI. Instead STOP amlodipine!
361
Explain JVP waves
There are 3 waves = A, C, V
There are 2 troughs = X, Y
```
A = atrial contraction
X = atrial relaxation
C = bulging of tricuspid valve with ventricular contraction
X' = downward movement of tricuspid valve with ventricular contraction
V = passive atrial filling
Y = atrial emptying with opening of the tricuspid valve
```
362
How would you treat a house fire victim? What value would you look for? What test would you perform?
Treat CO exposure with oxygen. Perform ABG to check CO levels.
363
How would you manage an acute asthma attack (what's the mnemonic)?
O SHIT ME
```
Oxygen
Salbutamol
Hydrocortisone
Ipratropium
Theophylline
Magnesium
Escalate (get help from senior!)
```
364
What are the 4 broad possible causes of a fall?
1. Cardiogenic
2. Vasovagal
3. Mechanical
4. Seizure
