Respiratory Medicine

Question 1

Define
Dyspnoea:
Exertional Dyspnoea:
Paroxysmal Nocturnal Dyspnoea:

Answer 1

Dyspnoea: Shortness of breath
Exertional Dyspnoea: Shortness of breath on exertion
Paroxysmal Nocturnal Dyspnoea: Acute shortness of breath awakening patient from sleep.

Question 2

Define Orthopnoea?
What is it associated with

Answer 2

Dypsnoea on lying flat, relieved by sitting up.
Left heart dysfunction, pulmonary oedema, and cor pulmonare

Question 3

Paroxysmal nocturnal dyspnoea is the acute shortness of breath awakening a patient from sleep. The patient would need to sit up or get out of bed for relief. What is this associated with?

Answer 3

pulmonary oedema and cor pulmonare

Question 4

What is the normal RR for different ages?

Answer 4

<1yo - 30-40
1-5 - 25-35
5-12 - 20-25
12+ 12-20

Question 5

Give 1 cause of increased RR from each of the following categories
Lung disease:
Heart disease:
Metabolic:
Drugs:
Psychological:

Then give 4 causes of reduced RR

Answer 5

Lung disease: Pneumonia, asthma
Heart disease: LVF
Metabolic: Ketoacidosis
Drugs: Salicylates
Psychological: Anxiety

Reduced RR:
CNS disease: Brainstem lesions, Guillain barre
Neuromuscular disease (myasthenia gravis)
Opioids
Kyphoscoliosis (limits chest expsnsion)

Question 6

Give 20 ddx for Dyspnoea (good luck!)

Answer 6

Cardiac:
Acute: Arrhythmia (A.fib), MI, LVF, Aortic dissection, pericarditis, tamponade
Chronic: Congestive cardiac failure, valvular disease, Congenital heart disease

Resp:
Acute: Asthma exacerbation, COPD exacerbation, pneumonia, PE, pneumothorax, pleural effusion, upper airway obstruction
Chronic: Asthma, COPD, CF, Lung Ca, Mesothelioma

Other:
Acute: Ketoacidosis (Kussmaul breathing), MSK pain (costochondritis), oesophagitis/pain, salicylates, thyrotoxicosis
Chronic: Obesity, anemia, neuromuscular

Question 7

Define Kussmaul breathing

Answer 7

Deep, sighing breathing due to metabolic acidosis commonly seen in diabetic ketoacidosis.

Question 8

Define Cheyne-Stokes Respiration
What is it caused by?

Answer 8

Breathing gets progressively deeper and shallower +/- episodic apnoea
Caused by brainstem lesions/compression (stroke/TIA), pulmonary oedema

Question 9

Neurogenic hyperventilation is one of the causes of dyspnoea. What are examples of this?

Answer 9

Stroke, tumour, CNS infection. This puts pressure on the brainstem => Cheyne-stokes respiration

Question 10

Give 7 ddx for acute Dyspnoea + Chest pain

Answer 10

Cardiac: MI, Pericarditis, dissecting aneurysm

Resp: PE, pneumonia, pulmonary malignancy

Other: MSK pain/Costochondritis, oesophageal pain/spasm/itis

Question 11

How can a pulmonary malignancy cause acute chest pain and SOB?

Answer 11

Superior vena cava obstruction

Question 12

How does superior vena cava obstruction present

Answer 12

Remember the cause would be a pulmonary malignancy

=> Obstruction: Acute breathlessness + headache worse on stooping + Swelling of face and neck (increased ICP)
+
=> Malignancy: Haemoptysis, unexplained cough, reduced weight and appetite, fatigue

Question 13

What timeframe would be considered an acute cough?

