Respiratory Medicine Flashcards
Dyspnoea, obstructive pattern on spirometry in patient with rheumatoid
Bronchiolitis Obliterans
HRCT of bronchiolitis obliterans:
Mossaic Pattern
Which pattern in Bronchiolitis Obliterans ?
Obstructive
Contraindications for Surgery in Lung Cancer :
ROPE
Reduced FEV1
Obstruction of SVC
Paralysis of vocal cords
Effusion
Stage 3 or 4
Tumour Near Hilum
Rx for Sarcoidosis :
Monitoring
Asthma Symptoms+ Pco2-Normal. What category of asthma ?
Life threatening
In life threatening asthma, pco2 level ?
Normal
Life threatening asthma criteria :
CHESS 33
Cyanosis
Normal PCo2
Hypotension
Exhaustion
Silent chest
Sats< 92 %
PEFR < 33%
First line Ix for Asthma :
FeNO > 50
Raised Eosinophil count
If asthma is not diagnosed by FeNO and Eosinophil count :
Improvement of FEV1 of 12 % and rise in volume of 200 ML or more in response to B Agonist or steroids.
Significant ( > 20 %) in diurnal PEFR
To diagnose Asthma , Improvement of FEV1 of __ and rise in volume of __ ML or more in response to B Agonist or steroids.
12% and 200 ML
To diagnose Asthma , how variation in Diurnal PEFR ?
> 20 %
Management of high altitude cerebral edema
Descent and Dexamethasone
Climb to mountain + Headchae + Poor coordination + slurred speech
High Altitude Cerebral edema
reason for using inhaled corticosteroids In COPD :
Reduced Exacerbations
In around__of patients subsequently diagnosed with lung cancer the chest x-ray was reported as normal
10%
Is Lambert Eaton associated with Squamous Cell Carcinoma ?
No
Squamous cell Carcinoma features:
PTHrP—Hypercalcemia
Ectopic TSH—Hypthyroidism
Hypertrophic Pulmonary Osteoatrhopathy
Clubbing
Is clubbing a feature of Squamous Cell Carcinoma ?
Yes
Does Amyloidosis cause B/L Hilar Lymphadenopathy ?
No
The first line investigation for adults with suspected asthma is:
Eosinophil count and FeNo
Should NIV be done in Bronchiectasis ?
No
the most useful marker for monitoring the progression of patients with chronic obstructive pulmonary disease (COPD)?
FEV 1
Now, FEV1 is like measuring how much air you can blow out of the balloons in 1 second. For people with COPD, their lungs are like balloons that don’t work very well, so they can’t blow out as much air in that 1 second. Doctors use FEV1 to see how well the lungs are working and if they’re getting worse over time.
FEV1/FVC is like comparing how much air you can blow out in 1 second to how much air you can blow out in total. But in COPD, the problem is mostly about how hard it is to blow air out quickly (that’s the FEV1 part). The FVC part (total air you can blow out) doesn’t change as much, so FEV1 is the most useful number to watch.
Hypercalcaemia + bilateral hilar lymphadenopathy :
Sarcoidosis
Sarcoidosis
Hypercalcaemia + bilateral hilar lymphadenopathy
The parents of a 3-year-old boy with cystic fibrosis ask for advice. They are considering having more children. Neither of the parents have cystic fibrosis. What is the chance that their next child will be a carrier of the cystic fibrosis gene?
there is a 50% chance that their next child will be a carrier of cystic fibrosis (i.e. be heterozygous for the genetic defect) and a 25% chance that the child will actually have the disease (be homozygous).
The ‘cherry-red’ lesion is a typical finding of:
Lung Carcinoid
Vital capacity -
4,500 ML in males
Is coal dust a risk factor for lung cancer ?
