Respiratory (MCQBank) Flashcards
Test to diagnose COPD
Post-bronchodilator spirometry
Severity rating stages of COPD
Stage 1 - FEV1 80%
Stage 2 - FEV1 50-79%
Stage 3 - FEV1 30-49%
Stage 4 - FEV1 <30%
White stuff on tongue:
- can be scraped off
- cannot be scraped off
Diagnosis?
Can be scraped off: candidiasis
Cannot be scraped off: leukoplakia (for HIV.organ transplant patients & due to EBV)
What are the stats of D-dimer? Good at diagnosing OR excluding PE/DVT?
High sensitivity (95%) - if test is positive, then it may indicate that patients may have disease but does not confirm it.
Low specificity (25%) - if test is negative, patients can still have the disease.
Specificity reduces with age (approx 10% in patients >80y/o)- therefore, if the test is negative, patient can still have the disease.
High negative predictive value (ie if patient doesn’t have the disease, the test will be negative)
Low positive predictive value (ie if patient has the disease, the test is not good at showing positive results)
CXR findings of PE
Westermark sign (sharp cut-off of pulmonary vessels)
Hampton hump (dome shaped, pleural-based opacification)
Palla sign (enlarged R descending pulmonary artery)
Most common bacteria for CAP
Strep pneumoniae
Other bacterial causes of CAP
H. influenza
Staph aureus
Group A streptococci
Atypicals: Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila
Bacterial causes of HAP
- Early onset (<5 days since admission)
- Late onset
Early onset: Strep pneumoniae. H. infleunza
Late onset: MRSA, Pseudomonas aeruginosa, Klebsiella pneumoniae, E.coli, Enterobacter spp.
Difference in presentation between bronchiectasis and COPD
Bronchiectasis: recurrent infection in childhood, large purulent sputum. Coarse crackles. Chest CT shows bronchial dilation and bronchial wall thickening. Prob has history of pertussis or TB.
Pathophys: abnormal dilation of the bronchi due to destruction of elastic and muscular components of bronchial wall. CF is the most common cause of bronchiectasis in children and young adult.
COPD: SOB, cough, wheeze, barrel chest. Can also have fatigue, weight loss, muscle loss, anorexia, cyanosis, morning headaches due to hypercapnia.
What is kvein test?
test for sarcoidosis
extract of sarcoid involved spleen is injected intradermally and 4-6weeks later a skin nodule appears which is biopsied and examined for evidence of granuloma formation. Positive result can also occur in other diseases with enlarged lymph nodes such as TB or leukaemia. Test is no longer used due to infection risk.
What is the difference between Ghon focus and Ghon complex?
Ghon focus: initial granulomatous lesion in CXR (for TB patients)
Ghon complex: calcified focus with associated mediastinal lymphadenopathy on CXR (for TB patients)
Treatment for LATENT TB.
Both Rifampicin and Isoniazid for 3 months OR Single Isoniazid for 6 months
Antibiotics of choice of IECOPD
1st line: Amoxicillin 500mg TDS OR doxycycline 200mg for 1 day then 100mg OD OR clarithromycin 500mg BD (for 5 days)
2nd line: if at high risk of tx failure: co-amoxiclav 625mg TDS OR co-trimoxazole 960mg BD OR levofloxacin 500mg OD (for 5 days)
Antibiotic of choice for acute bronchitis
1st line: doxycycline
2nd line: amoxiciliin, clarithromycin, erythromycin
Antibiotics of choice for CAP
CURB score =0 : 1st line - amox, 2nd line - doxycycline, clarithromycin, erythromycin
CURB score=1/2 : 1st line - amox & clari/ery (if pen allergic - doxy or clarithromycin)
Antibiotic of choice for HAP
1st line: co-amoxiclav 625mg TDS for 5 days
Alternative (pick ONE): doxycyline 200mg for day 1 then 100mg OD, cefalexin 500mg BD or TDS, co-trimoxazole 960mg BD, levofloxacin 500mg OD or BD (for 5 day)
Children alternative to first line: clarithromycin
Difference between acute bronchitis and COPD.
How is bronchitis different to pneumonia?
Acute bronchitis: Cough +/- SOB. wheeze, sputum
COPD: COPD AND >=1 of: sputum, wheeze, sputum, pleuritic pain
Acute Bronchitis: wheeze often present but no other focal chest signs +/- systemic features (raised T, sweats, myalgia)
COPD: focal chest signs AND >=1 systemic features
Acute bronchitis: CXR normal
COPD: CXR abnormal
Bronchitis: LRTI (bronchial airways)
Pneumonia: LRTI (lungs parenchyma - ie the portion where gas exchange occurs) - hence, consolidation in CXR
What is the investigation for central VS peripheral lesions of lungs?
Eg thoracoscopy, mediastonostomy, bronchoscopy, CT-guided biopsy, USS-guided biopsy
Centrally located lesions: bronchoscopy. (mediastinoscopy is only used to evaluate for enlarged mediastinal LN before attempting definitive surgical resection of lung cancer)
Peripherally located lesions: CT-guided biopsy OR USS-guided biopsy
If tumour is still undiagnosed after bronchoscopy/CT_guided: thoracoscopy. (thoracoscopy is also good for malignant pleural effusion)
Should the chest drain be clamped when patient is moved/transported/having a wash?