Answer 13

Acute cough <3 weeks => chronic is >3 weeks

Question 14

Give 5 causes of acute and 5 causes of a chronic cough

Answer 14

Acute:
1) URTI
2) Croup
3) Bronchitis
4) Acute exacerbation of COPD/Asthma
5) Tumour
6) Pneumonia

Chronic:
1) Post-nasal drip
2) Post-viral
3) COPD/Asthma
4) Lung Ca
5) TB, Pertussis
6) Bronchiectasis
7) Cystic fibrosis
8) Pulmonary oedema
9) GORD!
10) ACEinhibitors
11) Smoking

Question 15

You ask for a sputum sample from the patient with a cough. What does each of the following sputum samples indicate?
Clear:
Black specks:
Yellow-green:
Pink Froth:

Answer 15

Clear: Normal saliva, maybe test for Tb
Black specks: Smoking
Yellow-green: Bronchiectasis, cellular debris (infection)
Pink Froth: Pulmonary oedema => do CXR

Question 16

Blood in sputum always requires investigation => requires urgent referral or emergency admission. Give 5 causes of Haemoptysis

Answer 16

1) Infection (bronchitis, abscess Tb)
2) Lung Ca/Bronchial adenoma
3) PE
4) Anticoagulation (iatrogenic)
5) Trauma (violent coughing)
6) Cardiac (acute LVF, Mitral stenosis)
7) Collagen vascular disease e.g. Wegner’s/polyangitis with granulomatosis
8) Good Pasture’s Syndrome
9) Bronchiectasis!

Question 17

Bronchiectasis is the permanent widening of the bronchioles due to chronic inflammation and infection. What is the typical presentation of a patient with bronchiectasis?
Include Examination findings

Answer 17

Mild: Asymptomatic with prolonged winter exacerbations (fever cough, purulent green sputum, pleuritic chest pain, dyspnoea)

Moderate/severe: Persistent or recurrent chest infection, haemoptysis, clubbing, inspiratory/exp. crackles + wheeze

Question 18

What are the causes of bronchiectasis

Answer 18

1) Cilia => CF, PCD, Kartagener syndrome, smoking
2) Post-infection: TB, Pertussis, measles, pneumonia
3) Other: Bronchial obstruction, gastric aspiration, aspergillosis

Question 19

What investigations would you perform on a patient presenting with recurrent chest infections on a background of CF? What is the gold standard for diagnosis?

Answer 19

Chest Xray
CT chest (gold standard)

Question 20

What is involved in the management of bronchiectasis

Answer 20

Referral to resp physician
Chest physiotherapy
Antibiotics
Bronchodilators
Vaccination for influenza and pneumococcus.

Question 21

Define Asthma

Answer 21

Asthma is a condition of paroxysmal, reversible airway obstruction characterized by
1) Reversible airflow limitation
2) Airway hyper-responsiveness to wide range of stimuli
3) Inflammation of the bronchi

Question 22

What are the symptoms of Asthma along with characteristic features

These features allow for clinical suspicion of asthma. What are the diagnostic tests you would perform to complete the diagnosis?

Answer 22

1) Recurrent episodic asthma symptoms: Wheeze, breathlessness, chest tightness, cough
2) Diurnal variability
3) Audible expiratory wheeze
4) Variable airflow obstruction (PEFR)

Diagnosis:
1) Spirometry demonstrating reversibility
2) FBC showing raised eosinophils
3) CXR showing hyperinflation and bronchial thickening

Question 23

How is spirometry conducted?
What findings would be consistent with the diagnosis of asthma?

Answer 23

Spirometry is conducted initially to achieve baseline. 400mcg of salbutamol (SABA) is then given via a spacer. Spirometry is then conducted again 20 minutes later.
200+ increase in PEFT suggests asthma
400+ is a strong indication
Alternatively this can be tested before and after a 6 week trial of BD beclomethasone.

Question 24

What is the difference between spirometry and peak flow

Answer 24

Spirometry allows you to measure all the components of breathing (vital capacity, tidal flow…). Peak flow is not as comprehensive and only measures the maximum speed of airflow during expiration. It is useful in monitoring.

Question 25

What is occupational asthma and how would you enquire about it in the history?

Answer 25

Occupational asthma is reversible airway obstruction due to the work environment such as in factories Breathing better when on holidays or days away from work?

Question 26

What is the diagnostic definition of airflow obstruction?

