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
What CURB-65 score indicates ICU admission? [1]
3 or more is an indication to consider ICU admission.
Which of the following lung malignancies is most likely to develop in a non-smoker?
Squamous Cell Carcinoma
Small Cell Carcinoma
Adenocarcinoma
Large Cell Carcinoma
Which of the following lung malignancies is most likely to develop in a non-smoker?
Squamous Cell Carcinoma
Small Cell Carcinoma
Adenocarcinoma
Large Cell Carcinoma
Which of the following respiratory conditions does not classically cause clubbing?
Bronchiectasis
Lung cancer
Lung abscess
Empyema
COPD
Which of the following respiratory conditions does not classically cause clubbing?
Bronchiectasis
Lung cancer
Lung abscess
Empyema
COPD
A handy mnemonic for respiratory causes of clubbing is ABCDE:
Abscess
Bronchiectasis
Cancer
Don’t say COPD!
Empyema.
What are signs and symptoms of Legionnaire’s disease? [5]
Signs and symptoms of Legionnaires’ disease include:
- cough
- shortness of breath
- fever
- muscle pains
- acute kidney injury,
- hyponatraemia
- headaches
Nausea, vomiting, and diarrhoea may also occur. Symptoms often begin two to ten days after exposure.
What is the most common presenting complaint of patients with undiagnosed lung cancer?
Cough
Haemoptysis
Dyspnoea
Pleuritic chest pain
What is the most common presenting complaint of patients with undiagnosed lung cancer?
Cough
Haemoptysis
Dyspnoea
Pleuritic chest pain
In the UK, how long does a patient need to have been in hospital to be diagnosed with hospital-acquired pneumonia (HAP)?
72 hours
48 hours
24 hours
12 hours
36 hours
48 hours
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
A 70-year-old female presents with a 2-day history of fever, rigors, and sweats. She has a cough and brings up foul smelling green sputum. She has a past medical history of COPD and chronic kidney disease. She is on home oxygen.
Her vitals are as follows:
BP: 110/75,
HR: 85
RR: 26
Temperature: 39 degrees Celsius
SpO2: 89%.
The patient is given oxygen upon arrival at the hospital.
Given the most likely diagnosis, what is the treatment regimen that is recommended in this patient?
Salbutamol, no antibiotics needed
Vancomycin
Ciprofloxacin
Gentamicin
Co-amoxiclav
This patient has an infective exacerbation of chronic obstructive pulmonary disease (COPD). The most common organisms to cause this infection are Streptococcus Pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae. Treatment with antibiotics is warranted in this case and coverage with amoxicillin-clavulanic acid is appropriate.
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
Which three antibodies are found in MG? [3]
Acetylcholine receptor (AChR) antibodies
Muscle-specific kinase (MuSK) antibodies
Low-density lipoprotein receptor-related protein 4 (LRP4) antibodies
MuSK and LRP4 are important proteins for the creation and organisation of the acetylcholine receptor. Destruction of these proteins leads to inadequate acetylcholine receptors.
MG has a strong link with which other pathology? [1]
There is a strong link with thymomas (thymus gland tumours). 10-20% of patients with myasthenia gravis have a thymoma. 30% of patients with a thymoma develop myasthenia gravis.
What investigations do you conduct for MG [4]
.1. Antibody testing:
- AChR antibodies (around 85%)
- MuSK antibodies (less than 10%)
- LRP4 antibodies (less than 5%)
.2. A CT or MRI of the thymus gland is used to look for a thymoma.
.3. Edrophonium test:
- Patients are given **intravenous edrophonium chloride **
- Normally, cholinesterase enzymes in the neuromuscular junction break down acetylcholine. Edrophonium blocks these enzymes, reducing the breakdown of acetylcholine
- As a result, the level of acetylcholine at the neuromuscular junction rises, temporarily relieving the weakness.
- A positive result suggests a diagnosis of myasthenia gravis.
Describe 4 treatment options for MG [4]
Pyridostigmine is a cholinesterase inhibitor that prolongs the action of acetylcholine and improves symptoms. First-line
Immunosuppression (e.g., prednisolone or azathioprine) suppresses the production of antibodies
Thymectomy can improve symptoms, even in patients without a thymoma
Rituximab (a monoclonal antibody against B cells) is considered where other treatments fail
MG presents with what results on spirometry? [1]
Restrictive pattern
wWhich drug is a risk factor for causing pulmonary fibrosis? [1]
Methotrexate
What is a pneumonic for remembering causes of pulmonary fibrosis? [5]
CHARTS
Coal-worker pneumoconiosis
Histiocytosis/hypersensitivity pneumonitis
Ankylosing spondylitis / RA - Methotrexate use
Radiation
Tuberculosis
Silicosis/sarcoidosis
Which of the following drugs administered intravenously would be most suitable as an alternative to penicillin for mild penicillin allergies for HAP?
Ampicillin
Piperacillin/tazobactam (Tazocin)
Phenoxymethylpenicillin
Cefuroxime
Co-amoxiclav
Which of the following drugs administered intravenously would be most suitable as an alternative to penicillin for mild penicillin allergies for HAP?
Ampicillin
Piperacillin/tazobactam (Tazocin)
Phenoxymethylpenicillin
Cefuroxime
Co-amoxiclav
Which of the following is not an indication for long-term oxygen therapy (LTOT) in patients with stable chronic obstructive pulmonary disease (COPD)?