No. AS this can increase the risk of pneumothorax.
Where can the chest drain be inserted?
5th intercostal space in the mid-axillary line
What paraneoplastic syndrome is associated with:
- small cell lung cancer
- squamous cell lung cancer
Small: ACTH, SiADH, Lambert-Eaton myasthenic syndrome
Squamous Cell: PTHrP, hypertrophic pulmonary osteoarthropathy (HPOA)
what type of cancer is increased (in risk) by asbestos?
Bronchogenic lung cancer (MOST COMMON)
Mesothelioma (rare)
Gastric & colonic & renal adenocarcinoma
GI lymphomas
Tx of Legionnaire’s disease
Macrolide (erythromycin, azithromycin)
Fluoroquinolones (levofloxacin, ciprofloxacin)
How does salicylate create toxic effect?
Respiratory centres are directly stimulated.
Inhibition of citric acid cycle and uncoupling of oxidative phosphorylation.
Lipid metabolism is stimulated and amino acid metabolism inhibited. Catabolism occurs secondary to inhibition of ATP-dependent reactions.
Who is recommended to have the flu vaccine?
people >65 y/o
those who have >6months of chronic resp disease, chronic heart disease, hypertension WITH cardiac complications, CKD, chronic neurological disease, diabetics, immunosuppressed, asplenic.
health & social care people
those living in long-stay residential homes
carers of elderly/disabled person
those in close contact with poultry
Well’s score for PE
Don’t die - Tell the team to calculate criteria.
DVT symtoms/signs (3)
Diagnosis most likely PE (3)
Tachycardia: HR>100 (1.5)
Three days of immobilisation OR surgery in past Thirty days (1.5)
Thromboembolism in the past (1.5)
Cough up blood (1)
Cancer +/- tx within 6 months or palliative (1)
> 4 means likely PE
Well’s score for DVT
Active cancer / palliative (1)
Paralysis/recent plaster immobilisation (1)
Recent bedridden for 3 days or major surger within 12 weeks requiring GA/regional anaesthesia (1)
Localised tenderness along deep veins (1)
entire leg swollen (1)
calf swelling >3cm compared to other leg (1)
pitting oedema (1)
collateral superficial veins (non-varicose) (1)
previously documented DVT (1)
alternative diagnosis is at least likely as DVT (-2)
> 2 means likely DVT
Fibrosis examples (upper VS lower)
Upper lobe fibrosis: pulmonary TB, ank spon, silicosis, sarcoidosis, RA, radiation
Lower lobe fibrosis: idiopathic pul fibrosis (aka cryptogenic fibrosing alveolitis), asbestosis, bronchiectasis, scleroderma, Loeffler’s syndrome, drugs (nitro, amiodarone, methotrexate, cyclophosphamide, sulfasalazine)
MRC score for dyspnoea
Grade 1 - SOB on strenuous exercise
Grade 2 - SOB when walking uphill
Grade 3 - Walks slower on level ground due to SOB or have to stop for breath when walking at own pace
Grade 4 - SOB when walking 100m or after a few minutes on level ground
Grade 5 - Too SOB to leave the house
(Modified MRC score is Grade 0.1.2.3.4)
What diseases cause bronchial breath sounds? What is bronchial breath sounds?
Bronchial breath sounds: patent bronchi plue conducting tissue
Consolidation. Neoplasm. Fibrosis. Abscess.
What diseases cause diminished breath sounds?
Pleural effusion. Pneumothorax. Emphysema. Collapse.
What disease cause crackles/rales/creptitations?
Fine: heart failure/alveolitis
Medium: consolidation
Coarse: Bronchiectasis
Bullous myringitis, dry cough, low grade fever, maculopapular rash. Diagnosis?
Mycoplasma pneumoniae infection
CXR changes for sarcoidosis VS SLE?
SArcoidosis: bilateral hilar lymphadenopathy with pulmonary infiltrates
SLE: pleural effusion, infiltrates or cardiomegaly
What can a mom do to a newborn to ensure reduce risk of asthma for the child?
Breastfeeding!
Apparently, breastfeeding also helps with:
- acute and chronic infections including gastroenteritis, LRTI, UTI, otitis media
- allergic reactions like atopic eczema and asthma
- type 1 DM
- IBD
- RA
What bacteria causes these:
- rusty-coloured sputum
- green-coloured sputum
- red currant jelly
- dry cough
Rusty coloured: Strep pneumoniae
Green colour: Pseudomonas, Haemophilus
Red currant jelly: Klebsiella
Dry cough: mycoplasma pneumonia
repiratory tract infection + conjunctivitis + hepatomegaly + diffuse rales with/without tachypnoea + rose spots on skin
cause of the resp infection?
Chlamydophila psittaci (bird-fancier lung)
Tx: 1st line: tetracycline (doxycycline). 2nd line: macrolide (erythromycin, azithromycin) and fluoroquinolones (moxifloxacin)
Mild pyrexia, tachypnoeic, reduced breath sounds bilaterally. Had recent resection of rectal cancer. Diagnosis?
