Respiratory PassMed Learning Points Flashcards
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What is the most appropriate next step in the investigation of suspected pulmonary embolism if D-dimer negative?
Stop anticoagulation and consider an alternative diagnosis
What is the most appropriate next step in the investigation of suspected pulmonary embolism if medium-high (> 15%) pre-test probability of PE? [1]
A 2-level PE Wells score should be performed:
Clinical probability simplified scores
PE likely - more than 4 points
PE unlikely - 4 points or less
What is the most appropriate next step in the investigation of suspected pulmonary embolism if CTPA negative? [1]
Consider the possibility of DVT and arrange proximal leg vein ultrasound if suspected
What is the best investigation for pulmonary embolism (history of CKD stage 4)? [1]
Ventilation-perfusion scan
PE would cause change to axis deviation? [1]
Right axis deviation
Which drug is contraindicated in pneumothorax? [1]
Nitrous oxide
Why is nitrous oxide contraindicated in pneumothorax? [1]
May diffuse into gas-filled body compartments → increase in pressure.
What is the most likely diagnosis?
Lung cancer
PE
Pneumonia
Heart failure
What is the most likely diagnosis?
Lung cancer
PE
Pneumonia
Heart failure
Which test should be done next?
CT Chest
Sputum microscopy
Pleural tap
Echo
What are expected changes to baseline investigations of mineral levels would you expect to see in sarcoidosis? [1]
Raised Ca2+
A 62-year-old female is admitted with a suspected infective exacerbation of COPD. A chest x-ray shows no evidence of consolidation. What is the most likely causative organism?
Pseudomonas aeruginosa
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pneumoniae
Moraxella catarrhalis
Haemophilus influenzae is the most common cause of infective exacerbations of COPD. The patient should be treated with a course of amoxicillin or a tetracycline together with prednisolone.
NOTE: If the patient had pneumonia then Streptococcus pneumoniae would be the most likely causative organism. However, the chest x-ray shows no evidence of consolidation making a diagnosis of pneumonia unlikely.
Prior to discharge, following an acute asthma attack, PEF should be [] of best or predicted
Prior to discharge, following an acute asthma attack, PEF should be >75% of best or predicted
What characteristics of a cough would indicate that a patient is suffering from bronchiectasis? [3]
Persistent productive cough
+/- haemoptysis in a young person with a history of respiratory problems
How would you know if asthma is severe solely from talking to a patient? [1]
If they cannot complete their sentences: severe
Where is alpha1-antitrypsin produced? [1]
Liver
Alpha1-antitrypsin deficiency can be diagnosed in which period of life? [1]
Alpha1-antitrypsin deficiency can be diagnosed in the pre-natal period
Alpha1-antitrypsin deficiency is commonly found in which age groups? [1]
It is most commonly found in those aged 20-50.
Which organs does alpha1-antitrypsin deficiency predominately effect? [2]
Describe how this occurs in each organ [2]
Lungs and Liver
Lungs:
- Panacinar emphysema (lower lobes)
Liver:
- Cirrhosis in adults
- Hepatocellular carcinoma in adults
- Cholestasis in children
How do you treat alpha1 anti-trypsin? [4]
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
What clinical markers help to distinguish between tension and normal pneumothorax? [1]
Tracheal deviation
How do you treat tension pneumothorax? [1]
Inserting a wide bore cannula into the second intercostal space, mid-clavicular line to decompress the tension pneumothorax, leading to the formation of a ‘regular’ pneumothorax.
How do you determine if a tension pneumothorax needs a chest drain or needle thoracostomy? [1]
If being resuscitated: **needle thoracostomy **
State two examination findings that might indicate IPF [2]
Bibasal inspiratory crackle
Clubbing (~25)
Describe the spirometry and TLCO findings for IPF [2]
FEV1/FVC: normal (both reduced)
TLCO reduced (TLCO: amount of uptake O2 in lungs)
What spirometry pattern would you expect of someone who presents like this? [1]
Kyphoscoliosis: causes restrictive lung defects on spirometry: FEV1/FVC normal
What investigation would you conduct to investigate occcupational asthma? [1]
serial peak floe measurements at work and home: compare the two
When would you use patch testing when investigating a pathology? [1]
When investigating contact dermatitis
A patient is suffering from COPD and present with findings suggestive of pneumonia. What drugs should you prescribe? [1]
30mg predinisolone for 5 days
Give for COPD patients with pneumonia even if there is no evidence of COPD being worsened
How do you diagnose asthma patients if:
- < 5 y/o [1]
- 5-16 [2]
< 5:
-clinical judgement
5-16
- All children should have bronchodilator reversibility test (BDR)
- FENO should be given if spirometry normal; or BDR negative
What is the only guidance from BTS about when to conduct an ABG for asthma exacerbations [1]
If SpO2 < 92
What pathology would you consider if a young person presents with COPD symptoms? [1]
Alpha1 anti-trypsin deficiency
In which cases would you use 94-98% O2 sats for COPD patients? [1]
If CO2 levels are normal
What pulse what indicate:
- moderate asthma [1]
- severe asthma? [1]
- life threatening asthma? [1]
- moderate asthma: < 100 bpm
- severe asthma: > 110bpm
- life threatening asthma: bradycardia
What PEFR best / predicted what indicate:
- moderate asthma [1]
- severe asthma? [1]
- life threatening asthma? [1]
What PEFR best / predicted what indicate:
- moderate asthma: 50-75%
- severe asthma: 33-50%
- life threatening asthma: < 33%
What speech level would indicate:
- moderate asthma [1]
- severe asthma? [1]
- life threatening asthma? [1]
What speech level would indicate:
- moderate asthma: normal
- severe asthma can’t complete sentences
- life threatening asthma cant complete sentence ++
What RR would indicate:
- moderate asthma [1]
- severe asthma? [1]
- life threatening asthma? [1]
What RR would indicate:
- moderate asthma: < 25/min
- severe asthma: > 25min
- life threatening asthma: feeble respiratory effort
What O2 saturation would suggest life-threatening asthma? [1]
< 92%
What would a normal pCO2 indicate in an acute asthma attack? [1]
In addition, a normal pCO2 in an acute asthma attack indicates exhaustion and should, therefore, be classified as life-threatening.
