Respiratory for history taking

Question 1

DVT

Answer 1

Two level wells score:
Risk of DVT likely if ≥2
Risk of DVT unlikely if ≤1

• Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity).
• Localised tenderness alonog deep venous distribution
• Immobilization of the legs.
• Pitting oedema (greater than on the asymptomatic leg).
• Surgery in last 12 weeks
• Collateral superficial veins (non-varicose).
• Active cancer (treatment ongoing, within the last 6 months, or palliative).
• Previously documented DVT.
• Entire leg is swollen.

Likely: US scan within 4 hours/ treat
Unlikely D dimer
- if negative excluded
- if positive proceed to US

Exception:
US directly if pregnant/ delivered in last 2 weeks

Treatment: DOAC first line. provoked 3 months, unprovoked 6.

Investigations:

• examine and basic bloods FBC, UsE, LFTs, clotting. only ix for cancer if concerns
• thrombophilia screen if not for lifelong anticoagulant

Thrombophilia screen:

• Antithrombin
• Protein C
• Protein S
• APCR (screening test for Factor V Leiden)
• Prothrombin (PT) gene mutation
• antiphosophlipid antibody

Question 2

PE

Answer 2

-PERC score to exclude

• Two level wells score for PE
  Likely > 4
  Unlikely <= 4

Likely:

• CTPA
• if delay LMWH

Unlikely:
- D dimer

Massive PE= hypotension <90
Thrombolysis 50mg alteplase

Question 3

PE/DVT RF

Answer 3

Immobilisation (>3 days)
Recent surgery (past 4 weeks)
Previous DVT/PE or family history
Malignancy in last 6 months
OCP/ oestrogen meds
Travel >4 hours (past 4 weeks)
Smoker
Pregnancy/ postpartum
Obesity

Question 4

NIV indications and CI

Answer 4

Indications:
After 1 hour optimal treatment:
pH <7.35
pCO2 >6.5
 RR >23
OR in NM disease RR >20 if usual VC <1L

Contraindicaitons:
Facial deformity
Facial burns
Fixed upper airway obstruction
pH <7.15
GCS <8
Confusion/agitation

Question 5

Bronchiectasis symptoms

Bronchiectasis clinical signs

Answer 5

• persistent cough
• purulent sputum
• repeated infections
• clubbing
• coarse inspiratory creps
• localised wheeze

Question 6

Bronchiectasis next steps

Imaging findings

Answer 6

1- Full set of observations including sats and RR
2- sputum culture +/- AFB
3- CXR
4- HRCT chest
\+/-  spirometry

Think about causes for specific ix.

Imaging findings:

• CXR tramlines and ring shadows
• CT signet ring appearance

Question 7

Kartagener

Answer 7

Primary ciliary dyskinesia
Autosomal recessive

Triad:

• dextrocardia/ situs inverts
• bronchiectasis/ recurrent sinusitis
• sub fertility

Question 8

Youngs syndrome

Answer 8

Abnormality of mucus- increased viscosity

Autosomal recessive
Infertility

Question 9

Bronchiectasis treatment

Answer 9

Postural drainage
Prophylactic ab if 3x exacerbations per year (ECG prior for QTc)

Bronchodilators may help
Surgery if localised/ haemoptysis

Question 10

Bronchiectasis causes

Answer 10

1- infection

• recurrent childhood
• TB
• ABPA
• immunodeficiencies
• aspiration

2- congenital

• CF
• primary ciliary dyskinesia
• Youngs
• alpha 1 antitrypsin

3- CTD

• RA
• SLE

4- Idiopathic

5- traction bronchiectasis

Question 11

Cystic fibrosis

Answer 11

Autosomal recessive defect in CFTR gene= altered viscosity of mucus

Symptoms:

• respiratory- bronchiectasis, sinusitis, polyps
• Pancreatic insufficiency - steatorrhoea and DM
• meconium ileus + SBO
• Infertility- no vas deferent

Investigations:
High sweat sodium
Genetic testing

Treatment:

• physio
• orkambi for delta F508
• abs
• mucolytics
• beta agonists
• transplant

infections:
burkholderia cepacia worst prognosis + CI to transplant