Respiratory Block Flashcards
What is PCP?
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)
What drug is used to prevent/treat pneumocystis jirovecii pneumonia?
Trimethoprim/sulfamethoxazole (co-trimoxazole)
Give for 3 weeks by mouth/IV
Side Effects: Rash, fever
How is PCP diagnosed?
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)
What is wernicke-korsakoff syndrome?
The combined presence of Wernicke encephalopathy and alcoholic Korsakoff syndrome
Caused by thiamine (Vitamin B1) deficiency
What disorders stem from thiamine deficiency?
- Beriberi
- Wernicke encephalopathy
- Alcoholic Korsakoff syndrome
What is the difference between Wernicke encephalopathy and Korsakoff syndrome?
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
What are the symptoms of wernicke encephalopathy?
- Ocular disturbances (nystagmus)
- Changes in mental state (confusion)
- Unsteady stance and gait (ataxia)
What are the symptoms of Korsakoff syndrome?
- Anterograde amnesia
- Variable retrograde amnesia
- Aphasia
- Apraxia
- Agnostic
- Defect in executive functions
- Confabulation
What is the treatment of Wernicke Syndrome?
IV thiamine to reverse it before it becomes irreversible Korsakoff syndrome
What are the signs and symptoms of hypovolemia?
- Increased HR
- Low BP
- Pale/cold skin
- Altered mental status
- Oliguria
- Low JVP
- Headache
- Fatigue
- Weakness
- Thirst
- Dizziness
What are causes of hyperkalemia?
- 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
What is the treatment for active pulmonary TB?
- Isoniazid + rifampicin (6mo)
2. Pyrazinamide + ethambutol (first 2mo of 6mo treatment)
How long after TB treatment is the patient no longer infectious?
After taking antibiotics for 2 weeks
When can patients make their own decisions about their treatment (when do patients have capacity)?
Age 16
How does the MCA set out a 2-stage test of capacity?
- 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?
The MCA says a person is unable to make a decision if they can’t:
- 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
Explain the WHO’s cancer pain ladder and name 1 drug for each step of the ladder
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)
Describe what emphysema look like on a (1) x-ray (2) CT
(1) Lungs appear much larger than they should be
2) CT will show destruction of alveoli (air sacs
How is one diagnosed with schizophrenia?
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
Identify the stages of AKI
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
What are risk factors for AKI?
- Kidney disease
- Malignancy
- Heart failure
- Ischemic heart disease
- Liver disease
- Urological intervention
What are the nephrotoxic drugs?
- Angiotensin-converting enzyme inhibitors/angiotensin-II receptor antagonists
- NSAIDs
- Antivirals/antifungals
- Vancomycin/gentamicin
- Chemotherapy/contrast
How can an azygous lung lobe form?
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.
Which drugs can cause hyponatremia?
- Diuretics (thiazides, loop diuretics, indapamide, amiloride)
- Antidepressants (amitryptilline)
- Anti-epileptic drugs (carbamazepine)
- Anticancer agents
- NSAIDS
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.
What are signs/symptoms of type 2 respiratory failure?
- Drowsiness
- Peripheral cyanosis
- Confusion
- Headache
- Asterixis
- Shortness of breath
- Syncope
- Irregular heart rhythms
What are the top 4 most common causes of COPD?
- Smoke exposure
- Biomass exposure
- Previous TB
- Alpha-1 antitrypsin deficiency
How many units are in 1 pint of beer?
2 units
How do you calculate pack years of cigarettes?
(# of cigs/20 cigs in a pack) x # of years smoking
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
What is search satisficing (premature closure)?
To stop investigating after 1 diagnosis is found
What is confirmation bias?
To look for supporting evidence for a diagnosis rather than seeking information to rule it out
What is posterior probability?
To be unduly influenced by the patient’s previous medical history
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
What is fundamental attribution error?
To blame patients, especially psychiatric, minority, and marginalised groups, for their illness
What is ascertainment bias?
To be influenced by prior expectations (I.e. gender bias + stereotyping)
What is triage cueing?
To create bias at the initiation of triage that then influences the ultimate choice of patient management
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
What is psych-out?
To minimise or misdiagnose serious medical conditions in psychiatric patients
What is illusory correlation: superstition?
A perception that there is a causal relationship between conditions, events, and actions when no actual relationship exists
What is sarcoidosis?
Inflammation in the form of granulomatous tissue that can affect lymph nodes, lungs, eyes, joints, kidneys
What blood test can indicate sarcoidosis or TB?
Increased ACE levels
- As ACE is found in macrophages (I.e. granulomas)
What is the treatment of sarcoidosis?