Answer 26

FEV1/FVC <0.7

Question 27

Give 6 differentials for airway obstruction (FEV1/FVC <0.7)

Answer 27

Asthma COPD Foreign body Lung Ca GORD HF/pulmonary oedema Pulmonary fibrosis Bronchiectasis Sarcoidosis Hyperventilation syndrome

Question 28

How would you identify a severe asthma attack/exacerbation? How would you correctly identify if it is life threatening?

Answer 28

Severe asthma: PEFR 33-50% O2 Sat >92% Unable to complete sentences Tachypnea/tachycardia Life Threatening PEFR <33% O2 Sat <92% Altered conciousness Cyanosis Hypotension Exhaustion Silent chest Tachycardia

Question 29

What questionnaire is used to objectively measure asthma control

Answer 29

RCP3 questionnaire

Question 30

What advice would you give an asthmatic patient as part of your conservative management?

Answer 30

Allergen avoidance Correct technique of spacer Medication adherence Weight loss (a/w improved sx) Tailored action plan in case of exacerbation Advice for vaccination for exacerbation prevention

Question 31

An asthmatic patient presents to you for their annual checkup. What will you do during the review

Answer 31

Symptoms: RCP3 Smoking -> Cessation Exacerbations: Asthma diary -> Update medications Examination: Spirometry, PEFR Education: Tailored to patient, Allergen avoidance, Weight loss, action plan Medication: Use, aherence, inhaler technique, side effects. Prevention: Influenza and pneumococcal vaccine

Question 32

What does Symbicort contain? (include type of drug and name)

Answer 32

Contains both Inhaled corticosteroid: Budenoside LABA: Fomoterol

Question 33

What does seretide contain? (include type of drug and name)

Answer 33

ICS: Fluticazone LABA: Salmeterol

Question 34

What is the role of leukotrienes in the management of asthma

Answer 34

Leukotriene !receptor antagonists! such as montelukast block the leukotriene pathway involved in bronchoconstriction, inflammation, and mucous production It is used for mild-moderate asthma in those who prefer oral rather than inhaled medication

Question 35

A patient on high dose seretide has presented complaining of excessive exacerbations. medication adherence and inhaler technique are correct. She is a non-smoker. What is your next course of action

Answer 35

Referral to specialist to prescribe them biologic therapy (Omalizumab tagetting IgE or Mepolizumab and others which all target IL-5

Question 36

According to the GINA guidelines, what is the medical management of asthma? According to the British thoracic society, do the same

Answer 36

Step 1: PRN Symbicort +/- PRN Salbutamol (SABA) Step 2: OD Symbicort +/- PRN Salbutamol Alternatively Leukotriene receptor antagonist (montelukast) Step 3: Low dose Seretide Step 4: Medium dose Seretide Step 5: High dose Seretide Step 6: Referral - Biologic therapy (Omalizumab) Step 1: PRN SABA Step 2: Inhaled ICS OD + PRN SABA Step 3: Symbicort/Seretide + PRN SABA Step 4: Increase ICS dose or Add LTRA Step 5: Refer to Specialist for biologic therapy (Omalizumab)

Question 37

A patient presents with acute exacerbation of asthma. He is tachypnoeic and tachycardic. SPO2 is 95%. How will you manage this patient

Answer 37

ABCDE Take salbutamol 10x Take salbutamol 10x again 20 minutes later Prednisolone OD 40mg for 1-2 weeks

Question 38

What is COPD? Give 4 causes

Answer 38

Slowly progressive disorder characterised by airflow obstruction. Caused by 1) Tobacco smoking (90%) 2) Occupational exposure to pollutants 3) Genetic: alpha-1 Antitrypsin deficiency 4) Poor lung growth due to low birth weight and infections

Question 39

Go through the Dyspnoea scale in relation to physical activity

Answer 39

1 - Only on strenuous exercise 2 - When hurrying up or going up a slight hill 3 - Walks slower than others or has to stop for breath 4 - Stops for breath after 100m 5 - Too breathless to leave home/ on dressing clothes

Question 40

What would you like to elicit in a patient with COPD?