PaO2 = 7.3-8.0 kPa with secondary polycythaemia
PaO2 = 7.3-8.0 kPa with anaemia
PaO2 = 7.3-8.0 kPa with pulmonary hypertension
PaO2 < 7.3 kPa
PaO2 = 7.3-8.0 kPa with peripheral oedema
PaO2 = 7.3-8.0 kPa with anaemia
NICE recommends that LTOT should be considered in patients with stable COPD who do not smoke and are on optimal medical therapy in the following circumstances:
PaO2 < 7.3 kPa
PaO2 7.3-8.0 kPa with secondary polycythaemia
PaO2 7.3-8.0 kPa with peripheral oedema
PaO2 7.3-8.0 kPa with pulmonary hypertension (eg. loud P2, RVH on ECG)
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
[] should not be used in a patient with epilepsy as it reduces seizure threshold
HINT: smoking cessation medication
Bupropion should not be used in a patient with epilepsy as it reduces seizure threshold
[] is the first-line antibiotic for low severity community-acquired pneumonia
Amoxicillin is the first-line antibiotic for low severity community-acquired pneumonia
What blood gas occurs from DKA? [1]
Metabolic acidosis with raised anion gap
[] are the first line treatment of choice for allergic bronchopulmonary aspergillosis
What is the second line treatment? [1]
Oral glucocorticoids are the treatment of choice for allergic bronchopulmonary aspergillosis
itraconazole is sometimes introduced as a second-line agent
What is meant by allergic bronchopulmonary aspergillosis? [1]
What are the clinical features? [3]
Allergy to Aspergillus spores. Causes:
bronchoconstriction: wheeze, cough, dyspnoea.
Patients may have a previous label of asthma
bronchiectasis (proximal)
In the exam questions, patients with allergic bronchopulmonary aspergillosis often have a history of [] and [].
history of bronchiectasis and eosinophilia.
Which investigation would indicate asllerigc bronchopulmonary aspergillosis? [5]
- eosinophilia
- Flitting CXR changes (bronchiectasis changes - Tram-track opacities & Ring shadows
- positive radioallergosorbent (RAST) test to Aspergillus
- positive IgG precipitins (not as positive as in aspergilloma)
- raised IgE
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 definitive diagnosis for PCP infection? [1]
What finding would indicate this infection? [1]
The diagnosis can often be confirmed with bronchoalveolar lavage which has a sensitivity of 85-90%:
- focally vacuolated exudates
Occupational lung fibrosis occurs due to exposure to which substance? [1]
Silica dust
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
What pathologies do unilateral pleural effusions indicate? [3]
Infection
Trauma
Malignancy
Describe the murmur that occurs in a pulmonary hypertension [1]
High pitched diastolic decrescendo murmur
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
Pleural fluid in patients with mesothelioma is what colour? [1]
Pleural fluid in patients with mesothelioma is straw coloured or blood stained
How do you differentiate between IPF and asbestosis from HRCT? [1]
In contrast to idiopathic pulmonary fibrosis, confluent ground glass changes are rare in asbestosis, whereas thick band-like opacities are more common
Pigeon breeding / exposure to animals is a risk factor to which disease? [1]
Where in the lung parenchyma do changes occur? [1]
What happens? [1]
Hypersensitivity pneumonitis / extrensic allergic alveolitis
Usually affects apices of the lungs
Describe the pathophysiology of hypersensitivity pneumonitis / extrensic allergic alveolitis [3]
Lung parenchymal inflammation in HP is a combination of type-III and type-IV hypersensitivity reactions
The result of non-IgE mediated immunological inflammation.
The inflammation of HP manifests itself in the alveoli and distal bronchioles.
Which four risk factors are at higher risk of hypersensitivty pneumonitis? [4]
Farmer’s lung: seen in farmers and cattle workers, this condition is caused by breathing in mold that grows on hay, straw and grain.
Bird fancier’s lung: (also called pigeon breeder’s disease) caused by breathing particles from feathers or droppings of many species of birds.
Humidifier lung: can develop by breathing in fungus growing in humidifiers, air conditioners and heating systems, particularly if they are not well maintained.
Hot tub lung
Yellow nail syndrome classically presents clinically with a triad of ? [3]
Yellow nails
Exudative pleural effusion
Lymphoedema
As the underlying cause of YNS is unknown, the pathophysiology is also unclear. The most widely accepted cause of YNS is thought to be related to abnormalities in lymphatic flow
Describe what is meant by byssinosis [1]
Byssinosis:
- occupational lung disease specifically from exposure to cotton dust, flax & hemp
How does byssinosis present acutely [1] and chronically? [1]
Acute: airway narrowing
Chronic: Sx worse after coming back to work & FEV1 progressively drops off during work day
Describe what is meant by reactive airway dysfunction [1]
How do you test for this? [1]
Bronchial hyperresponsitivity to exposure: specifically to inhaled gas; aerosols and other particles.
To test: perform a methacholine challenge test
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
The International Society for Heart and Lung Transplantation states that patients with COPD should have an FEV1 < []% predicted in order to be considered for lung transplantation.
< 25% FEV1
What size chest drain would you use to treat a large, but spontaneous pneuomothorax? [1]
14F chest drain insertion over a Seldinger wire
What is the typical discription of silicosis after performing imaging? [2]
What does chronic silicosis lead to? [1]
- small numerous opacities in upper lung zones with holar lymphadenopathy
- hilar lymph nodes have egg shell pattern
Chronic silicosis: leads to widespread fibrosis
Which of following causes SIADH?
Large cell
Bronchoalveolar cell
Squamous cell
Small cell
Adenocarcinoma
Which of following causes SIADH?
Small cell
When is NIV indicated in COPD patients? [1]
Persistent respiratory acidosis after maximum medical treatment
You review a patient in the respiratory clinic who has a history of recurrent pulmonary embolism despite anticoagulation with warfarin. Which one of the following physiological changes would be expected?
Increased lung compliance
Reduced TLCO
Reduced forced vital capacity
Reduced FEV1
Increased FEV1 / FVC ratio
You review a patient in the respiratory clinic who has a history of recurrent pulmonary embolism despite anticoagulation with warfarin. Which one of the following physiological changes would be expected?
Reduced TLCO
The correct answer is Reduced TLCO. The transfer factor of the lung for carbon monoxide (TLCO) measures the ability of the lungs to transfer gas from inhaled air to red blood cells in pulmonary capillaries. Recurrent pulmonary embolism can cause areas of the lung to be poorly perfused and ventilated, leading to a ventilation-perfusion mismatch. This results in reduced gas exchange, hence a reduced TLCO.
Asbesosis and Coal workers’ pneumoconiosis both cause interstitial lung fibrosis.