Steroids for 1-2yrs
Name 2 anti-acids used to treat GORD and side effects?
Omeprazole + ranitidine
SE: increased risk of gastroenteritis
Name the antibiotic typically prescribed for bronchiectasis prophylaxis and its class and possible side effects
Azithromycin
Macrolide
SE: hearing loss + balance problems
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
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
What drug is used to treat aspergillosis?
Voriconazole (antifungal)
What is Anoro?
It’s a combination drug used in COPD that contains vilanterol (B2 agonist - ultra LABA) and umeclidinium (long-acting muscarinic antagonist)
What are side effects of excess steroid use?
- Increased risk of infections
- Cushing’s syndrome
- Glaucoma
- Indigestion
- Increased appetite -> weight gain
- Difficulty sleeping
- Changes in mood/behaviour
- High blood sugar/diabetes
- Osteoporosis
- High BP
- Mental health problems
What are the 3 main causes of clubbing?
- Infective endocarditis
- Chronic lung infection
- Bronchiectasis
Which drug is used to treat glaucoma?
Latanoprost
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
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
What is the progression of common infections in COPD?
- Hemophilius
- Influenza
- Staph. Aureus
- Pseudomonas
What lobes are affected by TB?
Upper lobes of lungs
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
What is typical of asthmatics that are SOB?
Diurnal variation of SOB (worse at night)
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
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)
What are the typical drugs prescribed for the respiratory system?
- Bronchodilators (salbutamol + steroid to settle inflammation)
- Antibiotics (for infections)
- Mucolytics (to loosen up phlegm to more easily cough it up)
What would a patient be prescribed in addition to their salbutamol inhaler in a severe asthma attack?
A beclomethasone (steroid) inhaler
What are atypical organisms that can cause pneumonia?
Listeria, Mycoplasma, Legionella, Chlamydia
What is the treatment for atypical pneumonia?
Macrolides (i.e. clarithromycin) -> as these atypical organisms lack a cell wall
How do beta-lactams/penicillins work?
Destroy the cell wall of the organism
How do macrolides work?
Destroys the protein synthesis process within the organism
What condition should you think of when you hear a heart murmur?
Infective endocarditis
What murmur causes a collapsing pulse?
Aortic regurgitation
How many lobes does the R lung have?
3
How many lobes/features does the L lung have?
2 + cardiac notch + lingula
What is dyshemaglobinemia?
Hemoglobin molecule is functionally altered, and prevented from carrying O2
What is the equation for vital capacity in spirometry?
Tidal volume + Inspiratory reserve volume + Expiratory reserve volume
What is the equation for functional reserve capacity?
Expiratory reserve volume + residual volume
What is the equation for total lung capacity?
Residual volume + expiratory reserve volume + tidal volume + inspiratory reserve volume
What is the normal TLC for an adult male?
Approx 6L
What is FEV1
Forced expiratory volume in 1sec
What is a normal FEV1/FVC ratio?
~80%
Name 4 obstructive lung disorders
- COPD
- Asthma
- Cystic fibrosis
- Bronchiectasis
What occurs in obstructive lung disorders?
Reduction in airflow + air remains in lung at expiration + hyperinflation
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
Name 5 restrictive lung disorders
- Fibrosis
- Sarcoidosis
- Pneumonia
- Connective tissue defects
- Pleural effusion
What occurs in restrictive lung disease?
Reduction in lung volume
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
What is the best imaging for each of the following:
- Pleural effusions + empyema
- Pulmonary embolism
- Bone metastases
- Cancer/inflammation
- Lung cancer, interstitial lung disease
- Ultrasound
- Radionucleotide scans
- Bone scan
- PET scan
- CT scan
What are the 2 most common antibiotics used to treat pneumonia?
Amoxicillin + clarithromycin
What are the most common community-acquired organisms leading to pneumonia?
- Strep. pneumoniae
- H. influenzae
- Moraxella catarrhalis
- 15% are viruses
What are the most common hospital-acquired organisms leading to pneumonia?
- Gram negative enterobacteria
2. Staph. aureus
Name 3 clinical features of pneumonia?
- Purulent sputum
- Hemoptysis
- Pleuritic pain
What are 5 signs of pneumonia?
- Tachypnea
- Tachycardia
- Hypotension
- Signs of consolidation (i.e. dull percussion)
- Pleural rub
What is the most common bacteria to cause pneumonia?
Pneumococcal pneumonia
Name 6 complications of pneumonia
- Hypotension
- Type 1 respiratory failure
- Atrial fibrillation
- Pleural effusion
- Empyema
- Lung abscess (septicemia, jaundice, pericarditis/myocarditis)
What is cystic fibrosis?
