Respiratory Medicine Flashcards
(138 cards)
1
Q
What are some of iatrogenic causes of a pneumothorax?
A
Pleural Effusion Treatment
Pacemaker Insertion
Central Line Insertion (Subclavian Vein)
Ventilation (ICU)
2
Q
How do you know whether a pneumothorax is small or large?
A
2cm + on CXR = LARGE
3
Q
Risk Factors for spontaneous pneumothorax?
A
Tall, athletic young man
Drug Use (cannabis/heroin)
Smoking
COPD/Asthma
Sub-pleural blebs
Pulmonary Fibrosis
CF/Bronchiectasis
HIV
TB
Smoking
Marfans/Ehlers-Danlos (other connective disorder issues)
4
Q
What is the management cascade for a pneumothorax?
A
1) Observe + give high flow o2
2) Needle Aspiration
3) Chest Drain
4) Chest Drain + Suction
5) Surgical Intervention
5
Q
Where do you insert a needle aspiration for a pneumothorax?
A
2nd Intercostal Space Midclavicular Line
6
Q
Where do you insert a chest drain for a pneumothorax? How can you tell if it’s working? What could cause it to stop working?
A
Triangle of Safety Borders:
Midaxillary line (lat dorsi)
Anterior axillary line (pec major)
5th ICS (inferior nipple line)
Insert above rib to avoid neurovascular bundle under rib
Swinging/Bubbling of the water
Incorrect position of tube
Blocked/Kinked tube
7
Q
What are some complications of chest drains?
A
Air leaks (bubbling of fluid on coughing)
Surgical Emphysema (air under subcutaneous tissue)
8
Q
What piece of advice should you give to prevent further pneumothorax?
A
SMOKING CESSATION
Avoid flying/diving
9
Q
What are indications for surgical referral for pneumothorax?
A
2nd ipsilateral pneumothorax
1st contralateral pneumothorax
Bilateral spontaneous pneumothorax
Persistant Air Leak
Tension Pneumothorax
Pregnancy
Divers/Pilots/Military
10
Q
What 5 things should you give for a COPD exacerbation?
A
1) O2
2) Abx
3) Nebulised Salbutamol
4) Nebulised Ipiatropium
5) Prednisolone
11
Q
How do you know if it’s a bullae rupture or pneumothorax?
A
CT will differentiate
CXR - bulla will appear more bottom zone and look like it has a meniscus
12
Q
What is a hydro-pneumothorax?What would it look like on CXR?
A
Air and fluid in pleural cavity
(CXR - horizontal line with pleural effusion at bottom and loss of lung markings higher)
13
Q
What is Boerhave’s syndrome and how does it present?
A
Oesophageal tear from aggressive wretching/vomiting)
Leads to mediastinitis or surgical emphysema
Food debris will be coming out of chest drain
DEADLY
14
Q
What is pneumomediastinum? How does it present?
A
Air in the mediastinum
Severe Chest pain/SOB
On auscultation hear a crunching sound with every heart beat
Usually presents with surgical emphysema
Nasal sound to voice
Diagnose on CXR
15
Q
What is a trapped lung?
A
The inability of the lung to expand and fill the thoracic cavity
16
Q
A patient presents with a cough, what other details do we need to know?
A
Dry or Productive?
Triggers?
Associated fever or chest pain?
Travel Hx?
Any relatives have it too?
SOB?
17
Q
What are some common causes of cough that need to be investigated further?
A
Pneumonia
TB
Lung Cancer
GORD
Asthma
18
Q
What drugs can cause a cough?
A
ACEi (build up of bradykinin)
(Ramipril, Lisinopril)
19
Q
What investigations should you put in place for a patient presenting with a cough?
A
CXR
Bloods inc CRP
Sputum Culture if productive
Lung Function Test
Urinary pneumococcal/Legionella
20
Q
What is idiopathic cough and when can this be diagnosed?