Answer 40

1) Weight 2) Exertional dyspnoea/ Effort intolerance 3) Chronic productive cough 4) Audible wheeze 5) Paroxysmal nocturnal dyspnoea (Do you ever wake up at night gasping for breath) 6) Orthopnea 7) Ankle Oedema 8) !!Smoking history Rule out cardiac cause e.g. chest pain

Question 41

T or F: Lung hyperinflation is a feature of CXR that is present in BOTH asthma and COPD.

Answer 41

True

Question 42

How would you assess for lung hyperinflation without an X-ray?

Answer 42

Poor chest rise which is measured via Cricosternal distance. Here it would be reduced.

Question 43

What is a normal cricosternal distance

Answer 43

Normal = 3-4 fingers or 3-6cm. Reduced in COPD

Question 44

You are asked to conduct an examination on a patient with Exertional dyspnoea, an audible wheeze, frequent chest infections and bronchitis. They have a 40 pack-year smoking hx. Go through what you are looking for on examination

Answer 44

Inspection: 1) Hyperinflated chest with poor chest rise => Reduced cricosternal distance (<3cm) 2) Pursed Lip breathing on expiration 3) Tachypnoea 4) Use of accessory muscles 5) Cyanosis 6) Cachexia Palpation: 1) Reduced Cricosternal distance 2) Raised JVP 3) Cachexia Percussion: Hyper-resonant chest/reduced cardiac dullness Auscultation: Wheeze/quiet breath sounds

Question 45

How would you differentiate between COPD and asthma?

Answer 45

1) Age: <35 asthma, >35 COPD 2) Smoking: More a/w. COPD (90%) 3) Good response to inhaled therapy on spirometry for asthma, poor response in COPD although both will have FEV1/FVC <0.7 4) Breathlessness variable throughout the day in asthma but persistent and progressive in COPD 5) COPD commonly has a chronic productive cough 6) Asthma more commonly has paroxysmal nocturnal dyspnoea

Question 46

You have conducted Hx and Exam on a patient and findings are suggestive of an obstructive lung disease. What investigations would you perform? How would you diagnose COPD and how is it classified?

Answer 46

Labs: FBC, U&E.. Alpha 1 antitrypsin Pulse oximetry CXR/CT to exclude other ddx ECG/ECHO/BNP to exclude cardiac causes BMI Spirometry to diagnose COPD and exclude asthma Diagnosis via Spirometery by calculating FEV1/FVC ratio (obstruction at <0.7) Classification is based on PEFR Stage 1 - >80% => Cough Stage 2 - 50-79% => + dyspnoea + Wheeze => known to GP Stage 3 - 30-49% => + Signs on exam + marked sx => known to specialist Stage 4 - <30% => Severely restricted daily living

Question 47

What is the conservative management of COPD?

Answer 47

1) Smoking cessation 2) Vaccination (influenza + pneumo) 3) Pulmonary/Chest physiotherapy 4) Weight loss 5) CBT, screen for depression

Question 48

What is tiotropium?

Answer 48

Long acting Muscarinic/Anticholinergic (same thing) agonist used in steps 2 and 3 of the management of COPD

Question 49

What guideline is used to manage a patient with COPD? Explain What is the full management of COPD based on Oxford?

Answer 49

GOLD Guidelines. Based on 1) Risk: by number of moderate exacerbations/yr - 0,1 vs 2+ - (+ whether leading to hospital admission) 2) Disease impact based on CAT (COPD assessment test) or mMRC (modified medical research council dyspnoea questionnaire. Group A: Low risk, Low Sx - SABA/SAMA Group B: Low risk, High Sx - LABA/LAMA Group C: High risk, Low Sx - LAMA Group D: High risk, High Sx - LAMA or LAMA + LABA or ICS + LABA Step 1: SABA/SAMA Step 2: If asthma-like + LABA, otherwise +LABA+LAMA Step 3: LABA + LAMA + ICS +/- Mucolytics +/- Antibiotics Or Theophylline +/- Roflunilast (PDE4 inhibitor)