Autosomal recessive disorder on chromosome 7
Decreased Cl- secretion + increased Na+ absorption across airway epithelium
What 2 drugs target the cystic fibrosis transmembrane conductance receptor?
Ivacaftor + lumacaftor
What are signs of a lung tumour?
- Cough
- Hemoptysis
- Chest pain
- Recurrent pneumonia
- Weight loss/anorexia
- Lethargy
What is asthma and what are the 3 things that cause it?
Reversible airway obstruction caused by:
- Bronchial muscle contraction
- Mucosal swelling/inflammation (mast cell + basophil degradation)
- Increased mucus production
What does the British Thoracic Society Prescribing Guidelines say about asthma medications? What are the 5 steps of prescribing for asthma?
- Short-acting B2 agonist (salbutamol)
- Inhaled steroid (beclomethasone)
- Long-acting B2 agonist (salmeterol)
- Leukotriene receptor antagonist (Theophylline)
- Regular prednisolone
What is a side effect of B2 agonists?
Paradoxical bronchospasm
What is COPD?
Chronic bronchitis + emphysema
What are signs/symptoms of COPD?
- > 35yrs of age
- Smoking (active/passive)/pollutants
- Chronic dyspnea
- Sputum production
- Minimal diurnal variation
How does one diagnose chronic bronchitis?
Cough, sputum production on most days for 3mo of 2 successive years. Symptoms decrease if smoking stops
What is emphysema?
Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls visible on CT
What are the signs of a “Pink Puffer” COPD patient?
- Increased alveolar ventilation
- Near normal PaO2
- Normal/low PaCO2
- Breathless
- NOT cyanosed
- At risk of type 1 respiratory failure
What are the signs of a “Blue Bloater” COPD patient?
- Decreased alveolar ventilation
- Low PaO2
- High PaCO2
- NOT breathless
- Cyanosed
- At risk of Cor Pulmonale (R sided heart failure)
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
How can hyperinflation be measured?
By the cricosternal distance (if more than 3cm = hyperinflation)
What is seen clinically on examination of a COPD patient?
- Decreased expansion
- Resonant/hyperresonant percussion
- Decreased breath sounds
- Wheeze
- Cyanosis
- Cor pulmonale
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
What are the x-ray findings for COPD?
- Increased bronchovascular markings
- Cardiomegaly
- Lung hyperinflation
- Flattened hemidiaphragms
- Small heart
- Bullous changes
- Lateral view = barrel chest (widened AP diameter)
What would an ECG of COPD show?
R atrial + ventricular hypertrophy (cor pulmonale)
What would be present on the ABGs of a patient with COPD?
Decreased PaCO2 + hypercapnea
What is the treatment of an Acute exacerbation of COPD?
- Nebulised bronchodilators salbutamol + ipratropium
- Oxygen therapy if SaO2 < 88% (start with 24-28%; aim for PaO2 > 8kPa and PaCO2 not to rise > 1.5kPa
- Steroids (prednisolone, hydrocortisone)
- Antibiotics if infection
- Physio for sputum expectoration
- If no response to steroids/bronchodilators use IV aminophylline
- Use non-invasive positive pressure ventilation (if reap rate > 30, pH < 7.35, PaCO2 increases despite tx)
What are 2 causes of acute respiratory distress syndrome?
- Direct lung injury (primary)
2. Severe systemic illness (secondary)
What are the signs/symptoms of Acute respiratory distress syndrome?
Cyanosis, tachypnea, tachycardia, peripheral vasodilation, fine inspiratory crackles bilaterally
What is a normal PaO2/FiO2 ratio? What is it in Acute respiratory distress syndrome?
500
< 200 in ARDS
How is respiratory failure defined?
PaO2 < 8kPa
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
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
What do the ABGs show if the cause is respiratory?
pH and PaCO2 in opposite directions
What do the ABGs show if the cause is metabolic?
pH and HCO3 change in the same direction
What is a normal anion gap?
10-18mmol/L
What O2 % should you start COPD patients on?
24-28%
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
What are 5 risk factors for PE?
- Thrombophilia (hypercoag)
- Recent surgery
- Pregnancy, postpartum, combined OCP
- Malignancy
- Previous PE (assess family hx)
What are the symptoms of PE?
Breathlessness, pleuritic chest pain, hemoptysis, dizziness, syncope
What are the signs of PE?
Pyrexia, hypotension, cyanosis, tachypnea/cardia, raised JVP, pleural rub, pleural effusion
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
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
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)
What is the treatment to prevent PE?