Where do each of them cause fibrosis in the lungs? [2]
Asbestos:
- lower lobes: in the roof and falls down
Silicosis and Coal workers’ pneumoconiosis:
- upper lobes drifts up from the ground to up
What is important to think when looking at CRP levels? [1]
C-reactive protein shows a lag in decreasing in comparison to the white cell count in treatment of acute bacterial infection
Allergic bronchopulmonary aspergillosis is diagnosed with elevated serum-specific IgE and positive skin testing for Aspergillus.
Which of the following is the treatment of choice for this patient?
Oral azithromycin
Oral cetirizine
Oral itraconazole
Oral levofloxacin
Oral prednisolone
Allergic bronchopulmonary aspergillosis is diagnosed with elevated serum-specific IgE and positive skin testing for Aspergillus.
Which of the following is the treatment of choice for this patient?
Oral prednisolone
Oral glucocorticoids are the treatment of choice for allergic bronchopulmonary aspergillosis
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
State 5 causes of ARDS [5]
infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute pancreatitis
Covid-19
cardio-pulmonary bypass
Which clinical features are required for a diagnosis of ARDS? [4]
acute onset (within 1 week of a known risk factor)
pulmonary oedema: bilateral infiltrates on chest x-ray (‘not fully explained by effusions, lobar/lung collapse or nodules)
non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
pO2/FiO2 < 40kPa (300 mmHg)
How do you manage ARDS? [4]
oxygenation/ventilation to treat the hypoxaemia
general organ support e.g. vasopressors as needed
treatment of the underlying cause e.g. antibiotics for sepsis
certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
A 65-year-old man is currently on the ward recovering from a case of acute pancreatitis when he complains of severe breathlessness over the past hour. Observations reveal a heart rate of 124 bpm, a respiratory rate of 39 breaths per minute, and a blood pressure of 89/56 mmHg. Auscultation reveals bilateral lung crackles and a chest x-ray shows bilateral infiltrates. Pulmonary wedge pressure is not raised, and a non-cardiogenic cause is suspected. He continues to deteriorate and is moved to the intensive care unit, where he is ventilated.
What positioning would be beneficial for this patient?
- Left-lateral positioning
- Prone positioning
- Right-lateral positioning
- Supine positioning
- Trendelenburg positioning
Prone positioning is helpful in ventilated patients with ARDS
Prophylaxis with which antibiotic is recommended in COPD patients who meet certain criteria and who continue to have exacerbations? [1]
Azithromycin prophylaxis is recommended in COPD patients who meet certain criteria and who continue to have exacerbations
PE, anxiety & hyperventilation, altitude, pregnancy and CNS disorders like stroke & SAH lead to which acid/base change? [1]
Respiratory alkalosis
Give 5 reasons fo respiratory alkalosis [5]
- anxiety leading to hyperventilation
- pulmonary embolism
- salicylate poisoning
- CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
- altitude
- pregnancy
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
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Usually long history of cough and daily purulent sputum production
Pulmonary oedema
Tuberculosis
Mitral stenosis
Lower respiratory tract infection
Bronchiectasis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Usually long history of cough and daily purulent sputum production
Bronchiectasis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Atrial fibrillation & Malar flush on cheeks
Pulmonary oedema
Tuberculosis
Mitral stenosis
Lower respiratory tract infection
Bronchiectasis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Atrial fibrillation & Malar flush on cheeks
Mitral stenosis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Fever, night sweats, anorexia, weight loss
Pulmonary oedema
Tuberculosis
Mitral stenosis
Lower respiratory tract infection
Bronchiectasis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Fever, night sweats, anorexia, weight loss
Pulmonary oedema
Tuberculosis
Mitral stenosis
Lower respiratory tract infection
Bronchiectasis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Dyspnoea & Bibasal crackles and S3
Pulmonary oedema
Tuberculosis
Mitral stenosis
Lower respiratory tract infection
Bronchiectasis
The following are all causes of haemoptysis. Which is the most likely based off the symptoms present?
Dyspnoea & Bibasal crackles and S3
Pulmonary oedema
Tuberculosis
Mitral stenosis
Lower respiratory tract infection
Bronchiectasis
These clinical features suggest what pathology? [1]
Upper respiratory tract: epistaxis, sinusitis, nasal crusting
Lower respiratory tract: dyspnoea, haemoptysis
Glomerulonephritis
Saddle-shape nose deformity
Granulomatosis with polyangiitis
What happens to the position of the lung [1] and chest [1] in a pneumothorax?
Lung: goes inwards
Chest: goes outwards
An acute asthma attack causes a risk of which secondary pathologies? [3]
Pneumothorax
Surgical emphysema
Pneumomediastinum
Which smoking cessation drug is contraindicated in patients with epilepsy? [1]
Bupropion - can lead to seizures
What makes up the histopathological farmers triad in Hypersensitivity pneumonitis (extrinsic allergic alveolitis) [3]
Hypersensitivity pneumonitis (extrinsic allergic alveolitis):
- Interstitial inflammation
- Chronic bronchiolitis
- Non-necrotising granuloma
Which abx can be used to treat pseudomonas? [1]
Ciprofloxacin
Name one common side effect of rifampicin & isoniazid? [1]
Both can cause vitamin D deficiency: low Ca and raised ALPs
When are O2 sats targets in COPD patients:
88-92% and 94-98%? [2]
pCO2 is known to be normal the target oxygen saturations should be 94-98%.
pCO2 is known to be high the target oxygen saturations should be 88-92%.
What adaptations to asthma control medication should pregnant patients undertake? [1]
Both the BNF and British Thoracic Society guidelines stress the need for good control of asthma during pregnancy. The BNF advises that ‘inhaled drugs, theophylline and prednisolone can be taken as normal during pregnancy and breast-feeding’.