Question 50

Give an example of a SAMA

Answer 50

Ipratropium

Question 51

Give an example of a LABA

Answer 51

Formetorol (in Symbicort)

Question 52

Give an example of a LAMA

Answer 52

Tiotropium

Question 53

With a chronic productive cough in a COPD patient who is finding it hard to get rid of it, what will you prescribe? Give the name of the drug

Answer 53

Oral mucolytic therapy - Carbocisteine (Exputex)

Question 54

What prophylactic Antibiotic would you give to patients with severe COPD?

Answer 54

Azithromycin

Question 55

What is the role of Theophylline?

Answer 55

It is a bronchodilator, anti-inflammatory agent (both like montelukast), and CNS-stimulant used in refractory asthma AND COPD. Requires monitoring for serum drug levels

Question 56

What is the medical management of COPD

Answer 56

Based on GOLD Guidelines 1) Bronchodilation Group A: Low risk, Low Sx - SABA/SAMA (Salbutamol/Ipratropium) Group B: Low risk, High Sx - LABA/LAMA (Formetorol/Tiotropium) Group C: High risk, Low Sx - LAMA (Tiotropium) Group D: High risk, High Sx - LAMA + LABA or ICS + LABA: Formetorol + Tiotropium or Seretide 2) Adjuvant: For more severe cases a) Oral mucolytic therapy - Carbocisteine b) Oral prophylactic antibiotics - Azithromycin c) Roflunilast - PDE4 inhibitor to reduce exacerbations (only as an adjuvant as it does not bronchodilate) 4) Oxygen therapy (very very severe) 3) Theophylline for refractory Asthma or COPD 4) Oxygen therapy

Question 57

The RF for asthma as well as COPD exacerbation are the same except with regards to physical activity. State 4 RF

Answer 57

1) Physical activity: Exacerbates asthma. The lack of exercise is a RF for COPD exacerbation 2) Smoking 3) Viral infection 4) Pollution 5) Seasonal variation

Question 58

How are COPD exacerbations managed?

Answer 58

The same way you would manage acute asthma + antibiotics => Patients should have an individualised escalation/action plan to manage exacerbations. => Corticosteroids prednisolone 30-40mg OD + Send sputum culture!!! then give antibiotics (amoxicillin 500mg TDS) If deterioration => send to hospital

Question 59

Lung cancer is the 3rd most common cancer but the leading cause of cancer death. What are the different types?

Answer 59

Small Cell - 20% Non-Small Cell Ca - 80% - Adeno or Squamous

Question 60

A patient has lung Ca disseminated at diagnosis. What type is this likely to be?

Answer 60

Small Cell Lung Ca

Question 61

What is a Pancoast Tumour? What are it's unique features?

Answer 61

Pancoast tumour is an apical lung cancer It causes the loss of sympathetic stimulation from C8-T2 leading to Ipsilateral Horner's Syndrome => Ptosis, Miosis, and Anhydrosis. Also, Shoulder pain and hoarse voice due to phrenic nerve irritation and recurrent laryngeal nerve palsy

Question 62

What are the 2 most important preventative measures for Lung Ca?

Answer 62

Smoking cessation Diet (increased vegetable and fruit consumption a/w reduced incidence)

Question 63

Give 6 sx of Lung Ca

Answer 63

1) B symptoms: Fever, night sweats, weight loss/anorexia 2) Chest/shoulder pain (phrenic nerve) 3) Hemoptysis 4) Dyspnoea 5) Finger clubbing 6) Hoarseness of voice (Recurrent laryngeal nerve) 7) Malaise

Question 64

How would you manage a patient presenting with chronic hemoptysis, chest pain, unintentional weight loss.