Give all immobile patients heparin + stop HRT/combined OCP
What are DOACs?
Rapid onset + don’t need continuous monitoring because of fixed dose. Antidotes for DOACs becoming available.
Who is at increased risk of pneumothorax?
Increased risk in young thin males due to rupture of suprapleural bulla
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
What is the management for a primary/secondary pneumothorax?
Aspiration + chest drain if unsuccessful
What is a pleural effusion?
Fluid in pleural spaces
How can pleural effusions be classed?
Based on their protein components:
- Exudates = >35g/L
- Transudates = <25g/L
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
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)
Define the following: Hemothorax Empyema Hemopneumothorax Chylothorax
- Blood in pleural space
- Pus in pleural space
- Blood + air in pleural space
- Chyle (lymph with fat) in pleural space
What are the symptoms of a pleural effusion?
Asymptomatic or pleuritic pain + dyspnea
What are the signs of a pleural effusion?
- Decreased expansion
- Stony dull perussion
- Decreased breath sounds on affected side
- Vocal resonance decreased
- Bronchial breathing above effusion
What are good investigations to confirm a pleural effusion diagnosis?
- Chest x-ray -> blunted costophrenic angles
2. Ultrasound -> to guide aspiration treatment
What is obstructive sleep apnea syndrome?
Collapse/intermittent closure of pharyngeal airway. Terminated by partial arousal
Who is at risk of obstructive sleep apnea syndrome?
Typically obese, middle-aged men
What are the symptoms of obstructive sleep apnea?
Snoring + daytime somnolence
Morning headache, decreased libido, nocturia
What are 3 complications of obstructive sleep apnea syndrome?
- Pulmonary HTN
- T2 respiratory failure
- Risk factor for HTN
What is cor pulmonale?
Right heart failure caused by chronic pulmonary arterial HTN
Name 6 causes of cor pulmonale
- Lung disease (i.e. COPD, bronchiectasis)
- Pulmonary vessel disease (i.e. pulmonary emboli, ARDS, sickle cell)
- Thoracic cage abnormalities (i.e. kyphosis, scoliosis)
- Neuromuscular disease (i.e. myesthenia gravis, MND, Polio)
- Hypoventilation (i.e. sleep apnea, enlarged adenoids in kids)
- Cerebrovascular disease (i.e. stroke)
What are the clinical features of cor pulmonale?
Dyspnea
Fatigue
Syncope
What are the clinical signs of cor pulmonale?
Cyanosis Raised JVP RV heave Loud P2 Pansystolic murmur (tricuspid regurgitation) Hepatomegaly Oedema
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
What is sarcoidosis? Who is at risk?
Multisystem granulomatous disorder of unknown cause
Higher prevalence in Northern Europe, Females, AfroCarribean, 20-40yr age group
What are the clinical features of sarcoidosis?
- 20-40% asymptomatic
- Erythema nodosum -> acute sarcoidosis
- Polyarthralgia (joint pain)
- Bilateral hilar lymphadenopathy (BHL)
What are the symptoms of sarcoidosis?
Dry cough, progressive dyspnea, decreased exercise tolerance, chest pain
List 6 causes of Bilateral Hilar Lymphadenopathy
- Sarcoidosis
- Malignancy
- Infection
- Organic dust disease
- Hypersensitivity pneumonitis (i.e. Bird Fancier’s Disease)
- Histocytosis X (eosinophilic granuloma)
What is interstitial lung disease?
A condition that affects lung parenchyma and leads to chronic inflammation and interstitial fibrosis
What are the clinical features of interstitial lung disease?
- Dyspnea on exertion
- Non-productive paroxysmal cough
- Abnormal breath sounds
- Restricted pulmonary spirometry with decreased diffusion capacity of lung for CO2
What are the 3 steps of the pathophysiology of interstitial lung disease?
- Fibrosis and remodelling of interstitium
- Chronic inflammation
- Hyperplasia of type II epithelial cells or pneumocytes
How can interstitial lung disease be broadly classified?
- Those with known causes
- Those associated with systemic disorders
- Idiopathic
What is extrinsic allergic alveolitis?
Inhalation of allergens triggers a hypersensitivity reaction
What occurs in the acute phase of extrinsic allergic alveolitis?
Alveoli are infiltrated with inflammatory cells
What occurs with chronic exposure to the allergen in extrinsic allergic alveolitis?
granulomas and obliterative bronchiolitis occurs
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
What cell types are present at increased levels in bilateral hilar lymphadenopathy?
Lymphocytes + mast cells
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
How is idiopathic pulmonary fibrosis treated?