No
Occupational asthma M/C/C :
Isocyanates
Occupational Asthma causes :
GF works at PEPSI
Glutaraldehyde
Flour
Platinum salt
Epoxy Resins
Proteolytic Enzymes
Soldering FLux resins
Isocyanates
Allergic Bronchopulmonary Aspergillosis Rx:
Oral Prednisolone
Previous H/o or Label of Asthma—C/o Dry cough + wheeze + progressive Dyspnoea + Recurrent chest infections/ frequent Hospitalisation + On Imaging—Bronchictasis: Tram Tack Opacities/signet ring / ring shadow
High eosinophilia
Raised IgE
RAST positive for Aspergilus
Positive IgG
Allergic Bronchopulmonary Aspergillosis
Allergic Bronchopulmonary Aspergillosis
Previous H/o or Label of Asthma—C/o Dry cough + wheeze + progressive Dyspnoea + Recurrent chest infections/ frequent Hospitalisation + On Imaging—Bronchictasis: Tram Tack Opacities/signet ring / ring shadow
High eosinophilia
Raised IgE
RAST positive for Aspergilus
Positive IgG
Blood of ABPA
High eosinophilia
Raised IgE
RAST positive for Aspergilus
Positive IgG
Triangle of safety for chest drain insertion :
Base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi
Extrinsic allergic alveolitis is associated with which zone fibrosis ?
Upper zone fibrosis
Upper zone fibrosis mnemonic :
CHARTS
Coal worker pnemoconiosis
Histiocytosis/Hypersensitivity pneumonitis—Extrinsic allergic Pneumonitis.
Ankylosing spondylitis
Radiation
TB
Silicosis/Sarcoidosis
Asthma attack with Normal PCo2. Rx?
Normal Pco2—life threatening asthma
Do Invasive Intubation and ventilation
The investigation of choice for upper airway compression:
Flow Volume Loop
Erythema Nodosum is good or ba prognosis in Sarcoidosis ?
Good
Indication for starting treatment in Sarcoidosis :
Hypercalcemia
Eye, heart, Neuro—facial nerve Palsy.
CXR—Stage 2 or Stage 3 with symptoms
Bupropion
Norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
Which one of the following is most important in the long term control of his symptoms of Bronchiectasis ?
Postural Drainage
malt workers’ lung
Aspergillus Calvatus
Bupropion Contraindication :
Epilepsy
PiMZ
carrier and unlikely to develop emphysema if a non-smoker
Recurrent chest infections + subfertility + Negative sweet test
Kartagener syndrome
Does COPD cause OSA ?
No
Asthmatic features/features suggesting steroid responsiveness in COPD:
previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
End stage Emphysema Rx?
Lung volume reduction surgery
Which type of hypersensitivity reaction predominates in the acute phase of extrinsic allergic alveolitis?
Type 3
Does extrinsic allergic alveolits cause Eosinophilia ?
No—Inflamation is typically Granulomatous and therefore does not involve eosinophils
Cystic Fibrosis diet recommendation :
High calorie and high fat with pancreatic enzyme supplementation for every meal.
Does Arthropathy occur in cystic fibrosis ?
No
Does Nasal Polyps occur in cystic fibrosis ?
Yes
Does diabetes occur in cystic fibrosis ?
Yes
Does steatorhea and rectal prolapse occur in cystic fibrosis ?
Yes
Does Delayed Puberty occur in cystic fibrosis ?
yes
In COPD, If PCO2 levels is normal—then target oxygen saturation level ?
94-98%
Indication for Intubation in Asthma :
PH < 7.35
Criteria for LTOT
2 readings of PH< 7.3 or (PH 7.3-8 + No PH)
Nocturnal Hypoxaemia
Oedema
Polycythemia
Hypertension
ARDS Diagnostic Criteria :
ABCD:
Acute onset
B/L Infiltrates
C- Not cardiogenic
D- Decreased Pao2:Fio2
Does Measels cause bronchiectasis ?
Yes
Does ABPA cause Bronchiectasis ?
Yes
Does Hypogamaglobulinaemia cause Bronchiectasis ?
Yes
Does Sarcoidosis cause Bronchiectasis ?
No
Does Amyloidosis cause Bronchiectasis ?
No.