What indicates COPD patients to start LTOT? [1]
LTOT if 2 measurements of pO2 < 7.3 kPa
[] plus [] think sarcoidosis
Facial rash plus lymphadenopathy think sarcoidosis
A 23-year-old man attends for his routine asthma review. He takes salbutamol and formoterol-beclometasone (Fostair) for his asthma, but tells you that he currently has no benefit from either medication. He was recently diagnosed with asthma on spirometry. He reports to be using the inhalers regularly but has some questions about how to use them. Both his inhalers are pressurised metered-dose inhalers.
What is the most appropriate advice for the patient?
After inhaling a dose of the medication, he should ideally hold his breath for 10 seconds
After inhaling a dose of the medication, he should ideally hold his breath for 5 seconds
Before inhaling, he should wait for 10 seconds after pressing down on the canister before inhaling
Before inhaling, he should wait for 5 seconds after pressing down on the canister before inhaling
For a second dose wait for approximately 15 seconds before repeating
After inhaling a dose of the medication, he should ideally hold his breath for 10 seconds
Describe the technique you should give patients with regards to inhaler technique.
If haven’t used it in 5 days or more / new - need to test: take cap off and shake well, undergo test spray
check that the inhaler dose counter is not at 0
check that there is nothing inhaler mouth piece
shake inhaler
sit / stand up straight and tilt head up
gently and slowly breath out away from inhaler
put lips around inhaler and form tight seal
slow and steady breath in and press inhaler once
continue breathing until lungs feel full
take inhaler off mouth and hold breath for 10 secs / as long as poss
breath out gently
if prescribed a second puff, wait 30 secs and repeat
if used steroids: wash mouth out
Explain why in acute asthma, a pH of < 7.35 is particularly alarming [1]
A pH less than 7.35 likely represents carbon dioxide retention in a tiring patient and is an ominous sign in acute asthma.
Before starting which Abx should you perform an ECG? [1]
Explain [2]
Before starting azithromycin do an ECG (to rule out prolonged QT interval) and baseline liver function tests
Before starting [] do an ECG (to rule out prolonged QT interval) and baseline liver function tests
Before starting azithromycin do an ECG (to rule out prolonged QT interval) and baseline liver function tests
Describe how you can you determine if should give Abx in a patient presenting with symptoms of acute bronchitis? [2]
If the patient has a CRP of 20-100mg/L they should be offered a delayed prescription
or
if they have a CRP >100mg/L you should **offer antibiotics immediately. **
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features → add what? [2]
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features → add a LABA + LAMA
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
What is the first and second line treatment for allergic bronchopulmonary aspergillosis? [2]
Which pathology is a major risk factor? [1]
1st line:
- prednisolone
2nd line:
- Itraconazole
Cystic fibrosis is a major risk factor
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of [] and [].
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
A patient is presenting with haemoptysis. Upon investigation this is a currant jelly colour. What is the likely infective organism? [1]
Name a complication that often occurs in patient population groups who commonly suffer from this disease [1]
Klebsiella causes currant jelly sputum
Risk of causing empyema formation
Which infective pathogen is most commonly associated with erythema multiforme? [1]
Mycoplasma Pneumonia is most commonly associated with this finding.
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add a [2]?
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add a LABA + ICS
A 48-year-old male presents with a 8 week history of epistaxis and nasal stuffiness. On examination there is evidence of nasal crusting. A chest x-ray demonstrates multiple cavitary lesions.
What is the most appropriate test from the options below?
Anti-CCP (cyclic citrullinated peptide) antibody
Anti-Ro / Anti-La antibodies
Anti-Jo1
Anti-dsDNA antibody
ANCA (anti-neutrophil cytoplasmic antibody)
ANCA (anti-neutrophil cytoplasmic antibody)
Granulomatosis with polyangiitis - cANCA positive
Which pathology is known to precipitate ARDS? [1]
Acute pancreatitis
You are reviewing the management of a number of patients with chronic obstructive pulmonary disease (COPD). Which one of the following factors should prompt an assessment for long-term oxygen therapy?
Failure to respond to inhaled and/or oral corticosteroids
FEV1/FVC of 0.47
Haemoglobin of 10.1 g/dl
Anxiety relating to chronic shortness-of-breath
Ankle oedema
You are reviewing the management of a number of patients with chronic obstructive pulmonary disease (COPD). Which one of the following factors should prompt an assessment for long-term oxygen therapy?
Ankle oedema - sign of cor pulmonale
A 33-year-old woman is prescribed varenicline to help her quit smoking. What is the mechanism of action of varenicline?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Dopamine agonist
Dopamine antagonist
Selective serotonin reuptake inhibitor
Nicotinic receptor partial agonist
Nicotinic receptor partial agonist
A 48-year-old man with severe pneumonia is admitted to the intensive care unit (ICU) due to worsening respiratory failure. He has been intubated and is receiving mechanical ventilation. The ICU team suspects that the patient is developing acute respiratory distress syndrome (ARDS).
What intervention is likely to improve oxygenation in this patient?
High-flow nasal oxygen
Increasing the fraction of inspired oxygen (FiO2)
Intravenous corticosteroids
Non-invasive ventilation
Prone positioning
Prone positioning
Prone positioning promotes more uniform lung inflation, which in turn helps to alleviate atelectasis (collapse of lung tissue) and prevent over-distention of the lung. Additionally, prone positioning reduces the ventilation-perfusion mismatch by improving blood flow to well-ventilated areas of the lung. This leads to better gas exchange and, consequently, better oxygenation. Finally, prone positioning can help recruit collapsed alveoli, further enhancing oxygenation and potentially reducing lung injury. In clinical practice, patients are typically placed in the prone position for extended periods (12-16 hours) as part of a comprehensive ARDS management strategy.
A patient presents with COPD. They are currently on a SAMA but are having worsening symptoms. They show no signs of asthmatic involvement / eosinophilic involvement.
What is the next step in their treatment? [1]
COPD: Discontinue SAMA (switch to SABA) if commencing LAMA
What is the rule about caring for pregnant asthma patients? [1]
Pregnant women who have a severe asthma attack should be admitted to hospital, EVEN if they initially improve with treatment
A 70-year-old man is admitted to the respiratory ward following an infective exacerbation of his chronic obstructive pulmonary disease (COPD). He is being treated with amoxicillin and prednisolone. This is his fourth exacerbation and second hospital admission in the last 12 months. He has previously given up smoking 10 years ago after receiving his diagnosis and has attended pulmonary rehabilitation courses which have offered minimal improvement to his symptoms.