- Opiates
- Oxygen
- Pulmonary rehab
- Palliative care (50% 5-yr survival)
- Lung transplant
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
What are the main causes of lung fibrosis?
Idiopathic pulmonary fibrosis, asbestos, drugs (methotrexate), systemic sclerosis + lupus, hypersensitivity pneumonitis, vasculitis
What is the prognosis for lung fibrosis?
3-5 years, there isn’t a cure
What is a signet ring sign?
When the bronchi is bigger than the neighbouring blood vessel on a CT scan
Indicative of bronchiectasis
What are the 3 main causes of a cough?
- GORD
- Asthma
- Post-nasal drip (tickling cough)
If someone has a cough for over 6 weeks what should you do and why?
Order chest X-ray to screen for lung cancer
What 4 conditions can rheumatoid arthritis cause?
- Interstitial lung disease
- Lung nodules
- Bronchiectasis
- Pleural effusion
What breath sounds are heard in idiopathic pulmonary fibrosis?
Fine end-inspiratory crackles (“walking on snow”)
What is a possible treatment for interstitial lung disease?
Antifibrotics (i.e. Perfenidone)
What are 3 characteristic features of interstitial lung disease on a CT scan?
- Subpleural reticulation worse in bases
- Traction bronchiectasis (bronchi present at end of lung border)
- Honeycombing (holes in the lung itself)
Raised Ca2+ can lead to what abnormality?
AKI
What is the medication used to treat alcohol withdrawal
Chlordiazepoxide
What is the treatment for sarcoidosis?
Prednisolone steroids
What tests can you perform to check for sarcoidosis? What test can diagnose sarcoidosis?
- ACE, Ca2+ levels in bloods; ECG
2. Biopsy
What are 5 causes of hypercalcemia?
- Cancers, especially lung cancer and breast cancer
Immobilization over a long period of time - Kidney failure
- Overactive thyroid (hyperthyroidism) or excessive thyroid hormone intake
- Use of certain medications such as the thiazide diuretics
Inherited kidney or metabolic conditions - Excessive vitamin D levels from vitamins, excessive dietary calcium, or from diseases that may result in excess vitamin D production
What CT view is best to see lymph nodes?
Mediastinal view
Outline sepsis 6
- Give high flow O2
- Take blood cultures
- Give IV antibiotics
- Give IV fluids
- Measure lactate
- Measure urine output
What are 2 causes of an increased ammonia on a blood test?
- Encephalopathy
2. Sodium valproate (used as an anti-epileptic)
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.
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
What drugs are used to treat TB?
Think PRIEST
```
Pyrazinamide
Rifampicin
Isoniazid
Ethambutol hydrochloride
Streptomycin
(TB drugs)
~~~
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
Outline the standard course of antibiotics for active TB
Ethambutol + pyrazinamide + rifampicin + isoniazid = 2mo
Rifampicin + isoniazid = for another 4mo
Total course of antibiotics = 6mo
What is the infectious agent that causes TB?
Mycobacterium tuberculosis
What are the systemic features of TB?
- Low-grade fever
- Anorexia
- Weight loss
- Malaise
- Night sweats
- Clubbing (bronchiectasis)
- Erythema nodosum
What are the clinical features of pulmonary TB?
- Cough (<2-3wks, dry then productive)
- Pleurisy
- Hempotysis (uncommon, seen with bronchiectasis, not always active disease)
- Pleural effusion
An aspergillosis/my stomach may form in the cavities. Presentation varies and may be silent/atypical especially with immunosuppression
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
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
What does active pulmonary TB look like on an X-ray?
- Fibronodular/linear opacities in upper lobe, middle/lower lobes (atypical)
- Cavitation
- Calcification
- Miliary disease
- Effusion
- Lymphadenopathy
What are diagnostic tests for TB?
- Chest x-ray
- Sputum smear (looking for acid-fast bacilli)
- Sputum culture (more sensitive than smear; can assess drug sensitivity)
- Nuclei acid amplification test (can detect drug resistance; <8hrs)
Which TB drugs can be toxic to the kidneys?
Pyrazinamide + ethambutol
Which TB drug inhibits formation of active pyridoxine and requires you to prescribe it prophylactically? What vitamin is pyridoxine?
Isoniazid
Vitamin B6
Which TB drug changes body secretion colours? What colour are the body secretions?
Rifampicin
Orange-red colour
What is an example of a Factor Xa inhibitor?
Rivaroxaban
What is an example of a Low-Molecular Weight Heparin (LMWH)?
Dalteparin
What are factor Xa inhibitors and heparins?