A
When you have ruled out every other cause of cough
A cough with no clear cause
21
Q
What is the CURB-65?
A
Confusion
Urea (7+)
Respiratory Rate (+30)
Blood pressure (<90/60)
65
+2 = hospital admission
+3 = ICU
Use with clinical judgement though
22
Q
What are the common pathogens associated with CAP (Community Acquired Pneumonia)? How do you treat it?
A
Streptococcus Pneumoniae
Haemophilus Influenza
Staphylococcus Aureus
Amoxicillin/Co-amoxiclav
Doxycycline
Clarithromycin
i.v. abx if ill
23
Q
What are the atypical organisms that cause pneumonia and when should be considered?
A
Klebsiella (alcoholics)
Staph aureus (post flu or i.v. drug users)
Mycoplasma pneumoniae (rash and neurological signs)
Pseudomonas (CF/Bronchiectasis)
Viral (COVID/influenzae)
Chlamydia psittaci (infected birds)
Legionella pneumophila (infected air con/water - travel history?)
24
Q
How do you treat atypical pneumonia? (x3)
A
Penicillin ineffective
Clarithromycin
Doxycycline (chlamydia)
Metronidazole (anaerobes - aspiration)
25
What pathogens cause Hospital Acquired Pneumonia (HAP)?
E.coli and MRSA
26
How do you know if pneumonia is a viral cause?
Procalcitonin is low if viral
27
What features can differentiate pneumonia from TB?
TB 3/4 wk history, Pneumonia shorter
TB more weight loss and night sweats
TB may have haemoptysis
TB may have been born abroad or travel hx to Asia
28
How do abx treatments differ for typical and atypical pneumonia?
Typical
Amoxicillin 500mg for 5 days
Co-amoxiclav if severe
If atypical/penicillin allergy:
Doxycycline 200mg for 5 days
Clarithromycin/erythomycin
Aspiration:
Metronidazole
29
What follow up arrangements should be made for a patient with pneumonia?
HIV test
Immunoglobulins
CXR 6wks after
30
What features in COVID patients would require hospital admission?
Hypoxic
Lymphopaenia
Bilateral lower zone changes on CXR
31
How can we manage patients with COVID in hospital?
1) Give o2
2) CPAP or invasive ventilation
3) Dexamethasone (Consider Tocilizumab)
4) Abx if suspect bacterial infection too
32
What part of social history can be important for suspected pneumonia?
Have birds or look after animals (clamydia)
33
What investigations are important in pneumonia?
Chest x-ray
Full blood count (raised white cell count)
Renal profile (urea level for the CURB-65 score and acute kidney injury)
C-reactive protein (raised in inflammation and infection)
Sputum cultures
Blood cultures
Pneumococcal and Legionella urinary antigen tests
34
How pneumonia would appear on a respiratory examination?
Reduced Chest expansion
Visibly SOB
Hyperresonant on vocal resonance on area of consolidation
Bronchial breathing (big gap between inspiration and expiration)
Crackles on auscultation
Dull on percussion
35
What is the border for URTI vs LRTI?
Lower border of cricoid cartilage
36
What is birdfancier's disease? How can we treat it?
Hypersensitivity pneumonitis in response to repeated exposure to birds
Best way to tx is remove the birds
Prednisolone helps dampen inflammation
37
How would vasculitis present? (Churg Strauss Vasculitis)
High troponin/ECG changes
Cardiomegaly
AKI
Pneumonia
(Multi organ failure)
Can treat with steroids/biologics
38
What are some risk factors for PE?
Immobility
Recent surgery
Long-haul travel
Pregnancy
Hormone therapy with oestrogen
Malignancy
Lupus
39
How does PE present?
SOB
Cough
Haemoptysis
Pleuritic chest pain
Hypoxia
Tachycardia
Raised respiratory rate
Low-grade fever
Haemodynamic instability causing hypotension
Unilateral leg swelling
40
How do we diagnose and investigate a PE?