Which antibiotic can be started as prophylaxis for this patient?
Azithromycin
Ciprofloxacin
Co-amoxiclav
Doxycycline
Flucloxacillin
A 70-year-old man is admitted to the respiratory ward following an infective exacerbation of his chronic obstructive pulmonary disease (COPD). He is being treated with amoxicillin and prednisolone. This is his fourth exacerbation and second hospital admission in the last 12 months. He has previously given up smoking 10 years ago after receiving his diagnosis and has attended pulmonary rehabilitation courses which have offered minimal improvement to his symptoms.
Which antibiotic can be started as prophylaxis for this patient?
Azithromycin
Ciprofloxacin
Co-amoxiclav
Doxycycline
Flucloxacillin
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 presentation of Eosinophilic granulomatosis with polyangiitis [4]
Patients typically present with:
- asthma
- pANCA antibodies
- blood eosinophilia (e.g. > 10%)
- paranasal sinusitis
Describe what is meant by Granulomatosis with polyangiitis (previously called Wegener’s granulomatosis) [1]
Granulomatosis with Polyangiitis:
- It is a small-vessel vasculitis that primarily affects the respiratory tract and kidneys.
Describe the typical presentation of Granulomatosis with polyangitis? [3]
cANCA positive
A classic sign is a saddle-shaped nose due to nasal bridge collapse, causing the nasal ridge to dip inwards.
In the lower respiratory tract:
- it can cause cough, wheeze and haemoptysis.
In the kidneys:
- it can cause a rapidly progressing glomerulonephritis.
Which antibodies do granulomatosis with polyangitis and Eosinophilic granulomatosis with polyangiitis present with? [2]
Granulomatosis with polyangitis:
- cANCA
Eosinophilic granulomatosis with polyangiitis:
- pANCA
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.
What is the inheritence pattern of A1AT? [1]
Alpha-1 antitrypsin deficiency is inherited in an autosomal co-dominant pattern.
Co-dominant refers to when both gene copies are expressed and contribute to the outcome (neither is dominant or recessive over the other). The disease severity results from the combination of both copies of the gene.
How do you diagnose A1AT? [4]
Low serum alpha-1 antitrypsin (the screening test)
Genetic testing
Obstructive spirometry
Lung imaging: CXR / HRCT
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.
How do you manage A1AT? [4]
- no smoking
- Symptomatic management (e.g., standard treatment of COPD)
- Organ transplant for end-stage liver or lung disease
- Monitoring for complications (e.g., hepatocellular carcinoma)
Where in the lungs does emphysema occur in A1AT? [1]
In the lower lobes
A patient presents with an exacerbation of COPD. They are given maximum pharmacological treatment. What would then indicate that BIPAP is the next appriopriate stage of management? [1]
Worsening T2RF:
- pH < 7.35 BUT > 7.26
- paCO2 > 6kpa
What type of spirometry pattern does A1AT show? [1]
What type of spirometry pattern does bronchiectasis show? [1]
A1AT: Obstructive
Bronchiectasis: Obtructive
What paCO2 would indicate a near fatal exacerbation of asthma? [1]
> 6.2
Describe the management of non-small cell lung cancers? [3]
20% suitable for surgery
Curative / palliative radiotherapy
Chemo unresponsive
What are the contraindications for non-small cell surgery? [6]
SVC obstruction
Stage IIIb / IV
Malignant pleural effusion
Tumour near hilum
Vocal cord paralysis
Describe the management plan of SVC obstruction [3]
SSS
- Sit them up
- Start steroids
- Stenting
Name 5 differentials for cavitations in lung fields [5]
Abscesses
Squamous cell carcinoma
TB
PE
RA
Aspergilliosis & histoplamsosis
Lung abscesses are often made from multi-bacteria species. Name the 3 most common found [3]
Staph. aureus
Klebsiella pneumonie
Pseudomonas aeruginosa
pANCA positive and nasal polyps would indicate which respiratory pathology? [1]
Eiosinophilic granulmatosis with polyangiitis
What drug would you prescribe for acute bronchitis? [1]
ABCD
Acute bronchitis consider doxycyline
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
What is the only criterion for an asthma exacerbation that includes oxygen saturation? [1]
Life threatening: < 92%
What are the features of life threatening asthma? [7]
33 92 CHEST
PEFT < 33
O2 sats < 92
Cyanosis / confusion
Hypotension
Exhaustion
Silent chest
Transiently normal CO2
Explain why normal CO2 levels is considered life-threatening in asthma excerbation [1]
The patient will be hyperventilating (expect CO2 to be low as is being blown off)
If normal, then a form of respiratory failure is occuring (due to exhaustion)
What is the minimum amount of time you should wait between first and second puff of asthma metered dose inhaler? [1]
30 secs
How often should COPD patients recieve influenza and pneumococcoal vaccines? [2]
Annual influenza
One off pneumoccocal
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.
Describe the inflammatory pathologies that can cause haemopytsis [3]
State their key features
Granulomatosis with Polyangiitis
- c-ANCA
- Nasal symptoms
- Respiratory symptoms
- Glomerulonephritis
Eosinophilic Granulomatosis with Polyangiitis
- Late-onset asthma
- Sinusitis and rhinitis
- p-ANCA
- Raised eosinophils
Goodpastures
- antibodies specific to a type of collagen in the the glomerular basement membrane in the kidneys and lungs lead to inflammation and destruction of the basement membrane leading to pulmonary haemorrhage and kidney failure.
Which symptoms should you ask about if a patient presents with SOB? [1]
Why? [1]
Pain - need to assess for PE
[] is an inflammatory marker that has been used as indicator of severe bacterial infection.
Procalcitonin (PCT) is an inflammatory marker that has been used as indicator of severe bacterial infection.