Anti-coagulates
What blood test abnormalities indicate TB?
- Increased erythrocyte sedimentation rate (ESR)
- Normocytic normochromic anemia
- Decreased serum albumin
- Hyponatremia
- Abnormal LFTs
- Leukocytosis
- Hypocalcemia
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)
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)
How can paradoxical reactions to TB be treated?
- Steroid treatment
2. Immunosuppression if severe
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
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
How do you treat long QT syndrome?
- Removal/treatment of causative factors
2. B-blockers, lifestyle modifications, monitoring
Which TB drug can be responsible for long QT syndrome?
Rifampicin
Name an anti-anginal
Ranolazine
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
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
What is the mechanism of action of HAART?
- CCR5 antagonists -> inhibit the entry of the virus into the cell by blocking the CCR5 co-receptor (I.e. Maraviroc)
- 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)
- Integrate strand transfer inhibitors -> inhibit integrate + prevent HIV DNA integrating into the nucleus (i.e. Dolutegravir, Elvitegravir, Raltegravir)
- Protease Inhibitors -> inhibit protease, an enzyme involved in the maturation of virus particles (i.e. Atazanavir, darunavir)
- Pharmacokinetic enhancers/boosters -> increase the effectiveness of antiretroviral drugs allowing lower doses (I.e. cobicistat, ritonavir)
What types of granulomas are found in TB?
Caseous/necrotising + non-caseous granulomas
What kind of bacteria is mycobacterium tuberculosis
Acid fast bacilli
TB doesn’t gram stain
What are the important things to check on a chest-X-ray before beginning analysis?
- Patient, date, time, quality of x-ray
- Orientation (PA/AP, R/L)
- Penetration (if overexposed see retrocardial vertebral bodies)
- Rotation (spinous processes + clavicles)
- Inspiration (anteriorly - 6th rib; posteriorly - 10th rib)
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)
What do prominent hilar areas indicate on a chest X-ray?
- Pulmonary HTN
- TB
- Sarcoidosis
- Lymphoma
What are the main causes of bilateral hilar lymphadenopathy?
- TB
- Sarcoid
- Hodgkin’s Lymphoma
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)
How are lung zones divided?
Upper zone = above anterior 2nd rib
Middle zone = anterior 2nd - 4th rib
Lower zone = below anterior 4th rib
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
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
What would absence of lung markings and blackness indicate on chest x-ray?
Pneumothorax
If trachea/mediastinum deviated = tension pneumothorax
When would you see spherical shadowing/opacity + diffuse shadowing on chest X-ray?
TB + aspergillosis (fungal infection)
What do multiple spherical opacities on a chest x-ray indicate?
Metastases in the lungs
What does diffuse shadowing throughout entirety of the lung on chest x-ray indicate?
Pulmonary fibrosis
What does air under the diaphragm indicate on chest x-ray?
Perforation
When ensuring proper insertion of nasogastric tubes, where should they be located on chest x-ray?
Should be under the diaphragm
Identify 3 causes of weight loss with normal eating
- Diabetes
- Hyperthyroidism
- Malabsorption
Name the 4 most common causes of hypoalbuminemia
- Nephrotic syndrome
- Hepatic cirrhosis
- Heart failure
- Malnutrition
What is the pathophysiology behind hypoalbuminemia?
Hypoalbuminemia is largely a function of increased vascular permeability and increased interstitial volume.
Smoking decreases the risk of which 3 conditions?
- Type 3 hypersensitivity reactions (i.e. Bird Fancier’s lung b/c alveolar macrophages aren’t able to gobble up allergens)
- Crohn’s Disease
- Ulcerative Colitis
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
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
Name 4 risk factors for developing Dupuytren’s Contracture
- Alcoholism
- Manual labour
- Diabetes
- Smoking
What is the biggest risk factor for mesothelioma?
Asbestos exposure (75% go on to develop mesothelioma)
What sign is observed on a chest x-ray indicative of mesothelioma?
Calcification in the hemi-diaphragm
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)
Which murmurs get louder on expiration? inspiration?
L-sided murmurs
R-sided murmurs
What does the pulse feel like in aortic stenosis?
Weak, plateau pulse
What does the pulse feel like in aortic regurgitation?
Collapsing pulse (very strong)
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
Name 3 causes of PE
- Stasis
- Vessel injury
- Coagulopathy
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.
What occurs in systole?
Closure of the tricuspid/mitral valve
Opening of aortic/pulmonary valve
What occurs in diastole?
Closure of aortic/pulmonary valves
Opening of mitral/tricuspid valves
What are the 3 questions to ask to determine the type of murmur?