Wells score
Likely: CTPA
Unlikely: D-dimer
41
What imaging technique can we do if a patient is allergic to contrast or has poor renal function?
Ventilation-Perfusion Scan
42
How do we manage PE?
O2 and analgesia if needed
Apixiban or rivaroxaban
Dalteparin (subcutaneous) (while awaiting CTPA)
43
What is a massive PE and how do we manage it?
Signs or R heart strain or hypotensive (echocardiogram)
I.v. alteplase
44
How long do we anticoagulant long term? What can we use?
3 months with reversible cause
3-6 months with cancer or unprovoked PE
1) Apixaban
2) Warfarin
3) Dalteparin (Renal failure or pregnant)
45
What classifies as severe asthma?
PEFR 33-55% of normal
Cannot complete sentences
RR > 25
HR > 110
*PEFR - peak expiratory flow rate
46
What classifies as life-threatening asthma?
PEFR < 33%
Sats > 92%
pO2 < 8KpA
Cyanosis
(near) silent chest
Exhaustion
Confusion
Hypotensive
Arrhythmias
NORMAL CO2
47
What classifies as NEAR FATAL asthma?
RAISED pCO2
(Becoming tired - CO2 should be low as hyperventilating)
48
What are considered mild or moderate asthma attacks?
Mild: PEFR > 75%
Moderate: PEFR 50-75%
*PEFR - peak expiratory flow rate
49
What are common triggers of acute asthma?
Smoking
URTI
Allergens (pollen, pets)
Exercise
Cold Air
Pollution
Occupational Irritants
Drugs - Aspirin/B blockers
Food and Drink (dairy, alcohol, OJ)
Stress
50
What is the management for an asthma attack?
1) ABCDE
2) Give O2 (Sats - 94-98%)
3) 5mg nebulised salbutamol
4) 40mg oral prednisolone (IV hydrocortisone if not possible)
5) Nebulised Ipatropium Bromide 500mg
Life-threatening/fatal:
ITU/Anaesthetist assessment (intubation and ventilation)
Urgent portable CXR
IV Aminophylline
IV Salbutamol
51
What does the term “Controlled Oxygen” refer to?
Low flow oxygen for patients that are at risk of hypercapnia/retain CO2
Aim for sats of 88-92%
52
Describe a safe asthma discharge bundle? What are the criteria for safe discharge?
- PEFR > 75%
- No nebulisers 24hrs prior to discharge
- Inpatient asthma nurse review of inhaler technique/adherence
- Left with PEFR meter + asthma action plan
- 5 days of oral prednisolone
- GP follow up within 2 days
- Rest clinic follow up within 1/12
53
What is the management for chronic asthma in adults?
Stepwise approach where each one is added on addition to previous medication:
1. SABA Inhaler (salbutamol)
2. Inhaled corticosteroids
3. LABA (Salmeterol)
4. Leukotriene receptor antagonist (Montelukast) + high dose ICS
5. Oral Prednisolone
Smoker Cessation
Inhaler Technique
Avoid triggers
Asthma Management Plan
54
What is an asthma management plan?
Record of best peak flow
What inhaler they are on currently
When to take reliever inhaler
What to do if feel asthma is getting worse and how much to increase dosage
How to know if they're having a severe asthma attack and what to do
55
What are the main causes of COPD?
1. SMOKING
a-1-antitrypsin deficiency
Industrial Exposure (soot)
56
What is COPD?
Emphysema and Chronic Bronchitis
Emphysema: Alveolar wall destruction causing reduced SA for gas exchange
Chronic Bronchitis: Airway obstruction due to inflammation of bronchi
Mucous gland hyperplasia
Loss of cilial function
57
What is the MRC Dyspnoea Scale?