Lung cancer can be indicated by what result on a blood test? [1]
Raised platelets
Which cancers present with raised platelets? [5]
LEGO-C
-Lung
-Endometrial
-Gastric
-Oesophageal
-Colorectal
What advice should you give smoking pregnant women who wish to continue smoking? [1]
Which anti-smoking drugs are contraindicated? [2]
nicotine replacement therapy
varenicline and bupropion are contraindicated
Bupropion is used as an anti-smoking drug. Which two populations is it contraindicated in? [2]
Pregnant
Epileptic
What is meant by Lambert-Eaton syndrome? [1]
Lambert Eaton syndrome (LES) is a rare autoimmune disorder in which antibodies are formed against pre-synaptic voltage-gated calcium channels in the neuromuscular junction.
A significant proportion of those affected have an underlying malignancy, most commonly small cell lung cancer.
It is therefore regarded as a paraneoplastic syndrome.
How does a patient with Lambert-Eaton syndrome present? [5]
Weakness in muscles of the proximal arms and legs
Weakness effects legs more than arms (causes difficulty climbing stairs / rising from seat)
Weakness is noramlly relieved temporarily after start of exercise
Autonomic dysfunction, causing dry mouth, blurred vision, impotence and dizziness
Reduced or absent tendon reflexes
Lambert-Eaton syndrome arises due to which type of lung cancer?
small-cell lung cancer
large cell lung cancer
adenocarcinoma
squamous cell cancer
Lambert-Eaton syndrome arises due to which type of lung cancer?
small-cell lung cancer
large cell lung cancer
adenocarcinoma
squamous cell cancer
Explain how you treat Lambert-Eaton syndrome [1]
Amifampridine works by blocking voltage-gated potassium channels in the presynaptic membrane, which in turn prolongs the depolarisation of the cell membrane and assists calcium channels in carrying out their action.
Which form of lung cancer causes ectopic ACTH? [1]
Small cell lung cancer: can cause Cushings
How does Cushings from small cell lung cancer differ to other forms of Cushings? [1]
Hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump
How can you determine if squamous cell lung cancer is more likely from a CXR? [1]
Cavitating lesions are more common with squamous cell than other types of lung cancer
A large cavity in the right mid to upper zone with a thin wall and a central air-fluid level.
The remainder of the lungs are normal.
Which type of lung cancer is not associated with smoking? [2]
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which type of lung cancer is not associated with smoking? [2]
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which is type of lung cancer is most likely to be carcinoid?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which is type of lung cancer is most likely to be carcinoid?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which is the most common?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which is the most common?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which of the following is characterised by lots and lots of sputum?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which of the following is characterised by lots and lots of sputum?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which of the following is characterised by hyponatraemia?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which of the following is characterised by hyponatraemia?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer - causes ectopic release of ADH
Which of the following is characterised by gynaecomastia?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
Which of the following is characterised by gynaecomastia?
alveolar cell carcinoma
large cell
squamous
adenocarcinoma
bronchial adenoma
small cell lung cancer
An 18-year-old man is admitted to the emergency department with an episode of acute asthma. He is unable to complete sentences, tachycardic (118 beats per minute) and tachypnoeic (respiratory rate 30). He has received salbutamol, ipratropium bromide nebulisers and intravenous hydrocortisone through a large bore cannula in the right antecubital fossa. Despite another salbutamol nebuliser, there is no improvement in his condition. What medication would be most appropriate to add?
Beclamethasone
Magnesium sulphate
Amoxicillin
Nifedipine
Adrenaline
Magnesium sulphate
The SIGN guidelines give clear instructions on how to escalate care.
1. Oxygen
2. Salbutamol nebulisers
3. Ipratropium bromide nebulisers
4. Hydrocortisone IV OR Oral Prednisolone
5. Magnesium Sulfate IV
6. Aminophylline/ IV salbutamol
What is the most likely diagnosis?
Left lower lobe collapse
Left middle lobe pneumonia
Right lower lobe pneumonia
Right middle lobe collapse
Right middle lobe pneumonia
What is the most likely diagnosis?
Left lower lobe collapse
Left middle lobe pneumonia
Right lower lobe pneumonia
Right middle lobe collapse
Right middle lobe pneumonia
Whats a pneumonic for remembering the treatment of asthma exacerbations? [4]
Oh
Shit,
I
Hate
My
Asthma
1) Oxygen
2) Salbutamol nebulisers
3) Ipratropium bromide nebulisers
4) Hydrocortisone IV or Oral Prednisolone
5) Magnesium Sulfate IV
6) Aminophylline / IV salbutamol
What is the biggest predictor of worse outcome in CAP? [1]
Explain your answer [2]
High urea levels
Elevated blood urea nitrogen levels indicate dehydration or reduced renal perfusion, both of which can lead to increased mortality.
How do you manage down-stepping asthma ICS medication? [1]
aim for a reduction of 25-50% in the dose of inhaled corticosteroids
How would a lung abscess present in a patient? [3]
- Subacute productive cough
- foul-smelling sputum
- night sweats
What is the most common causative agent of COPD exacerbations? [1]
Haemophilus influenzae
Which immunodeficiency is associated with bronchiectasis? [1]
bronchiectasis
What type of breathing is associated with bronchiectasis? [1]
Wheezing
When a patient is presenting at hospital with acute asthma, how do you decide what ICS might be prescribed? [2]
All patients with acute asthma should receive oral prednisolone
Only if vomiting: give IV hydrocortisone
What does this CXR depict? [1]
What could cause this?
Pleural plaques: often associated with exposure to asbestos
The chest x-ray in the question shows bilateral pleural thickening, which is characteristic of pleural plaques.
In the step-down treatment of asthma, aim for a reduction of []% in the dose of inhaled corticosteroids
In the step-down treatment of asthma, aim for a reduction of 25-50% in the dose of inhaled corticosteroids
Diagnosis of a mesothelioma is made on [], following a thoracoscopy
Diagnosis of a mesothelioma is made on histology, following a thoracoscopy
A 64-year-old woman presents to ED with productive cough, haemoptysis, and vague abdominal pain for the past 2 weeks. She has no past medical history of note. Chest X-ray shows multiple large, round, well-circumscribed masses in both lungs.
What is the most likely underlying diagnosis?
