respiratory medicine

Question 1

fine crackles causes

Answer 1

pulmonary oedema

Question 2

exudative vs transudative pulmonary effusions

Answer 2

transudative - high pressure eg. HF, LV, CKD, cirrhosis, Pulmonary embolism
exudative - high protein & LDH eg. infection, malignancy,

Question 3

end expiratory BILATERAL wheeze

Answer 3

asthma

Question 4

polyphonic inspiratory and expiratory (biphasic) wheeze

Answer 4

COPD

Question 5

clubbing in COPD?

Answer 5

no clubbing in COPD

Question 6

causes of stridor?

Answer 6

Croup
Epiglottitis
Post-extubation laryngeal edema
Foreign body aspiration

Question 7

breathlessness score?

Answer 7

MRC dyspnoea scale

MRC grade 1 - SOB only on strenerous exercise
grade 2 - even when climbing slight hill
5 grades with different statements that patient says when they get breathless

Question 8

causes of obstructive lung disease

Answer 8

Asthma, COPD, bronchiectasis

Question 9

causes of restrictive lung disease

Answer 9

pulmonary fibrosis, asbestos, sacroidosis, obesity, neuromuscular disorders, kyphosis, obesity, acute respiratory distress syndrome

Question 10

spirometry obstructive vs restrictive

Answer 10

obstructive: FEV1 significantly reduced & FVC normal or slightly reduced —-> FEV1:FVC reduced
restrictive: FEV1 slightly reduced & FVC is significantly reduced –> FEV1:FVC increased or normal

Question 11

investigations for obstructive sleep apnoea

Answer 11

ABG: compensated respiratory acidosis
Hypertension
Epworth sleepiness scale questionnaire
Multiple sleep latency test (MSLT) - time to fall asleep in dark room using EEG criteria
sleep studies (polysomnography) with pulse oximetry, EEG, thoraco-abdominal wall movement

Question 12

COPD patient, pneumothorax 1.5 cm

Answer 12

aspirate +/- chest drain
sit up
high flow oxygen but keep an eye on sats
monitor for 24hrs

Question 13

COPD patient, pneumothorax 0.5cm

Answer 13

sit up
high flow high flow oxygen but keep an eye on sats
monitor for 24hrs

Question 14

cut offs pneumothorax for do nothing vs aspiration vs chest drain

Answer 14

primary

• <2cm monitor and review
• > 2cm aspirate –> chest drain

secondary
<1cm do nothing
1-2cm aspirate –> chest drain
>2cm chest drain

Question 15

criteria for LTOT in COPD?

Answer 15

measure ABG on 2 occasions, 3 weeks apart on optimum medication
two ABGs pO2 < 7.3kPa
ABG pO2 7.3-8kPa + pulmonary HTN or peripheral oedema or secondary polycythemia

Question 16

COPD patient, pneumothorax 2.5cm

Answer 16

chest drain

Question 17

which heart murmur can give you haemoptysis?

Answer 17

mitral stenosis

Question 18

cardiac pulmonary oedema vs acute respiratory distress syndrome

Answer 18

pulmonary capillary wedge pressure is high then this is due to backlog into veins due to heart failure

ARDS can only be diagnosed in absence of heart failure

Question 19

Venturi mask in COPD

Answer 19

24/28% blue Venturi masks

Sats of 88-92%

Question 20

Steroid conc acute exacerbation of asthma or copd

Answer 20

In asthma, give 100mg IV hydrocortisone

In COPD, give 200mg IV hydrocortisone

Question 21

Asthma reversibility cut off

Answer 21

FEV1 > 12% with SABA

Question 22

site of aspiration in tension pneumothorax

Answer 22

2nd ICS mid clavicular line

6th ICS anterior axillary line in safe triangle

Question 23

site of safe triangle

Answer 23

lateral border of pec major
anterior border of lattisimus dorsi
6th ICS (nipple) directly ABOVE the rib

Question 24

what way does the trachea/mediastinum deviate for different pathologies?

Answer 24

tension - away
lobal collapse - towards
pleural effusion - away

Question 25

causes of pneumothorax

Answer 25

spontaneous secondary to chronic lung issues: COPD, asthma, Marfans, mechanical ventilation trauma - rib fractures, central line insertion

Question 26

left lobe collapse on X ray

Answer 26

1. sail sign/ triangle behind the heart + NB. lung field may actually seem normal 2. aortic -knob sign -- the aortic arch is very circular and prominent 3. reduction of volume on left (can be subtle) + elevation of the left diaphgram!

Question 27

normal ABG values

Answer 27

pH 7.35 - 7.45 pCO2 35-45 mmHg HCO3- 22-26 pO2 80-100 mmHg

Question 28

when do you do V/Q over CTPA for pulmonary embolism?

Answer 28

pregnancy renal failure (can't deal with contrast) allergic to contrast

Question 29

where is bifurcation of trachea?

Answer 29

T5 to 7 (behind sternum)

Question 30

where is bifurcation of AORTA?

Answer 30

L4 just above the junction of the left and right common iliac veins.