1 - Breathless w/ strenuous exercise
2 - Breathless walking up a slight hill
3 - On level ground, I have to stop for breathe or walk slower then others my age
4 - Stop for breath after 100 yards/few mins
5 - Too breathless to leave the house or when getting dressed
58
What clinical signs are seen on examination of a patient with COPD?
Tachypnoea
Use of accessory muscles of respiration
Tar staining
Barrel chest
Hyperresonant on percussion
Quiet breath sounds
Wheeze
Cyanosis
Ankle oedema
59
Why can COPD patients develop ankle oedema?
Cor pulmonale:
Pulmonary hypertension
Reduced blood flow back to R side heart
Blood pools in veins peripherally
60
What does spirometry show with COPD and how does this differ with asthma?
Spirometry:
Obstructive pattern (FEV1:FVC ratio of less than 70%)
Less than 12% improvement in FEV1:FVC after salbutamol in COPD
61
What does the COPD care bundle comprise of?
SMOKING CESSATION
Pneumococcal + annual flu vaccine
Pulmonary Rehabilitation
Bronchodilators
Antimuscarinincs
Steroids
Mucolytics
Long Term Oxygen Therapy (LTOT) if indicated (PaO2 < 7.3KPa)
62
What does pulmonary rehabilitation consist of?
6-12 week programme of MDT led exercise, nutritional advice and disease education
63
What medication is available for COPD patients?
1. SABA (Salbutamol)
If no asthmatic/steroid-responsive features:
2. LABA + LAMA (Anora Ellipta)
If asthmatic/steroid responsive features:
2. LABA + ICS (Fostair)
3. LABA + LAMA + ICS
64
What factors alter prognosis/mortality with COPD?
SMOKING CESSATION
Oxygen therapy if low sats
Regular Exercise
65
Why may uncontrolled oxygen be dangerous in someone with COPD?
Will worsen there hypercapnia and can go into respiratory acidosis
Rise in O2 levels will cause the patient to hypoventilate as no stimuli now (So CO2 rises)
Worsens V/Q mismatch - causes blood to flow to poorly ventilated alveoli
Haldane effect:
Deoxygenated blood more likely to take up CO2, less deoxygenated blood so less CO2 taken up
66
What co-morbid conditions may commonly be associated with lung cancer?
COPD
HF
MI
DMII
RESP CONDITIONS
67
What signs associated with lung cancer would you look for on examination?
Finger Clubbing / tar staining
Dyspnoea
Supraclavicular (R) or cervical lymphadenopathy
Wheeze (auscultation)
Dull (precision)
Paraneoplastic signs
68
What investigations would you order if you suspect lung cancer?
1. CXR
2. Staging CT (chest,abdo,pelvis)
3. Bronchoscopy for biopsy
4. PET Scan if surgical candidate
Bloods - thrombocytosis
FBC - anaemia
U+Es - hyponatraemia (SIADH)
LFTs - hepatic mets (ALP-bone mets)
Serum Ca - PTHrP
69
What sites do lung cancers met to?
Bone
Brain
Liver
Adrenal Glands
70
List the paraneoplastic syndromes associated with lung cancer and how they present?
Small-cell:
SIADH - ectopic ADH, hyponatraemia, N+V
Cushing's - ectopic ACTH, purple striae, moon face
Lambert-Eaton Syndrome - antibodies attacking small-cell lung cancer cells aslso attack voltage-gated Ca channels in motor neurones, muscle weakness
Squamous Cell:
Hypercalcaemia (PTHrp) - GROANS,MOANS,STONES,THRONES
Clubbing
71
How does Lambert-Eaton myasthenia syndrome present?
Proximal muscle weakness
Intraocular muscle weakness (diplopia, ptosis)
Pharyngela muscle weakness (slurred speech, dysphagia)
72
What abnormalities are seen on a CXR with lung cancer?
Opacification
Hilar Enlargement
Pleural Effusion
73
How is the stage of lung cancer determined?