Hepatocellular carcinoma
Miliary tuberculosis
Adenocarcinoma
Rheumatoid arthritis
Renal cell carcinoma
A 64-year-old woman presents to ED with productive cough, haemoptysis, and vague abdominal pain for the past 2 weeks. She has no past medical history of note. Chest X-ray shows multiple large, round, well-circumscribed masses in both lungs.
What is the most likely underlying diagnosis?
Hepatocellular carcinoma
Miliary tuberculosis
Adenocarcinoma
Rheumatoid arthritis
Renal cell carcinoma
Describe this CXR [1]
What could cause this CXR pattern? [1]
Chest x-ray showing cannonball metastases secondary to renal cell cancer. Multiple well defined nodules are noted distributed in both lung fields
Bronchiectasis and IPF both cause finger clubbing.
Describe the classical presentations of each, which would help you to differentiate between them [4 each]
Bronchiectasis
- a productive cough with copious amounts of purulent sputum
- occasional haemoptysis
- wheezing
- often related to a history of childhood respiratory infections
IPF:
- exertional dyspnoea
- dry cough
- Weight loss
- bibasal inspiratory crackles on auscultation
When is NIV indicated in acute exacerbations of COPD? [1]
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH < 7.35 ≥7.26) persists despite immediate maximum standard medical treatment
A 73-year-old man presents to the emergency department with a 3-day history of increased dyspnoea and cough. He has a past medical history of severe COPD and uses a Trimbow inhaler daily.
He is admitted and treated for an acute exacerbation with prednisolone 30 mg daily for 5 days and nebulisers. This is his fourth exacerbation in the past 3 months.
What option is most appropriate to reduce the risk of future exacerbations?
Amoxicillin
Carbocisteine
Doxycycline
Long-term oxygen therapy
Roflumilast
Roflumilast
Oral PDE-4 inhibitors such as roflumilast reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations
After smoking cessation, [] is one of the few interventions that has been shown to improve survival in COPD.
After smoking cessation, long-term oxygen therapy (LTOT) is one of the few interventions that has been shown to improve survival in COPD.
LTOT in COPD patients should be offered to patients with a pO2 of < [] kPa
or
to those with a pO2 of [] kPa and one of the following: [4]
LTOT should be offered to patients with a pO2 of < 7.3 kPa
or
to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension
A 48-year-old male presents to the GP as he has recently coughed up small amounts of blood on several occasions. He has also noticed his nose is ‘always blocked’ and has had a few episodes of nosebleeds. Upon questioning, he admits that his clothes feel a little looser but he has not weighed himself.
On examination, you notice a palpable rash on his lower legs.
Based on the most likely diagnosis, which antibodies are most likely to be found in this patient’s blood?
Anti-CCP
Anti-GBM
Anti-dsDNA
cANCA
pANCA
cANCA
This patient most likely has granulomatosis with polyangiitis (GPA) based on the history which includes ENT symptoms (rhinosinusitis and epistaxis), respiratory symptoms (cough and haemoptysis), and weight loss. Palpable purpura is also a common feature of GPA. cANCA is the antibody most commonly found in patients with GPA.
can also get from snorting too much cocaine so cocaine = cANCA
What is meant by Granulomatosis with polyangiitis? [1]
What would indicate a patient is suffering from GPA? [1]
autoimmune condition associated with a necrotizing granulomatous vasculitis, affecting both the upper and lower respiratory tract as well as the kidneys.
Consider granulomatosis with polyangiitis when a patient presents with ENT, respiratory and kidney involvement
Which anitbody is most commonly associated with patients of GPA? [1]
cANCA is the antibody most commonly found in patients with GPA.
How does a patient with GPA show on CXR and CT? [1]
chest x-ray: wide variety of presentations, including cavitating lesions
CT: cavities and central lesions
What is the treament regime for GPA? [3]
steroids
cyclophosphamide (90% response)
plasma exchange
The CENTOR score is used for bacterial cause of infection. What criteria is used for this score? [4]
CENTor
C an’t Cough
E xudates on tonsils
N odes tender
T emperature
If 3 or more of the 4 Centor criteria are present there is a 40-60% chance the sore throat is caused by []
If 3 or more of the 4 Centor criteria are present there is a 40-60% chance the sore throat is caused by Group A beta-haemolytic Streptococcus
Other than findings on respiratory examination, which observation makes the diagnosis of tension pneumothorax more likely than simple pneumothorax?
Blood pressure
Oxygen saturations
Pain score
Respiratory rate
Temperature
Blood pressure
Hypotension will occur in tension pneumothoraces as a result of cardiac outflow obstruction
These are all common organisms linked with patients with bronchiectasis. Which is the most common?
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
These are all common organisms linked with patients with bronchiectasis. Which is the most common?
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
You examine a CXR and see trachea deviation. The direction of the deviation compared to white out can help determine what the pathology is. How? [4]
What is a quick way of working out if a pleural effusion is exudative or transudative in source? [2]
Exudates are due to Enflammation (inflammatory processes)
Transudates are due to the failures. (Heart failure, kidney failure, liver failure)
What is a quick way of working out if a pleural effusion is exudative or transudative in source? [2]
Exudates are due to Enflammation (inflammatory processes)
Transudates are due to the failures. (Heart failure, kidney failure, liver failure)
What pathologies would a pleural fluid finding indicate if there was:
- Low glucose [2]
- Raised amylase [2]
- Heavy blood staining? [3]
Other characteristic pleural fluid findings:
low glucose:
- rheumatoid arthritis
- tuberculosis
raised amylase:
- pancreatitis
- oesophageal perforation
heavy blood staining:
- mesothelioma
- pulmonary embolism
- tuberculosis
A pleural effusion is found to have raised amylase after a pleural tap. What is the most likely cause of this?
What is the other differential? [1]
TB
RA
Mesothelioma
PE
Oesophageal perforation
Oesophageal perforation
or
Pancreatitis
A pleural effusion is found to have low blood glcose after a pleural tap. What is the most likely cause of this? [2]
TB
RA
Mesothelioma
PE
Oesophageal perforation
TB
RA
Bronchiectasis: most common organism = []?
Bronchiectasis: most common organism = Haemophilus influenzae
[] is the organism that can be found in patients with bronchiectasis secondary to cystic fibrosis?
Mycobacterium abscessus is the organism that can be found in patients with bronchiectasis secondary to cystic fibrosis?