- Where is it loudest?
- Does it radiate?
- Is it systolic or diastolic?
Where does aortic stenosis radiate to?
Carotids
Where does mitral regurgitation radiate to?
Axilla
What in the heart causes pulmonary oedema?
Backlog of blood and buildup of pressure from the L atrium
What is the benefit to using controlled humidified oxygen over unhumidified oxygen?
Generally more comfortable for the patient and lower risk of nose bleeds
What is the main side effect for COPD patients on steroids?
Increased bleeding risk
What is emphysema?
Lung tissue (alveoli) breakdown with exposure to smoke
What are the 3 commonest presentations of asthmatics to hospital?
- Acute exacerbation
- Pneumothorax
- Infection
What is the use of levetiracetam?
Used for seizures
What can cause a seizure?
- Epilepsy
- Infection
- Hyper/hypothyroidism
What are 2 signs of consolidation?
- Coarse crackles at bases
2. Bronchial breathing
What are 2 signs of pulmonary oedema?
- Fine crackles
2. Pink sputum
What are 4 causes of microcytic anemia?
- Sideroblastic anemia (lead poisoning)
- Iron deficiency anemia
- Chronic diseases
- Thalessemia
What are 3 causes of macrocytic anemia?
- Alcohol
- Folate deficiency
- B12 deficiency
What are 2 causes of normocytic anemia?
- Anemia of chronic disease
2. Acute blood loss
What are 4 main signs of aortic regurgitation?
- Collapsing pulse (Corrigan’s pulse)
- Head bobbing (De Musset’s sign)
- Audible murmur heard with bell over femoral artery (Duroziez sign)
- Pulating fingernail capillaries (Quinke’s sign)
What is an Austin Flint murmur?
Backflow of regurgitation hitting the mitral valve in aortic regurgitation
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
What time of day should statins be given?
Night time; work by blocking HMG-CoA Reductase enzyme in the liver which produces cholesterol
How is a hospital-acquired pneumonia (HAP) defined?
- Inpatient stay > 2wks then developing pneumonia
2. Pneumonias in a nursing home
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
What are the scores used for:
- CAP
- DVT/PE
- GI bleeds (before endoscopy)
- GI bleeds (after endoscopy)
- CURB-65
- Well’s Criteria
- Glasgow Blatchford Score
- Rockall Score
How is pH detected in the body?
By baroreceptors and chemoreceptors in the carotids + aortic arch
What is the primary and secondary drive to breath?
Primary = hypercapnia Secondary = hypoxia
What are the 2 types of COPD patients and how can you distinguish them?
- Retainers
- Non-retainers
Distinguish by performing blood gases
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.
Name a mucolytic
Carbocisteine
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.
Name 3 speech disturbances
- Dysarthria -> knows what their saying but its not articulating
- Dysphasia -> sensory (cant understand what’s being asked); motor (cant find words)
- Aphasia -> Inability to use spoken language
Name stroke investigations
- Non-invasive angiogram
- Angiogram
- Ultrasound
Coronary/carotid arteries need to be > 75% blocked on ultrasound before intervention is used
What is the intervention for stroke?
Carotid endarterectomy or balloon stent
Fibrinolytic (tPa)
What is the likely visual abnormality if a patient is looking away from their stroke arm?
L homonymous hemianopia
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
What are the commonest causes of AF?
Heart disease
Thyrotoxicosis
What are 3 signs of tricuspid valve incompetence (regurgitation)?
- Flicking v wave of JVP
- Enlarged liver
- Oedema
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
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
What are the 2 murmurs where you can see flicking v waves of the JVP in the neck?
Aortic regurgitation
Tricuspid regurgitation
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
What are 3 complications of aortic stenosis?
- L ventricular failure
- Angina
- Exertional syncope
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)
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)
What is the most common side effect of isoniazid?
Peripheral neuropathy
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
What breath sounds would you hear in someone with TB?
Bronchial breathing + crackles
What are the common side effects of rifampicin?
N+V, thrombocytopenia, changes in bodily fluid colour to orange/red
What are common side effects of ethambutol hydrochloride?
Hyperuricemia, nerve disorders, visual impairment
What does detection of Bence Jones protein suggest?
Multiple myeloma or Waldenström’s macroglobulinemia
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.
What are the 4 most common interstitial lung diseases?
- 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)
- 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.
- Hypersensitivity pneumonitis: Exposure to antigen (mostly fungus) causes fibrosis after initial inflammation. Fibrosis seen throughout the lung on CT.