Question 31

mx of massive PE

Answer 31

local guidelines intra-arterial: urgent pulmonary angiography and perfusion of thrombolytic drugs into the pulmonary arteries to dissolve the thrombus OR intravenous: thrombolysis can be done via peripheral IV if radiological expertise is not available or less severely comprised patients surgical thrombectomy is done at cardiothoracic units

Question 32

examples of thrombolytics | CI to thrombolytic agent use

Answer 32

egs. streptokinase, urocinase, recombinant tissue plasminogen activator CIs: BLEEDING - recent haemorrhage, trauma, surgery - suspected/known aortic dissection - suspected/known peptic ulcer disease - previous allergy - previous history of intracerebral haemorrhage event - severe HTN

Question 33

presenting CXR

Answer 33

Rotation - clavicles equidistant from spinous processes Inspiration - 6 anterior ribs Peneration - vertebrae (+ see anterior ribs, if over peneterated then will see mainly posterior ribs) Exposure - can you see entire chest

Question 34

presentation of any imaging/ investigations

Answer 34

what is it? orientation eg. PA/AP patient details date and time taken previous images was the patient symptomatic?

Question 35

how does cystic fibrosis result in chronic renal failure

Answer 35

CF --> systemic amyloidosis

Question 36

Hilar enlargement causes

Answer 36

Bilateral - - infection: TB, HIV - inflammation: sarcoidosis, pneumonoconiosis, silicosis, - malignancy: (lymphoma, mets) - vascular: pulmonary hypertension (COPD, recurrent mets) Unilateral/asymmetrical - malignancy, TB, pulmonary artery aneurysm

Question 37

TB diagnosis

Answer 37

1. CXR 2. sputum stain for acid fast bacilli 3. sputum culture for TB - most specific and sensitive - 3 samples, 8 hrs, at least one in the morning 4. NAAT (nucleic acid amplification test) - can use sputum sample or sample from bronchoscopy with broncholavage - quick diagnosis but not all centers have it 5. bloods - low Hb (chronic disease), raised WCC, pancytopenia (disseminated infection) tuberculin skin test is not so helpful

Question 38

what do you do if you have a patient with acid fast bacilli

Answer 38

TB until proven otherwise 1. negative pressure side room (minimise transmission to other parts of hospital) 2. tell hospital infection control team 3. inform local Health Protection Consultant

Question 39

cause of bronchial breath sounds

Answer 39

pneumonia | expiratory lasts longer than inspiratory

Question 40

DDx multiple ill defined opacities in CXR

Answer 40

``` infection - septic emboli Inflammation - rheumatoid arthritis - granulomatosis with polyangitis malignancy - pulmonary mets vascular - pulmonary infarcts (following PE, death of lung tissue) ``` NB. miliary TB gives much smaller lesions a few mm in diameter

Question 41

MX of mesothelioma

Answer 41

no effective treatments installation of sclerosant substances (dehydrating the pleural cells) to prevent re-accumulation of pleural effusions resulting in breathlessness typically mets to lungs, hilar, other pleura in the body

Question 42

Miliary shadowing CXR

Answer 42

Miliary - few mm blotches everywhere ``` Tuberculosis!! Sarcoidosis Mets Extrinsic allergic alveolilitis Occupational lung disease ```

Question 43

Mx of aspergilloma/ mycetoma

Answer 43

1. IV antifungals | 2. surgical resection

Question 44

which lung malignancy causes a horner's syndrome? | what can it result in?

Answer 44

superior sulcus/ apical lung carcinoma aka pancoast tumour tumours can invade and compress surrounding structures resulting in Pancoast syndrome invasion of sympathetic chain = Horners invasion of brachial plexus = shoulder/arm pain compession of spinal cord recurrent laryngeal nerve invasion = hoarse voice

Question 45

how does aspergillus species affect the lung?

Answer 45

1. asthma (type 1 hypersensitivity) 2. allergic bronchopulmonary aspergillosis (type 1 & 3 hypersensitivity) - recurrent asthma and bronchial damage and bronchiectasis 3. extrinsic allergic alveolitis - reccurent dyspnoea and dry cough and ultimately fibrosis 4. mycetoma (aspergilloma) - fungus bal forming in a pre-existing lung cavity 5. invasive aspergillosis in the immunosuppressed with high mortality

Question 46

DDx cavitating mass on chest radiograph

Answer 46

infection - s.aureus - klebsiella - mycetoma (aspergillus) - TB wegener's granulomatosis (granulomatosis with polyangitis) carcinoma of the bronchus, SCC metastasis pulmonary infarct

Question 47

diagnosis of aspergillus disease

Answer 47

serum preciptins is best | aspergillus skin test is positive in 30% of cases

Question 48

Mx of aspergilloma/ mycetoma

Answer 48

1. IV antifungals | 2. surgical resection

Question 49

most common histological subtype of lung cancer

Answer 49

adenocarcinoma 40%

Question 50

causes of superior vena cava syndrome

Answer 50

malignancy - bronchal ca, lymphoma in hilum thrombosis secondary to pacing wirses or central venous catheters

Question 51

mx of superior vena cava syndrome

Answer 51

1. oxygen, head elevate 2. steroids, diuretics to relieve laryngeal/ cerebral oedema 3. surgical bypass or SVC stenting

Question 52

ddx widespread opacity

Answer 52

``` pulmonary oedema (bat wing/ hilar) non-cardiogenic pulmonary oedema ``` aspiration pulmonary haemorrhage pneumocystis pneumonia (ground glass)