What is a pneumonic for discharge criteria for acute asthma? [3]
Mnemonic for remembering Discharge Criteria of Acute Asthma - PSI
P - PEF >75%
S - Stable on medication (no nebs / ox for 12/24 hours)
I - Inhaler Technique
A 60-year-old man presents to his GP with a 6-month history of a dry cough with associated diffuse chest pain. On questioning, he also has symptoms of fatigue and dyspnoea on exertion. An X-ray is performed before a secondary care appointment and appears as below:
He has no relevant medical history but has had several occupations during his life, including in labouring professions such as construction, shipbuilding and farming.
Is it:
Pleural plaques
Mesothelioma
Mesothelioma
This image shows pleural thickening indicative of mesothelioma on the right, almost certainly due to asbestos exposure during his shipbuilding or construction work. As a rule of thumb, the pleurae should only be the thickness of a pencil line on a radiograph, whereas here on the right it is diffusely thickened. There is also decreased volume of the right lung as a result, causing dyspnoe
Pleural plaques are asymptomatic
What would be the management of this CXR? [1]
Pleural plaques are benign and do not undergo malignant change. They, therefore don’t require any follow-up. They
Patient with acute asthma who do not respond to full medical treatment and are becoming acidotic should be given what treatment? [1]
Patient with acute asthma who do not respond to full medical treatment and are becoming acidotic should be intubated and ventilated, rather than given BiPAP/CPAP
A 40-year-old man is investigated for increasing shortness of breath. He has smoked for the past 25 years. Pulmonary function tests are performed and are reported as follows:
FEV1 1.4 L (predicted 3.8 L)
FVC 1.7 L (predicted 4.5 L)
FEV1/FVC 82% (normal > 75%)
Which one of the following disorders is most consistent with these results?
Asthma
Bronchiectasis
Neuromuscular disorder
Chronic obstructive pulmonary disease
Laryngeal malignancy
Neuromuscular disorder: Lambert Eaton syndrome
Shows a restrictive pattern on spirometry
Squamous cell cancer is associated with which three paraneoplastic syndromes? [4]
- parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
- clubbing
-
hypertrophic pulmonary osteoarthropathy (HPOA)
Hypertrophic osteoarthropathy (HOA) is mainly caused by mainly fibrovascular proliferation. It is characterized by a combination of clinical findings, including severe disabling arthralgia and arthritis, digital clubbing, and periostosis of tubular bones with or without synovial effusion - hyperthyroidism due to ectopic TSH
When calculating CURB65, what are the blood pressure recordings that would indicate a point? [2]
SBP < 90
DBP < 60
A patient presents with chronic cough, but non-red flag symptoms, no sputum. and normal spirometry. They are a non-smoker.
What are the three most common differentials should investigate? [3]
- cough-variant asthma
- gastro-oesophageal reflux
- post-nasal drip.
What do you give patients when performing bronchial provocation testing? [1]
Describe how you pefrom bronchial provocation testing [2]
Bronchial provocation testing is performed with methacholine or histamine
Increasing doses are given until the patient’s forced expiratory volume (FEV1) drops by 20% in one second. This dose is termed the PC20.
A PC20 dose of 8 mg/ml or less reflects a positive result.
How would you investigate if you suspected someone was suffering from respiratory muscle weakness? [1]
Look at maximal inspiratory and expiratory pressures are used to investigate respiratory muscle weakness, such as those seen in neuromuscular disorders.
A 36-year-old male call centre operator attends his routine outpatient clinic appointment. He has a 5-year history of sarcoidosis and admits to increasing shortness of breath over the past four weeks. This is his fourth episode of this nature since his diagnosis. He has previously responded well to tapered doses of oral steroids.
What initial test would be most helpful before prescribing steroids to assess his current pulmonary status objectively?
Chest X-ray
Pulmonary function tests with transfer factor
Arterial blood gas
Serum angiotensin-converting enzyme (ACE) level
High-resolution computed tomography (HRCT) of the chest
Pulmonary function tests with transfer factor
If a patient is suffering from pneumonia, where would consolidation be to suggest it is aspirational pneumonia? [1]
Right lower zone
What would indicate that someone is suffering from Staphylococcal pneumonia? [1]
Cavitational pneumonia
classically gives bilateral perihilar consolidations, with or without pneumatocele (lung cyst) formation.
This refers to pneumonia from which infective organism? [1]
Pneumocystis jiroveci pneumonia
A 23-year-old man has suffered a left-sided pneumothorax. A chest drain has been inserted through the left fifth intercostal space at the mid-axillary line.
As well as the intercostal muscles, which other muscle is likely to have been pierced?
External oblique
Latissimus dorsi
Pectoralis major
Pectoralis minor
Serratus anterior
Serratus anterior
A 69-year-old male is investigated by the respiratory team for worsening shortness of breath and cough over the past nine months. He has never smoked and is usually fit and well. The only significant history of note is that he has taken up pigeon racing since retiring. Following investigation, the patient is diagnosed with interstitial pneumonia.
Which of the following organisms is most commonly associated with interstitial pneumonia?
Haemophilus
Klebsiella
Streptococcus
Staphylococcus
Mycoplasma
Mycoplasma
Organisms that mainly cause interstitial lung patterns include Pneumocystis, Mycoplasma, viruses like RSV and CMV, and fungal infections like histoplasmosis
55-year-old male in the United Kingdom presents with a fever and cough. He smells strongly of alcohol and has no fixed abode. His heart rate was 123 bpm, blood pressure 93/75 mmHg, oxygen saturation 92% and respiratory rate 45 breaths per minute. Further history from him reveals no recent travel history and no contact with anyone with a history of foreign travel. Chest X-ray revealed consolidation of the right upper zone.
Which of the following drugs is the most prudent choice in his treatment?
Isoniazid, rifampicin, pyrazinamide, ethambutol
Co-trimoxazole
Phenoxymethylpenicillin
Meropenem
Azithromycin
Meropenem
Klebsiella pneumoniae (KP) is likely the causative organism in this case.
A 53-year-old presents with shortness of breath. A high-resolution computerised tomography (CT) scan of the chest is performed and an air-crescent sign is seen.
Which of the following organisms is typically associated with this sign?