TNM
Stage I: Small (<4cm) with no spread
Stage II: Local spread to lymph nodes
Stage III: Advanced local spread to lung, airways or other surrounding structures
Stage IV: Met to other Lung or another organ/part of body
74
What is the prognosis for the different lung cancers and stages?
NSCLC:
I: 65-80% (following resection)
II: 50-60% (following resection)
III: 20%
IV: 1-5%
SCLC:
Untreated - 8-16 weeks
Treated - 7-15 months
75
What treatment modalities are available for patients with lung cancer?
1. Surgical resection if small and localised (Stage I+II)
2. Radiotherapy (can be curative in NSCLC)
3. Radiotherapy & Chemo (palliative care)
Palliative + Supportive Care
SCLC - Chemo/Radio only
76
Why is lung cancer prognosis so poor?
Rapid growth rate
Patients usually present with advanced disease where it has already spread and too extensive for surgery
77
How does pleural effusion appear on CXR?
Opacacification/shadowing with meniscus
Blunting of costophrenic angles
Loss of lower lobe vessels
Fluid in the lung fissures
Mediastinal shift away from pleural effusion (severe)
78
What further imaging is needed if you suspect pleural effusion on CXR?
USS guided pleural aspiration
79
What clinical signs might you expect when examining a patient with pleural effusion?
Reduced breath sounds (auscultation)
Dullness to percussion
Tracheal deviation away from effusion (large)
Reduced chest expansion on the side
Reduced vocal resonance (fluid)
80
How can you investigate the underlying cause of a pleural effusion?
USS guided pleural aspiration
Send off fluid for:
pH (<7.2 - empyema - needs urgent chest drain)
Protein
LDH
Cytology
Microbiology (AAFB -alcohol acid fast bacilli)
81
When should you insert a chest drain with a pleural effusion?
ONLY WHEN DIAGNOSIS/CAUSE OF PLEURAL EFFUSION IS ESTABLISHED
otherwise will miss opportunity for pleural biopsies
82
How do you know if the cause of a pleural effusion is transudative or exudative?
Light's Criteria
Transudate:
Low protein (<30g/L)
Low pleural fluid protein (<0.5)
Low LDH (<0.6)
Pleural LDH < 2/3 of serum LDH
Exudate:
High protein (>30g/L)
High pleural fluid protein (>0.5)
High LDH (>0.6)
Pleural LDH > 2/3 of serum LDH
pH of less than 7.2 = empyema
83
What are the causes of transudative and exudative pleural effusion?
Transudative:
Cirrhosis
HF
Hypoalbuminanaemia (nephrotic/peritoneal dialysis)
Hypothyroidism
Meigs' syndrome (ovarian tumour)
Exudative:
Malignancy
Infection - TB, pneumonia, HIV
RA
SLE
Pancreatitis
PE
Yellow nail syndrome
84
How does a patient present with ILD?
Dyspnoea on exertion
Dry Cough
Fatigue
85
What clinical signs can be seen with ILD?
Clubbing
Reduced chest expansion
Bibasal fine end-inspiratory crackles
Pulmonary HTN signs (oedema of legs, cyanosis)
86
What are the common types of ILD?
Usual Interstitial Pneumonia (UIP) - Idiopathic Pulmonary Fibrosis
Non-Specific Interstitial Pneumonia (NSIP)
Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis)
Sarcoidosis
87
What drugs can cause ILD?
Bleomycin
Nitrofurantoin
Amiodarone
Methotrexate
chemo drugs
abx
88
How does the CXR appear in ILD??
Outline of heart appears less clear (shaggy outline)
Multiple shadowing which is more prominent towards the lung bases
Loss of lung space (higher diaphragm)
89
What do pulmonary function tests show in ILD?
Restrictive patern
FEV1 + FVC - both equally reduced
FEV1:FVC - greater then 70%
90
What are the symptoms of bronchiectasis?