If a patient presents with acidosis and is hypoglycaemic, what should you check and why? [1]
Check their cortisol levels:
What is most likely the cause of severe haemoptyisis? [1]
aspergillosis
What is the sepsis 6? [6]
3 in 3 out for sepsis management.
IN: O2, Abx, IVF
OUT: blood cultures, lactate, urine output
Out before in
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
Which pathologies should you consider for asthmatic features in COPD patients? [2]
Atopic pathologies
- Hayfever
- Eczema
A 45-year-old man is prescribed bupropion to help him quit smoking. What is the mechanism of action of bupropion?
Nicotinic receptor partial agonist
Selective serotonin reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Dopamine agonist
Dopamine antagonist
A 45-year-old man is prescribed bupropion to help him quit smoking. What is the mechanism of action of bupropion?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Exudate: pleural fluid >[]/L protein
Exudate (> 30g/L protein)
What are the indications for corticosteroid treatment for sarcoidosis? [4]
- parenchymal lung disease
- uveitis
- hypercalcaemia
- neurological or cardiac involvement
P- Parenchymal lung disease
U- Uveitis
N- Neurological involvement
C- Cardiac involvement
H- Hypercalcaemia
Which of the following features of Daisy’s history has put her most at risk of developing hepatocellular carcinoma?
Alcohol use
Hormonal replacement therapy use
Occupational exposure
Paracetamol use
Alpha-1 antitrypsin deficiency
Which of the following features of Daisy’s history has put her most at risk of developing hepatocellular carcinoma?
Alcohol use
Hormonal replacement therapy use
Occupational exposure
Paracetamol use
Alpha-1 antitrypsin deficiency
A 65-year-old man presents to the emergency department due to a fever and a productive cough with purulent sputum. After observations, blood tests and a chest X-ray, he is diagnosed with right-sided pneumonia with a CURB score=1. On discharge, he is told he requires an outpatient chest X-ray.
When should this imaging be booked for?
1 week
3 months
4 weeks
6 months
6 weeks
A 65-year-old man presents to the emergency department due to a fever and a productive cough with purulent sputum. After observations, blood tests and a chest X-ray, he is diagnosed with right-sided pneumonia with a CURB score=1. On discharge, he is told he requires an outpatient chest X-ray.
When should this imaging be booked for?
1 week
3 months
4 weeks
6 months
6 weeks
State if the following are causes of exudative or transudative pleural effusions [5]
Dressler’s syndrome
Hypothyroidism
Lung cancer
Meigs’ syndrome
Tuberculosis
State if the following are causes of exudative or transudative pleural effusions [5]
Dressler’s syndrome: exudative
Hypothyroidism: transudative
Lung cancer: exudative
Meigs’ syndrome: transudative
Tuberculosis: exudative
Name four contrindications for chest drain insertion in pleural effusion patients [4]
INR > 1.3
Platelet count < 75
Pulmonary bullae
Pleural adhesions
Acute respiratory distress syndrome is a complication of acute []
Acute respiratory distress syndrome is a complication of acute pancreatitis
Drug-induced pulmonary fibrosis is typically []-zone
State 3 common drugs which can cause PF [3]
Drug-induced pulmonary fibrosis is typically lower-zone.
methotrexate, amiodarone, and bleomycin
Where in the lung fields do most connective tissue disorders cause pulmonary fibrosis? [1]
Which pathology is the exception? [1]
Most connective tissue disorders, including rheumatoid arthritis cause lower zone fibrosis. Ankylosing spondylitis is an exception, typically affecting the upper zones.
A 58-year-old man originally from India presents with progressive shortness of breath. His history includes ankylosing spondylitis and atrial flutter for which he takes naproxen, amiodarone, and omeprazole. He is now retired but previously worked in stone and coal mines.
On examination, he appears breathless with a respiratory rate of 20/min. Chest examination reveals fine basal crepitations bilaterally.
What is the most likely underlying cause?
Amiodarone
Ankylosing spondylitis
Coal worker’s pneumoconiosis
Silicosis
Tuberculosis
Amiodarone - lower zone fibrosis
Infective exacerbation of COPD: first-line antibiotics are []
Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline
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
What pathology is a risk factor for aspiration pneumonia (and therefore lung abscess) [1]
Previous stroke, which suggests aspiration pneumonia and the development of an abscess
What is the most common cause of a lung abscess?
haematogenous spread e.g. secondary to infective endocarditis
direct extension e.g. from an empyema
secondary to aspiration pneumonia
bronchial obstruction e.g. secondary from a lung tumour
secondary to aspiration pneumonia
Name 4 causes of lung abscess [4]
secondary to aspiration pneumonia
haematogenous spread e.g. secondary to infective endocarditis
direct extension e.g. from an empyema
bronchial obstruction e.g. secondary from a lung tumour
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
A 62–year-old woman attends with a chronic productive cough and shortness of breath on exertion. She has never smoked.
A CT scan is arranged:
CT scan Abnormal widening and thickening of the bronchi; Consolidation of the right lower lobe
You arrange for a sputum sample to be sent to microbiology.
What is the most likely organism that will be cultured?
Haemophilus influenzae
Klebsiella oxytoca
Klebsiella pneumonia
Pseudomonas aeruginosa
Streptococcus pneumoniae
Bronchiectasis: most common organism = Haemophilus influenzae
A 28-year-old man develops nausea and a severe headache whilst trekking in Nepal. Within the next hour he becomes ataxic and confused. A diagnosis of high altitude cerebral oedema is suspected. Other than descent and oxygen, what is the most important treatment?
Acetazolamide
Dexamethasone
Burr hole
Naproxen
Furosemide
Dexamethasone
HACE: Oxygen and Dexamethasone
Pneumonic for remembering lower zone fibrosis? [4]
A - asbestos.
C - connective tissue diseases.
I - idiopathic pulmonary fibrosis.
D - drugs e.g. methotrexate, nitrofurantoin.
What value INR is a contraindication for a chest drain? [1]
An INR >1.3 is a relative contraindication for chest drain insertion
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.