Aspergillus
Mycobacterium avium intracellulare
Staphylococcus aureus
Pseudomonas aeruginosa
Mycobacterium tuberculosis
Aspergillus
A patient presenting with a history of taking which drugs might indicate investigating for TB? [1]
anti-TNF medication
Most tuberculosis cases have been seen with infliximab. The British Thoracic Society recommends clinical examination, chest X-ray and tuberculin test before starting treatment with anti-TNF antibody medications.
On the right side of the patient’s chest, which one of the following surface landmarks would be most likely to mark the boundary between the middle and lower lobes?
Fourth costal cartilage
Horizontal line at level of sternal angle
Horizontal line at level of nipple
Ninth costal cartilage
Sixth rib
On the right side of the patient’s chest, which one of the following surface landmarks would be most likely to mark the boundary between the middle and lower lobes?
Sixth rib
thought to start at the level of the T4 spinous process posteriorly, crossing the fifth intercostal space in the lateral chest and then anteriorly, following the contour of the sixth rib.
Which way is the trachea pushed in tension pneumothorax? [1]
It also pushes the trachea and mediastinum away from that lung (hence the contralateral tracheal deviation).
The area of lobe affected by bronchiectasis can help indicate the pathology.
For the following, name pathological causes of bronchiectasis in the:
Upper lobe [2]
MIddle lobe [2]
Lower lobe [3]
Central: [2]
upper lobe:
- cystic fibrosis
- tuberculosis
middle lobe:
- immotile cilia syndrome
- Mycobacterium avium complex infection:
lower lobe:
- interstitial lung disease
- congenital immune deficiency
- recurrent aspiration
central:
- ABPA (allergic bronchopulmonary aspergillosis)
-Williams–Campbell syndrome.
Bronchiestasis in the upper lobe is most likely to be because of [2]
interstitial lung disease
cystic fibrosis
immotile cilia syndrome
recurrent aspiration
tuberculosis
-
Cystic fibrosis
&
TB
Bronchiestasis in the middle lobe is most likely to be because of
interstitial lung disease
cystic fibrosis
immotile cilia syndrome
recurrent aspiration
tuberculosis
Name one more [1]
-
immotile cilia syndrome
&
Mycobacterium avium complex infection
Bronchiestasis in the lower lobe is most likely to be because of
interstitial lung disease
cystic fibrosis
immotile cilia syndrome
recurrent aspiration
tuberculosis
Name one more [1]
-
Bronchiestasis in the lower lobe is most likely to be because of [2]
interstitial lung disease
cystic fibrosis
immotile cilia syndrome
recurrent aspiration
tuberculosis
&
interstitial lung disease
congenital immune deficiency
What is meant by allergic bronchopulmonary aspergillosis (ABPA)? [3]
allergic bronchopulmonary aspergillosis:
- is a fungal infection of the lung due to a hypersensitivity reaction to antigens of Aspergillus fumigatus after colonization into the airways.
- ABPA causes bronchospasm and mucus buildup
resulting in coughing, breathing difficulty and airway
obstruction.
- Some people with ABPA will develop bronchiectasis,
a form of airway damage that can result in worse lung
function and increased risk of infection
What would indicate someone is suffering from allergic bronchopulmonary aspergillosis (ABPA)? [5]
- high serum IgE
- Black sputum
- peripheral eosinophilia
- positive skin tests for Aspergillus protein
- recurrent pulmonary infiltrates on chest X-ray are found.
What type of hypersensitivty reaction is TB?
Type I
Type II
Type III
Type IV
What type of hypersensitivty reaction is TB?
Type I
Type II
Type III
Type IV
Describe the cough that occurs in bronchiectasis? [1]
foul-smelling haemoptysis
Name two drugs that can cause pulmonary fibrosis? [2]
Bleomycin & azathioprine
Which of the following medications could be responsible for causing the gentleman’s pulmonary fibrosis?
Aspirin
Ramipril
Bleomycin
Spironolactone
Simvastatin
Bleomycin
The presentation of symptoms like eyelid drooping (ptosis), facial dryness & shrinking of pupils alongside lung cancer symptoms suggest location of a tumour to be where? [1]
Pancoast tumour:
an apical lung tumour causing damage to sympathetic fibres as they exit the spinal cord and ascend to the superior cervical ganglion.
What is important to consider about mesotheliomas? [1]
Indirect exposure occurs:
- when asbestos fibres are brought home on clothes. Industries such as textiles, tiles, insulation, and shipyards pose a risk
- Partners of workers are at risk
Pneumocystis jiroveci pneumonia occurs in which areas of the lung? [1]
bilateral perihilar consolidations
Aspiration pneumonia commonly affects which lobes of the lungs? [2]
Aspiration pneumonia often affects the lower lobes of the lungs, particularly the right middle or lower lobes and the left lower lobe, due to the gravitational flow of aspirated contents into the lower bronch
A 33-year-old man with acquired immune deficiency syndrome (AIDS) is admitted to the Emergency Department feeling unwell, pyrexic and short of breath. There is concern that this patient has Pneumocystis jirovecii pneumonia.
Which of the following clinical findings is most typical of this condition?
Cavitating lesions on chest X-ray (CXR)
Desaturation on exercise
Presence of cervical lymphadenopathy
Accompanying colourless frothy sputum
An obstructive pattern of pulmonary function tests (PFTs)
Desaturation on exercise
The classical feature of P. jirovecii is desaturation on exercise. This may be demonstrated clinically on the ward by measuring pulse oximetry. This is measured both before and after walking up and down the ward. If a significant drop is noted, this must be recorded.
Describe the cough produced by Pneumocystis jirovecii pneumonia? [1]
Non-productive
Need to work out Lights criteria from the information given. To meet Light’s criteria:
- Pleural: serum LDH needs to be > 0.6
- Serum protein ratio needs to ne > 0.5
Therefore C is correct:
Pleurul:serum LDH: 150:180 = 0.83
Serum protein: pleural protein: 7:4
Describe how hypercapnia may present initially [3]
Clinically, hypercapnia may manifest as warm, dilated peripheries with a flap (carbon dioxide retention asterixis) and papilloedema.
How does an ABG of patient in T2RF present? [3]
acidosis (low pH), hypercapnia and a degree of metabolic compensation giving rise to a raised bicarbonate level (HCO3–)
How does an ABG of patient in T1RF present? [3]
hypoxaemia (PaO2 < 8 kPa) and a normal or low CO2
A 55-year-old patient presented with progressive dyspnoea. On computerised tomography (CT) scan of the chest, a lesion was found in the middle lobe of the right lung. The radiologist reported the findings as ‘a region of ground-glass opacity surrounded by denser lung tissue’.