Expiratory reserve volume in obese patients :
Significantly Decreased— reduced expiratory reserve volume may be observed in cases of obesity, where increased abdominal fat restricts diaphragmatic movement, thus reducing the expiratory reserve.
Fev1 and FVC and ERV in Obese patients :
reduced FEV1 and FVC with a normal FEV1/FVC ratio, and reduced
expiratory reserve volume.
reduced expiratory reserve volume may be observed in cases of obesity, where increased abdominal fat restricts diaphragmatic movement, thus reducing the expiratory reserve.
CXR Findings of silicosis :
Egg shell Calcification of hilar lymph nodes
Most common organism in Bronchiectasis :
Haemophilus Influenza
Which drug to be avoided in Churg Strauss ?
Monteleukast(Leukotriene receptor antagonists)
FEV1/FVC = 0.72
0.72-0.8 —Restrictive
< 0.7–Obstructive
Pulmonary Haemorhage TLCO -
Raised TLCO
Chronic sinusitis + nephritic syndrome
Granulomatosis with polyangitis(Wegners)
Granulomatosis with Polyangitis is associated with which ANCA ?
C ANCA
G=C
Churg Strauss symptoms :
asthma
blood eosinophilia (e.g. > 10%)
paranasal sinusitis
mononeuritis multiplex
renal involvement occurs in around 20%
pANCA positive in 60%
Asthma + Rhinitis + The pain is associated with some altered sensation in the lateral palmar aspect of the hand. She feels that her thumb is slightly weaker than before.
Churg Strauss
Which blood picture is raised in Churg Strauss ?
Eosinophils
Asbestos causes which zone fibrosis?
Lower zone Fibrosis
Lower zone Fibrosis mnemonic?
ACID
Asbestos
Connective tissue
Idiopathic Pulmonary Fibrosis
Drugs—Amiodarone
Bromocriptine
Cyclophosphamide
Nitrofurantion
Methotrexate
Functional Residual Capacity :
ERV + RV
Light’s criteria for exudates :
Protein level > 30 g/l
If between 25-35:
Pleural fluid protein / Serum protein >0.5
Pleural fluid LDH / Serum LDH >0.6
Pleural fluid LDH > 2/3 * Serum LDH upper limit of normal
Glucose is not used in Light’s Criteria.
Prevention of acute mountain sickness :
Acetazolamide
H/o climb—On/off Headache + Nausea + Fatigue + No cerebral features + No Pulmonary edema. Dx:
Acute Mountain Sickness
C/I for lung transplant in cystic Fibrosis :
Burkholderia cepacia
Farmer’s Lungs is caused by :
Saccharopolyspora rectivirgula
Farmers are sacche log
Vital Capacity :
maximum volume of air that can be expired after a maximal inspiration
A 34-year-old steelworker presents complaining of episodic shortness of breath. This is particularly noted whilst at work where he describes feeling wheezy and having a tendency to cough. Which one of the following is the most appropriate diagnostic investigation?. Diagnosis and confirmatory test :
Occupational Asthma
Serial peak flow measurements at work and at home
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features → add
LABA + LAMA
Most associated substance with Occupational Asthma :
Isocyanates
What shifts O2 dissociation curve to let :
Methhaemoglobinaemia
Carboxyhaemoglobiin
HbF
Low pco2
Low temp
Low Acidity
Low 2-3 DPG
What shifts o2 dissociation curve to right ?
Cadet rise and face right :
Raised PCO2
Raised Acid
Raised 2-3 DPG
Raised Temperature
PTH-related peptide secretion is seen in which cancer ?
Sqaumous cell Carcinoma
PTH-rp related peptide secretion is seen in :
Small cell lung carcinoma
Sarcoidosis CXR Staging :
Sarcoidosis CXR
1 = BHL
2 = BHL + infiltrates
3 = infiltrates
4 = fibrosis
COPD + PH < 7.35 despite ongoing treatment:
Non invasive ventilation
( BiPAP— BI= Both oxygenation and ventilation )
Pulmonary arterial hypertension is defined as an elevated pulmonary arterial pressure of greater than:
20 MmHg
SOB + Chest examinataion normal + Hunched back + FEv1/fvc < 0.7
Restrictive lung disorders
Chest = Normal —so Not Fibrosis
Hunched back—Therefore its Kyphoscoliosis
Before starting azithromycin, which test need to be done ?