Describe the two theories of what happens when you give COPD patients too much oxygen? [2]
Patients lose their hypoxic drive for respiration, therefore retain CO2 and subsequently hypoventilate leading to respiratory arrest
OR
Increase in V/Q mismatch due to reperfusion of underventilated areas of lung by the increase in oxygen and suppression of HPV
What are the top three differentials for BHL? [3]
- Lymphoma
- TB
- Sarcoidosis
What is the arrow pointing to? [1]
Endotracheal tube
Describe the correct position of an endotracheal tube (ETT)
A correctly positioned ETT lies in the mid trachea and its tip is approximately 5-7 cm above the carina 3 as seen in Fig: 1 (CR-1827).
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
State 6 possible complications of a central venous catheter [6]
Tip misplaced
* Advanced too far into right atrium
* Passes into wrong vein
Arterial puncture instead of venous puncture
Pneumothorax
Haemothorax
Air embolism
Infection
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
What are the indications of NG tubes? [2]
- Decompression of dilated stomach
- Administration of medication / nutritional support
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 are the main indications for a chest drain insertion? [2]
Pneumothorax
* Tension
* Simple pneumothorax unresponsive to aspiration
* Pnemothorax in a patient with chronic lung disease
Drainage of pleural fluid
* Pleural effusion
* Haemothorax
What is outlined in red? [1]
surgical emphysema
Label each arrow for this patients pacemaker [5]
Name 4 contraindications to chest drain insertion [4]
- INR > 1.3
- Platelet count < 75
- Pulmonary bullae
- Pleural adhesions
Please note, all of the above represent only relative contraindications, addressing respiratory compromise in an emergency situation should always be on an individual case basis.
Describe the procedure for inserting a chest drain properly [5]
the patient should be positioned in a supine position or at a 45º angle
The patient’s forearm may be positioned behind the patient’s head to allow easy access to the axilla.
Identify the 5th intercostal space in the midaxillary line.
Alternatively, positioning may be determined by ultrasound guidance, British Thoracic Society Guidance ‘strongly recommend’ use of ultrasound guidance in all cases of fluid within the pleura.
The area should be anaesthetised using local anaesthetic injection (lidocaine, up to 3mg/kg).
The drainage tube should then be inserted using a Seldinger technique.
The drain tubing should then be secured using either a straight stitch or with an adhesive dressing.
A patient is given a chest drain and then presents with severe SOB and a cough.
What is the most likely diagnosis? [1]
What is the most appropriate management? [1]
Re-expansion pulmonary oedema
- preceded by the onset of a cough and/or shortness of breath.
- In the event of concerns regarding re-expansion pulmonary oedema, the chest drain should be clamped and an urgent chest x-ray should be obtained.
Which of the following is often contra indicated following head injury due to risks associated with tube insertion
Total parenteral nutrition
Percutaneous endoscopic gastrostomy
Feeding jejunostomy
Naso jejunal feeding
Naso gastric 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
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 should be administered via a central vein as it is strongly phlebitic
Total parenteral nutrition
Percutaneous endoscopic gastrostomy
Feeding jejunostomy
Naso jejunal feeding
Naso gastric feeding
Total parenteral nutrition
Which of the following with long term use is associated with fatty liver and deranged LFT’s
Total parenteral nutrition
Percutaneous endoscopic gastrostomy
Feeding jejunostomy
Naso jejunal feeding
Naso gastric feeding
Total parenteral nutrition
Tacrolimus specifically targets which WBC? [1]
What is the MoA? [1]
Lymphocytes
Selectively inhibit calcineurin, thereby impairing the transcription of interleukin (IL)-2 and several other cytokines in T lymphocytes.
What does a positive beta d glucan blood test indicate? [1]
invasive fungal infection.
It is important to remember that not all fungi produce Beta-D-glucan and there are other factors that can lead to raised Beta-D-glucan levels.
WIf someone is said to be infected with Flu A, which pathogen does that typically refer to? [1]
Staphylococcus aureus
Why is iv iron contraindicated in patients with an infection? [1]
The Fe feeds the bacteria
Describe the typical implications of sarcoid heart disease
Cardiac sarcoidosis can affect any part of the heart muscle and clinical manifestations are also nonspecific, depending on the location and extent of inflammation caused by the granuloma
- Complete heart block is the most common manifestation of the disease seen first and is reported in 25 to 30 per cent of patients.
- Granulomas build in the heart muscle: disrupting flow and increasing chance of arrythmias
- Granulomas in the cardiac arteries: cause disrupted blood supply
What is a common reason for death in sarcoid? [1]
Cardiac involvement is responsible for up to 75 per cent of deaths from sarcoidosis
What are the four patient types of consider for referral for sarcoid? [4]
When to suspect cardiac sarcoidosis
There are four patient types to consider for referral:
1.) Patients with known systemic sarcoidosis elsewhere in the body, with the following symptoms:
* Irregular heart activity
* Unexplained breathlessness
* Chest pains
* Dizziness
* Fainting or loss of consciousness
2.) Patients less than 60 years of age, with new-onset unexplained heart block.
3.) Unexplained ventricular arrhythmias originating from the ventricle at any age.
4.) Patients with unexplained new-onset heart failure.
What does a clot specifiaclly look like on CTPA showing a PE? [1]
Shows the abscense of contrast
Which drug should be used instead of enoxaparin if a patient has renal damage? [1]
Tinzaparin elimination is less dependent on renal function than other LMWHs,
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.
Which other antibiotics can cause red man syndrome? [4]
- vancomycin
- ciprofloxacin
- rifampicin
- teicoplanin
What are 4 pulmonary complications of RA? [4]
RA-related lung complications are the most common extra-articular (“outside of the joints”) symptoms of RA:
- pulmonary nodules (small growths in the lungs);
- pleural effusion (a buildup of fluid between the lung and chest wall);
- bronchiectasis (damage to the airways);
- interstitial lung disease (ILD) - 1/10 with RA get ILD!