What is this sign better known as?
Atoll sign
Halo sign
Kerley B lines
Signet ring sign
Tree-in-bud sign
A 55-year-old patient presented with progressive dyspnoea. On computerised tomography (CT) scan of the chest, a lesion was found in the middle lobe of the right lung. The radiologist reported the findings as ‘a region of ground-glass opacity surrounded by denser lung tissue’.
What is this sign better known as?
Atoll sign
Halo sign
Kerley B lines
Signet ring sign
Tree-in-bud sign
What pathology does an atoll sign indicate? [1]
The atoll sign is useful in differentiating pulmonary zygomycosis (PZ) from aspergillosis, with PZ showing the atoll sign in the acute stages and the air-crescent sign in the subacute stages. Additionally, the atoll sign can be observed after pulmonary tumour radiofrequency ablation (RFA), representing coagulation necrosis.
Which of the following radiographic signs would indicate bronchiectasis?
Atoll sign
Halo sign
Kerley B lines
Signet ring sign
Tree-in-bud sign
Which of the following radiographic signs would indicate bronchiectasis?
Atoll sign
Halo sign
Kerley B lines
Signet ring sign
Tree-in-bud sign
A 23-year-old female presents to her General Practitioner (GP) with breathlessness, dry cough and intermittent wheeze.
Which of the following investigation results supports a diagnosis of asthma?
Fraction exhaled nitric oxide (FeNO) 50 parts per billion (ppb)
Forced expiratory volume in 1 second/forced vital capacity ratio (FEV1/FVC ratio) ≥ 75%
A 10% or higher improvement in FEV1 following a nebulised bronchodilator
A 150 ml or higher improvement in FEV1 following a nebulised bronchodilator
Greater than 15% variability in peak expiratory flow rate (PEFR) on monitoring
Fraction exhaled nitric oxide (FeNO) 50 parts per billion (ppb)
A FeNO (Fractional Exhaled Nitric Oxide) level above 40 parts per billion (ppb) indicates asthma.
Greater than []% variability in PEFR on monitoring supports a diagnosis of asthma.
Greater than 20% variability in PEFR on monitoring supports a diagnosis of asthma.
A []% or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma.
A [] ml or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma.
A 12% or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma.
A 200 ml or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma.
Describe each stage of the modified MRC dyspnoea scale used for COPD [4]
Grade Degree of breathlessness
0 No breathlessness except with strenuous exercise
1 Breathlessness when hurrying on the level or walking up a slight hill
2 Walks slower than contemporaries on level ground due to breathlessness, or has to stop for own breath when walking at own pace
3 Stops for breath after walking about 100m or after a few minutes on level ground
4 Too breathless to leave the house, or breathless when dressing or undressing
What general type of pathologies cause an exudate c.f a transudate? [1]
An exudate is usually caused by inflammation and disruption to the cell architecture
Transudates are primarily caused by ‘systematic’ illnesses which cause either a decrease in oncotic pressure or an increase in hydrostatic pressure.
Name two endocrine causes of exudates [2]
Hypothyroidism
Ovarian hyperstimulation syndrome
Why does hypercapnia cause palmar erythema and bounding pulses? [2]
due to CO2-induced vasodilation
What are the two criteria need to have when deciding if primary spontaneous pneumothorax can be discharged? [2]
< 2 cm from rim
AND
Not SOB
Explain the characteristics of pH; LDH and CO2 in empyema [6]
- low glucose because bacteria use it for respiration
- low pH because bacteria producing CO2 in repsiration
- high LDH because lactate dehydrogenase is needed for the bacteria to convert glucose into energy
Exposure to which substance is a risk factor for pulmonary fibrosis? [1]
Wood dust
Which two antibodies can be present in pulmonary fibrosis? [2]
ANA positive in 30%, rheumatoid factor positive in 10%
Describe the imaging changes that might occur on silicosis [2]
upper zone fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes
Explain which disease silicosis is a risk factor for ? [2]
Silicosis is a fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica).
It is a risk factor for developing tuberculosis: silica is toxic to macrophages
Name 4 occupations at risk of silicosis [4]
Occupations at risk of silicosis
* mining
* slate works
* foundries
* potteries
Which pathology is depicted in this CXR? [1]
History of working in mines
Silicosis
upper zone fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes
Chest x-ray from a patient with silicosis. Note the bilateral diffuse upper lobe reticular shadowing superimposed with occasional scattered mass like opacities. These features are in keeping with silicosis and progressive massive fibrosis (PMF)
What would indicate a patient has mesothelioma c.f pleural plaques? [2]
pleural thickening which can be confirmed on CT confirm along with the presence of pleural fluid/effusion
A 62-year-old man presents to his general practitioner (GP) with symptoms of exertional breathlessness, wheeze and cough. He has a 30 pack-year smoking history.
As part of the patient’s work-up, spirometry is requested:
FEV1/FVC ratio 0.61
Given the likely diagnosis, which of the following would be an appropriate first-line treatment?
Ipratropium
Formoterol
Salmeterol
Tiotropium
Beclometasone
Ipratropium
A SABA or SAMA is the first-line pharmacological treatment of COPD
A 50-year-old man presents with a 2-month history of worsening shortness of breath. Based on the chest x-ray appearance, what is the most likely reason for the patient’s dyspnoea?
atelectasis
pleural effusion
pneumonia
prior pneumonectomy
atelectasis
The mediastinum is deviated to the right: atelectasis is the only option that will pull the mediastinum towards the side of the “total white-out”.
A patient presents with reports of increased anxiety, sweatiness and weight loss.
Her TFT results are outlined below.
TSH: 0.5
T3: 50.20
T4: 24.30
She is started on anti-thyroid treatment, but after 4 weeks comes back with reports of cough, a heavy chest and shortnes of breath.
She has a CXR performed and it is shown below.
You think that this CXR result might be due to the medication given to her.
What is the most likely medication given to the patient?
Carbimazole
Propylthiouracil
Radioactive Iodine
Propanolol
Propylthiouracil can give pleural effusions as a side effect
Which direction does tracheal deviation occur in significant pleural effusion? [1]
Away
Describe what is meant by hypersensitivity pneumonitis (HP) [1]
Which populations is it more common in? [1]
hypersensitivity pneumonitis (HP):
- an exaggerated immunologic response to inhaled antigens such as animal proteins, molds, and certain bacteria.