Do ECG
As azithromycin causes prolonged QT interval
Wood related work + Worsening dry cough + productive cough + SOB + Weight loss + CXR—B/L ground glass opacities in upper-mid zone
Extrinsic allergic alveolitis
OSA— lifestyle changes done. Next step ?
CPAP
Asthma + Confused. Next step ?
Referral to ITU
Confusion is life threatening
Painful skin rash + Coug. Dx and which blood level will be raised ?
Sarcoidosis
ACE levels
Known lung cancer + proximal Myopathy + Hypertesnsion + low pottasium, Dx and pathology ?
Small Cell Lung Cancer
Pathology—Ectopic ACTH Secretion
TLCO in Absestosis :
Decreased
Dockyard worker + Worsening SOB + Pleural Plaques
Asbestosis
No Smoking + Lung Cancer
Adenocarcinoma
Is malabsorption a feature of Kartaganner ?
No
Heart related condition in Kartagener :
Dextrocardia
fertility in Kartagener ?
Subfertility
Lungs related condition in Kartagener ?
Bronchiectasis and recurrent sinusitis
Silica predisposes to which lung condition ?
Tuberculosis
Diagnosis of COPD :
FEV1/FVC < 70% + symptoms suggestive of COPD.
According to NICE guidelines, the diagnosis of COPD requires both the presence of symptoms (such as breathlessness, chronic cough, regular sputum production, frequent winter bronchitis, and wheeze) and the demonstration of airflow obstruction on spirometry.
PEFR in COPD :
No Value
COPD : problem with smaller airways.
PEFR: Checks the bigger airways.
Therefore no role in copd
H/o Climb + shortness of breath and a pink frothy cough. Examination reveals bibasal crackles
high altitude pulmonary oedema (HAPE)
Nifedipine
Varenicline Side effect :
Nausea
Value of PEFR in life threatening Asthma :
PEFR < 33 %
COPD Staging
FEV1
> 80% Stage 1 - Mild - symptoms 50-79% Stage 2 - Moderate
30-49% Stage 3 - Severe
< 30% Stage 4 - Very Severe
Idiopathic pulmonary fibrosis area of fibrosis :
Lower zone fibrosis
Pleural Fluid point for Indication of placing Chest tube :
Pleural Fluid PH < 7.2
Purulent Pleural Fluid
Presence of organism
Genotype which confers the highest risk for developing emphysema
PIZZ
Cavitating lung cancer :
Squamous cell carcinoma
Which two conditions does amyloidosis does not cause ?
Bronchiectasis and B/l hilar lymphadenopathy
What kind of effusion does hypothyroidism cause ?
Transudate
Transudate Pleural effusion causes :
All the failures + Meigs
Heart failure
Thyroid Failure—hypothyroidism
Kidney failure—nephrotic
Liver failure—Hypoalbuminaemia
Cystic fibrosis which chromosome defect ?
Chromosome 7
Hypercalcemia pathology in Sarcoidosis :
Increased activation of Vitamin D
presentation of dyspnoea and hypoxaemia 72-hours postoperativel
Basal Atelectasis
Pneumothorax is typically more of acute onset shortness of breath which makes the answer incorrec
Pleural fluid >__ is exudative :
30
LABA examples :
Formeterol
Salmetrol
ICS examples:
Budesonide
PiMZ
carrier and unlikely to develop emphysema if a non-smoker
Pleural Plaques found. Next step ?
No follow up required
Which one of the following anti A 41-year-old man with a past history of asthma presents with pain and weakness in his left hand. Examination findings are consistent with a left ulnar nerve palsy. Blood tests reveal an eosinophilia. Which one of the following antibodies is most likely to be present?
P Anca
Mononeuritis multiplex —Purg straus
In emphysema, The TLCO ?