Recurrent chest infections
Productive cough
Increasing breathlessness
Weight loss
91
What would clinical signs would you find with bronchiectasis?
Finger clubbing
Cor pulmonate signs? (^JVP + peripheral oedema)
Scattered wheeze
Scattered crackles (clear when patient coughs)
92
What is the gold standard diagnostic test for bronchiectasis?
HRCT (High Resolution CT Thorax)
93
What are the common causes of bronchiectasis?
Post-infective:
TB
Whooping cough
Mucociliary clearance defects:
CF
Young's syndrome
RA
Alpha-1-antitrypsin deficiency
Hypogammaglobulinaemia
Associated with:
IBD
Yellow nail syndrome
94
What are the common pathogens seen in sputum of patients with bronchiectasis?
1) Haemophilus influenza
Pseudomonas aeruginosa
Moraxella catarrhalis
95
What are the key principles in managing bronchiectasis?
Treat underlying cause
Respiratory physiotherapy (mucus clearance)
Annual vaccines (pneumococcal + influenza)
Pulmonary Rehabilitation (if MRC dyspnoea score of 3+)
Prophylactic abx for patients with recurring infective exacerbations:
Haemophillus - Amoxicillin (doxycline)
Pseudomonas - Ciprofloxacin (Achilles tendonitis risk)
Long term O2 therapy
Bronchodilators if needed
96
How common is CF in the UK??
1 in 2,500
1 in 25 are carriers
97
What is the pathophysiology behind Cystic Fibrosis?
1. mutation in CFTR (cystic fibrosis transmembrane conductance regulator)
2. Less Cl transport out of cell
3. So less water in mucus so this becomes thick and sticky
4. Mucus blocks airways and other secretory pathways
98
What are the common multisystem complications of CF?
GI:
Meconium Ileus (newborn blockage of bowel, bilous vomiting seen)
Rectal prolapse
Pancreatic:
1. Intestinal malabsorption (pancreatic exocrine gland blocks digestive enzymes)
2. Diabetes
Resp:
1. Recurrent Chest infections
2. Bronchiectasis
3. Pneumothorax
4. Sinusitis/nasal polyps
Liver:
CLD + portal htn
Gallstones
MSK:
Osteoporosis (Ca malabsorption)
Finger clubbing
Arthritis
Repro:
Infertility
99
How does anaphylaxis/angioedema present?
Pruritis
Urticaria
Angioedema
Hoarseness
Wheeze
Stridor
Chest tightness
100
How do we treat anaphylaxis/angioedema?
1. Remove trigger
2. Give 100% o2
3. Im adrenaline every 5 mins
4. IV hydrocortisone (200mg)
5. IV chlorpheniramine (10mg) (antihistamine)
6. Fluid resus (if hypotensive)
7. Nebulised salbutamol - bronchospasm
8. Nebulised adrenaline - laryngeal oedema
101
How do we manage COPD exacerbation?
1. ABCDE
2. O2 for 88-92% if a retainer
3. NEB Salbutamol
4. NEB Ipratropium
5. Prednisolone 30mg po (hydrocortisone IV)
6. Amoxicillin (co-amoxiclav if unwell)
7. IV aminophylline
8. CPAP or ITU referral (if severe acidosis, 7.25-7.35)
102
What is massive heamoptysis? How do we manage massive haemoptysis?
>240mls in 1 day or >100mls for multiple days
1. ABCDE
2. Lie patient on side of suspected lesion
3. Stop NSAIDs, aspirin, anti-coags
4. Oral Tranexamic acid (clots blood)
5. Consider Vit K
6. CT aortogram
103
What are some causes of eosinophilia?
- Asthma/COPD
- Hayfever/allergies
- Abx
- SLE
- Lymphoma
- Parasites
- Eosinophilli pneumonia
104
Why could a pneumonia not be resolving?