Post-operative atelectasis (generally occur within 48 hours). mucus retained in bronchial tree, blocking finer bronchi, alveolar air is absorbed, collapse of lung (basal lobes), can be secondarily infected with inhaled organisms.
Tx: analgesia & physiotherapy
what is vocal resonance? What diseases reduce/increase vocal resonance?
(this is the same as tactile fremitus?)
assessment of the density of the lung tissue
reduce vocal resonance (ie you hear the voice softer/not loud) -> reduced density than air in the lung parenchyma (ie more air) -> pneumothorax, emphysema, haemothorax, plural effusion, obesity
(PS: plural effusion is due to fluid accumulating in the space between chest wall and lung parenchyma - therefore, cannot hear the voice well)
increase vocal resonance (ie you hear the voice louder)-> more solid than air present (ie increased density) in the lung parenchyma -> pneumonia, atelectasis, cancer
Tactile fremitus is the same theory except that you palpate with your hands rather than listening with stethoscope.
what is TLC and DLCO?
Total lung capacity
DLCO - diffusing capacity
Usually important for restrictive lung disease when trying to find out cause.
- if it is an anatomical chest problem (ie kyphoscoliosis) or muscular dystrophy, then DLCO is normal.
- if there is a lung parenchymal problem (ie lung cancer, interstitial lung disease, pulmonary oedema) - then DLCO will be reduced.
what is Caplan syndrome?
pulmonary fibrosis usually in coal miners with rheumatoid arthritis
cxr: rounded nodules that may cavitate and may look like TB
tx with steroids
patient on clomiphene complaining of breathlessness and abdominal distension. ?diagnosis
Ovarian hyperstimulation syndrome (OHSS)
get ascites and pleural effusion
tx of chlamydia pneumonia
macrolide: clarithromycin or eryhtromycin
what is the boerrhave syndrome?
dysphagia, retrosternal pain, surgical emphysema
ruptured oesophagus
bowel sounds heard over right scapula angle ?diagnosis
ruptured diaphragm
left sided chest pain and tachycardia post blunt trauma. irregular HR. ?diagnosis
what is the most common lung pathology post-blunt trauma?
cardiac contusion
pulmonary contusion (NOT haemothorax or pneumothorax)
hypotension and dullness of left lung base ?diagnosis
haemothorax
what mimics COPD (ie presentation and spirometry results) but due to patient’s young age and lack of smoking history, the diagnosis is now….?
Alpha-1 antitrypsin deficiency
- do blood test FIRST -> then genetic testing
can pulmonary embolism cause pleural effusion?
Yes. for patients under 40y/o - usually unilateral effusion
Causes of erythema nodosum
Mycobacteria and streptococcal infections
Drugs
Autoimmune - IBD, Behcet’s disease, Sarcoidosis
causes of clubbing
asbestosis
fibrosigng alveolitis
lung abscess
bronchial carcinoma
mesothelioma
empyema
Smoking is an enzyme inducer for which asthma drug?
Theophylline
- CYP1A2 involved here
- therefore, smoking cessation will increase plasma concentration of theophylline -> therefore, patients will reduce the dose first
extrinsic allergic alveolitis - what type of hypersensitivity reaction?
type 3
(antibody complexes)
tietze’ syndrome
inflammation of the costal cartilage that connects rib to sternum
there is swelling
unknown cause
Costochondritis: inflammation of costochondral or costosternal joints causing localised pain and tenderness. No swelling.
olgive synndrome
acute colonic pseudo-obstruction in the absence of mechanical obstruction.
dilatation of the caecum (diameter >10cm) and right colon on abdo xray
can be associated with electrolytic inbalance with small cell lung cancer
Occupation & substance exposed
- silica
- asbestos
- berrylium
Coal miner, sandblasting : silica -> silicosis
Construction trades, joiners, plumbers, electricians, painters, boilermakers, shipyward workers, railroad workers, asbestos miners, navy veterans: asbestos -> bronchocarcinoma & mestothelioma & GI cancers & renal cancers
aerospave, nuclear, telecommunications, semi-conductor, electrical industries : berrylium
organism causing exacerbation of COPD
H.influenza
S.pneumonia
M.catarrhalis
M.pneumonia
C.pneumonia
Acute Severe asthma - what is its components?
HR>=110
RR>=25
use of accessory muscles
sats >=92%
PEFR 33-50%
which TB medication is renally-excreted?
ethambutol
is emphysema an obstructive or restrictive lung disease?
obstructive!
- abnormal and irreversible enlargement of air spaces distal to terminal bronchioles WITH alveolar wall destruction (no fibrosis)
cyanide poisoning - ?features
convulsions
cardiac arrhythmia
acidosis
type of hypersensitivity reaction for extrinsic allergic alveolitis
type 3 (for acute episodes)
type 4 (for chronic types)
common allergens for extrinsic allergic alveolitis
Avian proteins in bird droppings: bird fancier’s lung and pigeon fancier’s lung
Fungal spores: farmer’s lung, malt worker’s lung, mushroom worker’s lung