Answer 64

Once the diagnosis is confirmed, Liase with MDT and refer to specialist oncologist Active Tx will include radiotherapy, chemotherapy, and surgery The role of the GP is to have regular followups with the patient

Question 65

A lung Ca presenting with what 2 features would be red flags indicating emergency admission

Answer 65

Stridor Evidence of superior vena cava obstruction (Swelling of face and neck, headache, fixed raised JVP

Question 66

Common Cold typically lasts 7 days (adult) or 14 days (children), cough lasting up to 3 weeks. What are the most common pathogens? What complications would we be worried about? How is it managed?

Answer 66

Rhinovirus > Coronavirus > Influenza viruses causing URTI Complications: Acute exacerbation of asthma and COPD Superinfection w bacterial (5%) Management: Rest + symptomatic management with paracetamol/ibuprofen.

Question 67

Bronchitis typically resolves within 3 weeks. Define Bronchitis What are the sx of bronchitis? How is it managed?

Answer 67

Inflammation of the major bronchi often following an URTI Sx: Cough (+/- productive), breathlessness, wheeze, fever, sweats Management: Self-limiting illness => Rest + symptomatic management with paracetamol/ibuprofen. Bronchodilators if wheeze heard

Question 68

When would you prescribe antibiotics in an individual presenting with acute bronchitis?

Answer 68

Antibiotics are only given if systemically unwell or evidence of pneumonia or past hx of hospitalisation

Question 69

Influenza causes annual epidemics due to constant minor shifts in surface proteins. Influenza presents, as with all these viral infections with fever, cough, sore throat, !myalgia, nausea, vomiting, headache... What complications can influenza cause? Give 5 RF of severe disease in influenza. What is the significance of these RF

Answer 69

Complications include superinfection with bacteria causing otitis media, pneumonia, and bronchitis RF: The significance is whether to prescribe antivirals for the tx of influenza 1) Age >65 or long-care facilities 2) DM 3) Immunosuppression/Asplenic or household contact to immunosuppressed 4) Pregnant women or <2 weeks post-partum 5) BMI >40 6) Healthcare and social care workers 7) Chronic Resp, heart, renal, liver, neuro disease 8) Hajj and umrah pilgrims

Question 70

How would you manage influenza

Answer 70

Management includes Rest, fluids, analgesia, sx control, treatment of exacerbation and superinfection (e.g. pneumonia) + Antivirals Oseltamivir and Zanamivir only if "at risk", national surveillace scheme indicates circulating virus, and can begin medication within 48 hours of onset of symptoms

Question 71

What are symptoms of LRTI?

Answer 71

productive cough, pleuritic chest pain, wheeze

Question 72

Define Pneumonia including sx

Answer 72

Acute infection of the lung parenchyma characterised by: 1) Sx of LRTI (cough, purulent sputum, pleuritic pain, wheeze) 2) New focal chest signs (consolidation, reduced air entry, coarse crackles, pleural rub) 3) Systemic features including sweating, fevers, chills, shivers, and myalgia If you say this GG

Question 73

The incidence of pneumonia increases with age and peaks in winter. What organisms most commonly cause pneumonia?

Answer 73

Strep pneumoniae H. Influenzae Staph Aureus Tb

Question 74

A patient presents with a productive cough, tachypnoea, and fever. What are your differentials?

Answer 74

Pneumonia (communit acquired) Pneumonitis Malignancy Pulmonary oedema PE Asthma/COPD exacerbation TB

Question 75

A patient presents with a productive cough, tachypnoea, and fever. How would you assess whether they would need to be referred to hospital?

Answer 75

CURB-65 (Urea often not done => go for CRB65) C - Confusion U - Urea BUN>7 R - RR 30+ B - BP <90/60 65 - Age 0-1 - GP care with antibiotics 2+ Send to A&E

Question 76

How would you manage pneumonia as a GP

Answer 76

If mild or moderate with low risk (e.g. young), 1) Smoking cessation 2) Supportive care: Analgesia, fluids, paracetamol/clarithromycin 3) Antibiotics: Amoxicillin/Clarithromycin (500mg TDS for 5/7) If moderate/severe => Admission to A&E

Question 77

What are the complications of pneumonia

Answer 77

Pleural effusion/empyema Lung abscess Septicemia Resp failure