If a patient is desaturating on exertion (far more out of proportion than expected), what are the two differential diagnoses? [2]
PE
PCP
COPD has a common link with which pathology in the head? [1]
Sinusitis
Epidemiologic studies suggest that as many as 75% of patients with COPD have concomitant nasal symptoms and more than 1/3 of patients with sinusitis also have lower airway symptoms of asthma or COPD
Because the inflammatory response of the upper and lower airways are similar, and both sites have a similar exposure to allergens and irritants
Explain why a hemi-diaphragm might be raised on a CXR? [4]
Loss of innervation due to phrenic nerve injury / C3-5
- head / neck trauma
Neurological disease
- MS / mysanthia gravis / MD
MCA stroke
- On contralateral side
Lung problems:
- Mucus plugging (stops inflation of the lung) causing post obstructive lung collapse
- Tumour causing post obstructive lung collapse
- Lady Winderemere syndrome: pulmonary Mycobacterium avium complex (MAC) infection seen typically in elderly white women
What is the difference between Duplex and Dopple? [2]
Duplex compares different arteries; Doppler compares A&V of adjacent
A patient suffers from hypoxia and you measure their LFTs are part of a FBC.
What changes might you expect to see? [1]
ALTs raised (into 1000s) due to hypoxic liver injury
- Hypoxic liver injury is defined as a massive, but transient, increase in serum transaminase levels due to an imbalance between hepatic oxygen supply and demand in the absence of other acute causes of liver damage.
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 suffering from pneumonia.
Despite abx treatment, they are still not recovering.
What are your differentials? [6]
Pneumonia causing:
- Lung abscess
- Empyema
- Lung cavitation
- Pneumothorax
- ARDS
- Sepsis
If have a patient on a statin, starting which abx would cause you to stop the statin? [1]
Why? [1]
Using clarithromycin together with statins (called simvastatin) is not recommended.
Combining these medications may significantly increase the blood levels of simvastatin. This can lead to liver damage and a rare but serious condition called rhabdomyolysis
A patient is coughing up over 120ml of blood. What is your main differential? [1]
Aspergillious infection
Possible side effect of IV co-amox? [1]
Raised LFTs
What trio of crtieria make a diagnosis of obesity hypoventilation syndrome? [3]
- Daytime hypercapnia PaCO2 ≥ 45 mmHg
- Obesity (BMI > 30)
- Sleep disordered breathing (which can include OSA)
How do you determine obesity hypoventilation syndrome vs OSA? [1]
Daytime hypercapnia in OHS
What is the treatment for OHS? [1]
First line:
- CPAP
Second line:
- NIV
Desribe a key difference in OSA and OHS [1]
Patients with OHS often experience daytime hypoventilation, which leads to chronic hypercapnia and hypoxemia, resulting in symptoms such as dyspnea, exercise intolerance, morning headaches, and cognitive dysfunction.
In summary, OHS is a more complex disorder involving chronic hypoventilation, obesity, and sleep-disordered breathing, whereas OSA is specifically characterized by upper airway obstruction during sleep
Describe the specific causes of primary [4] right sided heart failure
Primary:
Volume/presure overload:
- LVF, PE, ARDS
Mechanical:
- Mitral valve
Sepsis
Cardiac:
- cardiomyopathies, ARVD, TV rupture, tricuspid or pulmonary regurgitation
Describe the specific causes of primary secondary [+] right sided heart failure
respiratory:
- cor pulmonale, OSA, COPD
muscular disease
neuromuscular
- poliomyelitis, amyotrophic lateral sclerosis, muscular dystrophy
connective tissue
- SLE, CREST, RA, hepatic porto-pulmonary syndrome
cardiac:
- LVF, intra-cardiac shunt, cardiomyopathies
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
[] is the commonest cause of right heart failure.
Pulmonary hypertension is the commonest cause of right heart failure.
Which conditions would you not perform a needle aspiration and go straight to a chest drain to manage a pneumothorax? [6]
- Haemodynamic compromise (suggesting a tension pneumothorax)
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- ≥ 50 years of age with significant smoking history
- Haemothorax
If a patient has persistent pneumothoraces, how do you treat them? [1]
If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
How long should you get a primary spontaneous pneumothorax patient to come to outpatients after letting them go? [1]
How long should you get a secondary spontaneous pneumothorax patient to come to outpatients after letting them go? [1]
Primary spontaneous pneumothorax that is managed conservatively should be reviewed:
- every 2-4 days as an outpatient
Secondary spontaneous pneumothorax:
- follow-up in the outpatients department in 2-4 weeks
Which conditions would you not perform a needle aspiration and go straight to a chest drain to manage a pneumothorax? [6]
- Haemodynamic compromise (suggesting a tension pneumothorax)
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- ≥ 50 years of age with significant smoking history
- Haemothorax
If a patient has persistent pneumothoraces, how do you treat them? [1]
If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
How long should you get a primary spontaneous pneumothorax patient to come to outpatients after letting them go? [1]
How long should you get a secondary spontaneous pneumothorax patient to come to outpatients after letting them go? [1]
Primary spontaneous pneumothorax that is managed conservatively should be reviewed:
- every 2-4 days as an outpatient
Secondary spontaneous pneumothorax:
- follow-up in the outpatients department in 2-4 weeks
Terbutaline is which of the following drug class
SAMA
SABA
LAMA
LABA
Terbutaline is which of the following drug class
SAMA
SABA
LAMA
LABA
Tiotropium is which of the following drug class
SAMA
SABA
LAMA
LABA
Tiotropium is which of the following drug class
SAMA
SABA
LAMA
LABA
How does omalizumab work to treat asthma? [1]
It works by inhibiting binding of IgE to its receptor, located on mast cells and basophils. This action prevents release of mediators of allergic response (e.g., histamine) that cause bronchospasm.
Which of the following drug class, if prescribed without ICS, can increase chance of death in asthma patients?
SAMA
SABA
LAMA
LABA
Which of the following drug class, if prescribed without ICS, can increase chance of death in asthma patients?
SAMA
SABA
LAMA
LABA
a prolonged PR interval
Hepatotoxicity
Optic neuritis
Gout
Type IV