- HP is more common in patients with a history of atopy (eczema, asthma).
How would hypersensitivty pneumonitis present on CXR? [1]
What pattern on spirometry would be seen? [1]
Chest x-ray often shows interstitial opacities as a result of patchy interstitial inflammation
Chronic HP leads to
Restrictive pattern seen on acute or chronic
A 32-year-old Caucasian woman presents with a 3-month history of dry cough. She has not experienced any other symptoms. She is a non-smoker and has no history of recent travel. Chest X-ray shows a widened mediastinum.
A blood film reveals giant cells with an ‘owl’s eye’ appearance.
What is the most likely diagnosis?
Pulmonary tuberculosis
Asthma
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Pancoast tumour
Hodgkin’s lymphoma
Describe what is meant by mysanthenia gravis [3]
Myasthenia gravis (MG) is a chronic autoimmune condition of the post-synaptic membrane at the neuromuscular junction in skeletal muscle
Circulating antibodies against the nicotinic acetylcholine receptor (AChR) or associated proteins impair neuromuscular transmission
These antibodies also activate the complement system within the neuromuscular junction, leading to cell damage at the postsynaptic membrane, further worsening symptoms.
Describe the classic clinical presentation of mysanthenia gravis [+]
The critical feature is weakness that worsens with muscle use and improves with rest. Symptoms are typically best in the morning and worst at the end of the day.
The symptoms most affect the proximal muscles of the limbs and small muscles of the head and neck, with:
- Difficulty climbing stairs, standing from a seat or raising their hands above their head
- Extraocular muscle weakness, causing double vision (diplopia)
- Eyelid weakness, causing drooping of the eyelids (ptosis)
- Weakness in facial movements
- Difficulty with swallowing
- Fatigue in the jaw when chewing
- Slurred speech
MG presents with what results on spirometry? [1]
Restrictive pattern
A patient is prescribed a MART. This contains an ICS and which of the following?
Salbutamol
Montelukast
Fluticasone
Formoterol
A patient is prescribed a MART. This contains an ICS and which of the following?
Salbutamol
Montelukast
Fluticasone
Formoterol or also salmeterol as these are both LABAs
Based off this CXR alone, what might you suggest the infective organism is causing this pneumoniai [1]
Batwing appearance on CXR is associated with pneumocytis jiroveci
What is the name for this radiological sign? [1]
What pathology does it indicate? [1]
Tram-track sign indicates bronchiestasis
Label A & B [2]
What pathology do they indicate? [1]
A: signet ring sign
B: tram track sign
Indicates bronchiectasis
This CT shows which sign of bronchiectasis? [1]
String of pearls
What is this radiographic sign? [1]
What pathology does it indicate? [1]
Bunch of grapes; bronchiectasis
Describe the pattern of disease within the lungs in asbestosis
Exhibits interstitial pneumonitis and fibrosis:
- starts off in walls of respiratory bronchioles
- follows diffuse fibrosis and remodelling of lungs
- results in honeycombing
NB: remember + pleural effusion
Yellow nail syndrome classically presents clinically with a triad of ? [3]
Yellow nails
Exudative pleural effusion
Lymphoedema
Which lung cancer is most associated with cavitations? [1]
Squamous
Describe the two main classifications of emphysema [2]
Panacinar:
- entire acinus is destroyed from bronchioles to distal alveolus
Centriacinar:
- respiratory bronchioles manily affected
What’s the aeitology of panacinar & centriacinar emphysema [2]
Panacinar: alpha-1 anti-trypsin deficiency
Centriacinar: smoke and dust products
Describe what is meant by acute respiratory distress syndrome (ARDS) [1]
the alveoli are damaged by an inflammatory process like pneumonia or sepsis.
this causes an increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema
This leads to impaired gas exchange and hypoxia. The pulmonary oedema can wash away surfactant and cause lung collapse
Haemoptysis, past history of TB & the following description suggests what cause?
Chest x-ray shows a rounded opacity in the right upper zone surrounded by a rim of air
Aspergilloma
[] plus [] think sarcoidosis
Facial rash plus lymphadenopathy think sarcoidosis
A 28-year-old woman presents with a persistent cough and feeling of wheeziness after exercising. Which one of the following would make a diagnosis of asthma more likely?
Only gets symptoms after having a viral upper respiratory tract infection
Peripheral pins and needles during an episode
Symptoms worsen after taking aspirin
Unexplained neutrophilia on the full blood count
Cough productive of small amounts of clear sputum
Symptoms worsen after taking aspirin
Which infective pathogen is most commonly associated with erythema multiforme? [1]
Mycoplasma Pneumonia is most commonly associated with this finding.
Describe what is meant by Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss syndrome) ? [1]
Which organs does it primarily effect? [3]
It is an pANCA associated small-medium vessel vasculitis.
It is a small-vessel vasculitis that primarily affects the lungs and skin but can affect other organs, such as the kidneys.
Describe the pathophysiology of alpha-1 anti-trypsin deficiency [3]
Descrie the effect of this pathophysiology in the lungs [2]
and liver [1]
A common inherited condition caused by a lack of a protease inhibitor (Pi) normally produced by the liver
The role of A1AT is to protect cells from enzymes such as neutrophil elastase
Elastin is a protein in connective tissue that helps keep the tissues flexible.
Alpha-1 antitrypsin (AAT) offers protection by inhibiting the action of neutrophil elastase.
In the lungs, the lack of a normal, functioning alpha-1 antitrypsin protein leads to excess protease enzymes attacking the connective tissues
Destruction of elastic tissue in the lungs leads to bronchiectasis and emphysema
Alpha-1 antitrypsin is produced in the liver. In specific genotypes of alpha-1 antitrypsin deficiency, an abnormal mutant version of the protein is made that gets trapped and builds up inside the liver cells (hepatocytes)
Over time this progresses to fibrosis, cirrhosis and potentially hepatocellular carcinoma.
How can you investigate for A1AT specifically in the liver? [1]
Liver biopsy shows periodic acid-Schiff positive staining globules in hepatocytes, resistant to diastase treatment. These represent a buildup of the mutant proteins.
pANCA positive and nasal polyps would indicate which respiratory pathology? [1]
Eiosinophilic granulmatosis with polyangiitis
You perform a chest x-ray and find a patient to have dextrocardia and bronchiectasis.