Decreased
Left to right cardiac shunt, TLCO ?
More blood available , hence the TLCO increases
Polycythemia long term complication :
Stroke
Nasal Crusting + Hempotysis + Raised urea creat
Granulomatosis with polyangitis
Most common organism found in COPD exacerbation :
Haemophilus Influenza
the triad of erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis.
Lofgren’s syndrome
single most important intervention in patients with COPD
Smoking Cessation
For COPD, What are the most appropriate initial settings for the ventilator?
IPAP of 10 cm H20, EPAP=5 cm H20
Which one of the following is associated with a poor prognosis in patients with community-acquired pneumonia?
Urea > 7
Community acquired pneumonia 1st line Rx?
Penicillin—Amoxicillin
If you want to be respected in community, you have to be a man of pen (Penicillin )
Moderate to severe—Add Macrolides
Amoxicillin( Co-amoxiclav) + Clarithromycin
C/I for varenicline?
Past history of self harm
Is CRP a good tool to assess prognosis in pneumonia ?
No
What is the main role of alpha-1 antitrypsin in the body?
Protease Inhibitor
extrinsic allergic alveolitis (EAA), also known as hypersensitivity pneumonitis in farmers is caused by ?
Contaminated Hay
COPD patient with The posterioranterior (PA) chest x-ray on admission shows a unilateral pleural effusion. Which one of the following is the most useful next line investigation?
Pleural aspiration under ultrasound guidance.
The most direct way to determine the cause of a pleural effusion is by analysing the fluid itself. This can provide information about its nature (transudative vs exudative), microbiology (if infection is suspected) and cytology (for malignant cells). Therefore, pleural aspiration with ultrasound guidance would be the most appropriate next line investigation according to UK guidelines.
progressive exertional dyspnoea associated with clubbing and a spirometry—FEV1/FVC >0.7 + Bibasal crackles. Dx and Ix
Restrictive + Bibasal Crackles(lower zone—affected) : Fibrosis
Ix- CT
Acute asthma attack : Rx?
OSSIM
O2
SABA
Steroids
Ipratopium Bromide
Magnesium Sulphate
Aminophyline
Which HLA in Bronchiectasis ?
HLA DR1
Bronch1ectas1s
B/L Hilar Lymphadenopathy + parotid enlargement, fever, and anterior uveitis.
Heerfordt syndrome
Heerfordt syndrome
B/L Hilar Lymphadenopathy + parotid enlargement, fever, and anterior uveitis.
O2 dissociation curve in Hypocapnia ?
Shifts to left
diagnostic test for obstructive sleep apnoea
Polysomnography
Most imp aspect of management of asbestosis:
Smoking cessation
Oxygen in stroke patients ?
No oxygen therapy in stroke
Pathology of emphysema ?
destruction of alveolar walls secondary to proteinases
What is the normal function of the cystic fibrosis transmembrane regulator?
Chloride channel
Raised TLCO + Multifocal airspace consolidation noted
Pulmonary Haemorrhage
Asthma wont have this image finding
KCO in Obese :
Raised
Obese patient spirometry
Fev1/FVc > 0.7 + Raised KCO
ARDS CXR:
bilateral infiltrates in both bases.
CXR of Chondrosarcoma :
Calcification
Fever + Dry Cough + SOB + B/L Patchy Opacities + Raised ESR and CRP+ LACK OF RESPONSE TO ANTIBIOTICS.
LACK OF RESPONSE TO ANTIBIOTICS—Cryptogenic organising Pneumonia.
We would expect a community acquired pneumonia to respond to antibiotics.
Hypersensitivity pneumonitis is a possibility as the two conditions can have similar histories and chest x-ray appearances but the is no aetiologic agent mentioned in the history so it makes it less likely.
Our patient is a non-smoker so lung cancer is less likely.
pneumothoraces occurring in menstruating women:
Catamenial Pneumothorax
single most important piece of advice to reduce his risk of further pneumothoraces?
Stop Smoking
Differentiate PE and Anxiety :
PE has lower PCO2