- Asbestosis: Similar CT presentation as hypersensitivity pneumonitis but asbestos exposure in patient history
What are the 2 benefits of using fixed-flow oxygen masks?
- Obtain a more accurate PO2 on blood gases
2. Cannot give too much O2 as the rate is always fixed
What PaO2 calls for long-term oxygen therapy for patients normally?
PaO2 ≤ 7.3kPa
In what 3 conditions should the PaO2 ≤ 8kPa for long-term oxygen therapy?
- Peripheral oedema
- Polycythemia (hematocrit ≥ 55%)
- Pulmonary hypertension (cor pulmonale)
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
What hormone will increase with the development or worsening of heart failure?
BNP - B-type natriuretic hormone
What drug is used to help people stop smoking?
Varenicline
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
Other than LMWH, what other treatment is used to prevent clot formation?
- TEDS/GECS stockings —> used in post-surgical patients
2. Flow Trons —> used in stroke patients
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
What is the mechanism of action of aspirin + clopidogrel?
Work on platelets + arteries (not venous)
What is the mechanism of action of nitrates?
Cause cerebral vasoconstriction + peripheral vasodilation -> hypotension
SE = dizziness, headache
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.
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
What values are high from a blood test in myxoedema (other than thyroid function tests)?
High cholesterol + creatine kinase
What are the 2 true tests to determine if the liver is working properly?
- Clotting factors
2. Albumin
What is the progression of liver disease?
- Normal liver
- Fatty liver
- Acute hepatitis
- Cirrhosis
What can appear on a chest X-ray in a patient with hypoalbuminemia?
Pleural effusion
What is a patient’s liver like in cirrhosis?
Shrunken liver (not palpable)
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.
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.
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
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
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)
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
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
What is the normal PaO2 on a blood gas?
10.5 - 13.5kPa
What is the normal PaCO2 on a blood gas?
4.5-6kPa
What are the possible percentages of oxygen available through a Venturi mask?
24, 28, 31, 35, 40, 60%
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
What is the difference between hypoxia and hypoxemia?
Hypoxia < 8kPa
Hypoxemia = relative hypoxia. Less than what the oxygen levels should be.
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
What is the normal base excess range? What does it show?
-2 to +2
Lower than -2 = metabolic acidosis
Higher than +2 = metabolic alkalosis
What value on an ABG will tell you if the issue is metabolic?
HCO3- levels
What are the normal levels of HCO3-?
22-26kPa
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
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
What does lactate indicate on an ABG?
Anaerobic breakdown
This value would be high in METABOLIC disease (I.e. MI, ischemia bowel, seizures, sepsis)
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
Name a condition that would cause a small anion gap
Hypoalbuminemia (i.e. in CLD, nephrotic syndrome)
Name some conditions that would have a normal anion gap
Renal Tubular Acidosis, Diarrhea/vomiting, Addison’s Disease, Pancreatic fistula, Acetazolamide
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
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
What are the surgical options for COPD treatment?
- Lung volume reduction surgery (chop off top of lungs)
- Can put valves/coils in to do this - Transplant (end-stage; not allowed to smoke 6-12mo beforehand; no improvement in life expectancy)
Name 2 types of inhalers
- Metered-Dose Inhaler
2. Dry Powder Inhaler (DPI)
What is the treatment for gout?
Colchicine 500micrograms QDS + Naproxen 750mg STAT then regular dose
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
When should diuretics be given to patients?
Morning and at lunch time (so the patient wont have to urinate in the night)
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)
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
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)
Name 4 main causes of high calcium levels in the blood
- Primary hyperparathyroidism
- Malignancy (i.e. bone metastases)
- Thiazide diuretics
- Chronic Kidney disease
Name 4 main causes of hyponatremia
- Kidney failure
- Heart failure
- Cirrhosis
- Diuretic use
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
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
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
In simple terms why are lactate levels increased?
- Increased production by the liver
2. Decreased clearance by the liver
What 2 blood tests indicate acute systemic illness (i.e. sepsis, pancreatitis)?
- Increased CRP
2. Decreased albumin
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
What is the treatment of Guillain-Barré syndrome?
Intravenous immunoglobulin
What murmur is likely to cause exercise syncope?
Aortic stenosis
What is the most likely cause of SVC obstruction and what is a physical sign?
Bronchial tumour.
Physical sign = visible chest veins
Define Corrigan’s Sign
Powerful pulsations of the carotid arteries causing ear movement and/or head nodding
Sign of aortic regurgitation
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!
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
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.
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!)
What are the 4 broad possible causes of a fall?
- Cardiogenic
- Vasovagal
- Mechanical
- Seizure