CHAOS
Complication:
- empyema
- lung abscess
Host:
- immunecompromised
Antibiotic:
- Wrong type or dose or route
- Poor oral absorption
Organism:
- resistant
- atypical
Second diagnosis:
- PE
- Cancer
105
How will a patient present with TB?
- Fever
- Nocturnal sweats
- Weight loss
- Malaise
- Cough
- (Purulent sputum)
- Haemoptysis
- Pleural Effusion
- Erythema Nodosum
- Lymphadenopathy
106
What are some differential diagnosis for haemoptysis?
- TB
- PE
- Lung Cancer/Mets
- Bronciectasis/CF
- Cavitating Lung Lesion (fungal)
- Bronchial Artery Erosison
- Vasculitis
107
What are some risk factors for TB?
- Past hx of TB
- Known TB contact
- Born in country of high TB incidence (Africa/Asia)
- Foreign travel to high TB incidence country
- Immunosuppressed
108
What is the general management of a TB patient? (investigations+immediate mx)
1. ABCDE
2. Admit to side room + infection control
3. Sputum TB culture + x3 sputum sample for AAFB + ziehl-neelson stain
4. TB Abx
5. Routine bloods (especially LFTs)
6. HIV test, Vit D levels
Notify to public health and TB specialist nurse
109
What investigations do you order for a TB patient?
- CXR
- Sputum sample x 3 for AAFB (acid alcohol fast bacilli)
- Sputum TB culture
- Sputum ziehl-neelson stain
- CT Chest if CXR unclear but still suspicion of TB
110
What tests are needed before and to monitor ADRs of Anti TB-therapy?
Baseline LFT + monitor closely
Check visual acuity (ethambutol)
Directly Observed Therapy if required
111
What are the 4 abx for Anti TB therapy and what are there ADRs?
Rifampicin - orange urine
Isoniazid - peripheral neuropathy, hepatitis
Pyrazinamide - hepatitis
Ethambutol - reduced visual acuity
112
What else should be prescribed with RIPE for TB?
Pyridoxine (Vit B6) to prevent peripheral neuropathy caused by isoniazid
113
How do you define a bronchiectasis exacerbation?
Detonation in 3 of the following for 48 hrs +:
- Cough
- Sputum volume/consistency
- Breathlessness/exercise tolerance
- Fatigue
- Haemoptysis
114
How is a CF diagnosis made?
+ve newborn screen test
Increased sweat chloride test
115
What are the complications of CF? How can we manage these?
1. Chronic Resp Infections
- physio + prophylactic abx
2. Low body weight
- pancreatic enzyme sufficiency
- ^calorie intake + supplements
- NG or PEGE feeding
3. DIOS (Distal Intestinal Obstruction Syndrome)
- DIOS is faecal obstruction in ileocaecum vs constipation is whole bowel
- due to pancreatic insufficiency
- palpable RIF mass + mass at Cleo-caecal junction on AXR
- Tx = PO Gastrogroffin (draws water across bowel wall)
4. CF related diabetes
- insulin therapy
116
What lifestyle advice can we give for CF?
- No smoking
- Avoid other CF patients
- Avoid ill people
- Avoid jacuzzis (pseudomonas)
- Avoid stables/compost (aspergilus fumigates)
- Exercise
117
What is the medical management for CF? What conditions do we need to monitor for in the future?
- Annual influenza vaccine
- NaCl tablets in hot weater
- Airway clearance physio
- Mucolytics
- Pancreatic enzyme replacement therapy
- Vit A,D,E,K
- Long term Abx
- Nutritional supplementation
Monitor for diabetes, osteoporosis, CLD
118
What are the different parts of the pleura?
Parietal - outer part (attached to chest wall)
Visceral - inner part (covers lung)
119
What are the different pleural diseases?
Pneumothorax
Pleural effusion
Empyema
Pleural tumours
Pleural plaques (discrete fibrous areas)
Pleural thickening (scarring/calcification)
120
What is the pathophysiology behind sarcoidosis?