What is the most likely pathology? [1]
Name two further signs of this pathology [2]
Kartagener syndrome (aka primary ciliary dyskinesia):
- dextrocardia
- bronchiectasis
- recurrent sinisitis
- subfertility
A patient is given a CXR and shows pleural effusion. A chest drain is performed and appears below. What is the two most likely causes of this? [2]
Chylothorax:
- most commonly seen following traumatic disruption of the thoracic duct
- thoracic duct obstruction due to malignancy is the commonest cause of non-traumatic chylothorax
typically diagnosed based on the milky appearance of fluid due to high-fat content.
A chest x-ray is ordered:
What is the most likely diagnosis?
Mesothelioma
Methotrexate-induced pneumonitis
Multilobar pneumonia
Massive pleural effusion
Lung collapse
A chest x-ray is ordered:
What is the most likely diagnosis?
Lung collapse: trachea TOWARDs the collapsed lung field
Describe what is meant by the Golden S-sign on a CXR [1]
Which pathology does it indicate? [1]
Right upper lobe collpase due to obstructing mass
Margin of collapsed upper lobe looks like back-to-front S shape
Indicates bronchial carcinoma
What is the name for this sign seen on a CXR? [1]
What pathology does it indicate? [1]
Golden S-sign
Bronchial carcinoma
How does a lung abscess typically present on CXR? [2]
fluid-filled space within an area of consolidation
an air-fluid level is typically seen
What shaped chest indicates COPD? [1]
Barrel shaped chest
A barrel chest forms because your lungs are chronically overfilled with air and can’t deflate normally. This causes your rib cage to be partially expanded at all times.
What are the top three differentials for BHL? [3]
- Lymphoma
- TB
- Sarcoidosis
What is the arrow pointing to? [1]
Endotracheal tube
What indicates the use of a central venous catheter? [3] (central line)
Where can a central line be inserted? [2]
Where should the tip end? [1]
Uses:
* Rapid fluid replacement
* Monitoring of central venous pressure
* Administration of some drugs
Inserted at subclavian or IJV; tip end should lie within SVC
What is wrong with this central line?
What is a Pulmonary Artery Wedge Pressure Measurement? [1]
What is the route used to obtain this measurement? [1]
is the pressure measured by wedging a pulmonary artery catheter with an inflated balloon into a small pulmonary arterial branch
Route:
- via the right internal jugular vein
- the catheter passes through the SVC, the right atrium, the right ventricle and the tip lies within a pulmonary artery
What is shown by the red arrows?
Central line
Endotracheal tube
ECMO tube
ECG
Pulmonary artery wedge pressure catheter
Pulmonary artery wedge pressure catheter
What is most likely depicted in this CXR? [1]
Central line
Endotracheal tube
ECMO tube
ECG
Pulmonary artery wedge pressure catheter
Pulmonary artery wedge pressure catheter
Which of the following is A
Central line
Endotracheal tube
Intra-aortic balloon
ECG
Pulmonary artery wedge pressure catheter
Which of the following is A
Central line
Endotracheal tube
Intra-aortic balloon
ECG
Pulmonary artery wedge pressure catheter
Which of the following is C
Central line
Endotracheal tube
Intra-aortic balloon
ECG
Pulmonary artery wedge pressure catheter
Which of the following is C
Central line
Endotracheal tube
Intra-aortic balloon
ECG
Pulmonary artery wedge pressure catheter
Which of the following is B
Central line
Endotracheal tube
Intra-aortic balloon
ECG
Pulmonary artery wedge pressure catheter
Which of the following is B
Central line
Endotracheal tube
Intra-aortic balloon
ECG
Pulmonary artery wedge pressure catheter
Where should NG tubes be placed exactly? [1]
The tip should lie below the diaphragm with at least 10cm lying within the stomach
What is the most common complication of NG tube insertion? [1]
Commonest (and most dangerous) is placement within bronchial tree
* This can be FATAL if NG feeding occurs into the lung
Be suspicious of a misplaced NG tube if the patient is extremely uncomfortable during tube insertion with severe coughing
What are the arrows pointing to? [1]
Tracheostomy Tube
What is outlined in red? [1]
surgical emphysema
Label each arrow for this patients pacemaker [5]
Which of the following risks include aspiration and leakage at the insertion site
Total parenteral nutrition
Percutaneous endoscopic gastrostomy
Feeding jejunostomy
Naso jejunal feeding
Naso gastric feeding
Which of the following risks include aspiration and leakage at the insertion site
Total parenteral nutrition
Percutaneous endoscopic gastrostomy
Feeding jejunostomy
Naso jejunal feeding
Naso gastric feeding
What is the name for ths pathology? [1]
Empyema necessatins
Empyema necessitans is a rare complication of empyema with extension of the fluid collection and infection to the subcutaneous soft tissue
Describe the pathology of vancomycin flushing syndrome / red man syndrome
anaphylactoid reaction caused by the rapid infusion of the glycopeptide antibiotic vancomycin.
What is the difference between Duplex and Dopple? [2]
Duplex compares different arteries; Doppler compares A&V of adjacent
You perform an CXR for a patient with suspect pneumonia.
You are waiting for MC&S to return.
You think the patient might have a Klebsiella pneumonia because they are an alcoholic.
What pattern on a CXR would help to suggest this? [1]
A helpful feature which may help to distinguish from pneumococcal pneumonia is that Klebsiella pneumonia develops cavitation in 30-50% of cases.
You are asked to interpret a CXR.
Describe how you would go through RIPE [4]
Rotation
- If the L & R clavicles align with the spinous processes of the vertebral bodies
Inspiration:
- 5 anterior ribs visible?
- 8-10 posterior ribs visible?
Position
- AP or PA?
Exposure
- The left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heart.
A patient is coughing up over 120ml of blood. What is your main differential? [1]
Aspergillious infection
In ALS, if IV access cannot be achieved then drugs should be given via the [] route ?
In ALS, if IV access cannot be achieved then drugs should be given via the intraosseous route (IO) - the tracheal route is no longer recommended
a prolonged PR interval
Hepatotoxicity
Optic neuritis
Gout
Type IV