Multi-system inflammatory condition of non-caseating granulomas
Mostly affects lungs but can affect any other organ
121
What is the typical presentation of sarcoidosis?
Black woman (20-40yrs)
Dry cough
SOB
Erythema Nodusum (nodules on shins)
122
What systems can be effected with sarcoidosis and what symptoms are present?
Resp:
Dry cough
SOB
Liver:
Liver nodules
Cholestasis
Eye:
Uveits/conjunctivitis
Optic neuritis
Cardiac:
BBB
Heart block
Kidneys:
Kidney stones (Ca^)
Bones:
Arthritis
Skin:
Erythema nodosum
Lupus pernio (purple lesions on cheeks/nose)
Systemic:
Fever
Fatigue
Weight loss
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What investigations are needed for sarcoidosis?
Bloods:
^Ca
^ACE
CXR:
Hilar lymphadenopathy
ECG/Echo (cardiac involvement)
U+Es (kidneys)
CT/MRI Head (if headaches)
PFTs
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How do we manage sarcoidosis?
1. Conservative (50% spontaneous remission)
2. Oral steroids (6months-2yrs)
3. Methotrexate
4. Bisphosphonates (osteoporosis risk)
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What is the WHO scale?
0 - Normal
1 - Restricted in strenuous activity but can carry out office work/house work
2 - Capable of self-care but unable to work
3 - Capable of some self-care. Confined to bed/chair 50% of time awake
4 - Cannot self care and confined to bed/chair
5 - dead
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What are the different histological classifications of lung cancer?
1. Small cell lung cancer (SCLC)
2. Non-small cell lung cancer (NSCLC):
- Squamous cell
- Adenocarcinoma
- Large cell carcinoma
- Bronchoalveolar carcinoma
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What is Obstructive Sleep Apnoea?
Upper airway obstruction during sleep
(Clinical defintion - upper airway narrowing provoked by sleep, causing sufficient sleep fragmentation resulting in daytime symptoms)
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What is the pathophysiology behind OSA?
Pharyngeal dilators relax during sleep
Upper airway narrows normally
OSA - excessive narrowing
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What are some causes of OSA?
Small pharyngeal size:
-fatty infiltration from neck fat
- large tonsils
Excessive narrowing:
- obesity enhances muscle dilation action
- neuromuscular disease (stoke, MND)
- muscle relaxants - sedatives, alcohol
- increasing age
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What are the clinical features of OSA?
- Hypoxia during sleep
- Recurrent wakening
- Unrefreshed from sleep
- Nocturia
- Hypertension (50mmHg rise with every arousal)
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What is the Epworth sleepiness scale?
Points: 0 = no, 1= slight chance, 2 = moderate chance, 3 = high chance of dosing
>9 significant
Activities:
- reading
- watching TV
- sitting in public place
- passenger in a car for 1hr
- lying down to rest in afternoon
- sitting and talking
- in a car stopped in traffic
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How can we diagnose OSA?
Overnight oximetry
Limited sleep study
Full polysomnography
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What is the management of OSA?
Weight loss
Alter posture
CPAP
Driving Advice (DVLA report)
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What is the CHARTS pneumonic for upper lobe fibrosis?
C- Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis (Egg-shaped hilar calcification)
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Which lung cancer is associated with gynaecomastia?
Adenocarcinoma
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When should COPD patients receive oxygen therapy?
- FEV1 < 30% predicted (consider FEV1 30-49% predicted)
- cyanosis
- polycythaemia
- peripheral oedema
- raised jugular venous pressure
- oxygen saturations less than or equal to 92% on room air (less than PaO2 of 7.3)
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What features would suggest poorly controlled asthma?
Nocturnal cough/waking up SOB
Frequent occurance of usual asthma symptoms
Asthma interferes with usual activities
Decreased PEFR
Needing to use salbutamol more than once weekly
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