Respiratory (Quesmed) Flashcards

1
Q

What is Acute Respiratory Distress Syndrome?

What are 2 examples of diseases that typically cause it?

A

It is defined as a Non-Cardiogenic Pulmonary Oedema and Diffuse Lung Inflammation- usually secondary to an underlying illness (like Pancreatitis/ Pneumonia)

The pathophysiology includes Diffuse Alveolar Damage

Alveoli are being accumulated with Fluid

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2
Q

What is the pathophysiology of Acute Respiratory Distress Syndrome?

How is it different from NEONATAL RESPIRATORY DISTRESS SYNDROME?

A

1) ARDS is a respiratory failure that occurs within a week of onset of Lung Injury

2) It involves BILATERAL ALVEOLAR INJURY due to inflammation mediated by Inflammatory Mediators like TNF-Alpha, IL1 and IL8

3) The resulting Endothelial Injury ACTIVATES NEUTROPHILS in Pulmonary Capillaries- this releases Reactive OXYGEN SPECIES and PROTEASES that damage the Alveolar Endothelium and Type 2 Alveolar Cells

4) So the Vascular Permeability increases and the Lung Surfactant is lost. This Fluid Accumulation in the Alveoli causes Pulmonary Oedema and Hypoxaemia as a result

5) This is NOT DUE TO Cardiogenic Pulmonary Oedema, Pleural Effusion or Atelectasis

6) ARDS is not the same as Neonatal Respiratory Distress Syndrome btw (which is due to Inadequate Surfactant Production due to Prematurity)

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3
Q

What are the causes of ARDS?

What is the most common cause? What are the 3 other important causes of ARDS?

A

Pneumonia (most common cause)

Sepsis

!!!!!!!!!!!SMOKE INHALATION

Aspiration

Pancreatitis

Trauma and Fractures

Transfusion Reactions

Fat Embolism

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4
Q

What are the signs of ARDS? What are the Four Defining Features of ARDS?

What can you measure if there is a doubt on whether the ARDS is cardiogenic or not?

What is the ONLY Heart Failure symptom seen in ARDS?

A

It presents as Acute Respiratory Failure which does NOT improve with Supplemental Oxygen

There are FOUR Defining features of ARDS
1) Acute Onset (<1 week of a known risk factor)
2) Pulmonary Oedema (Bilateral Infiltrates on CXR)
3) Non-Cardiogenic (Pulmonary Artery Wedge Pressure needed if there is a doubt)
4) PaO2/FiO2<40

Dyspnoea

Tachypnoea

Confusion

Presyncope

There will be Bibasal Crackles (but no other signs of Heart Failure)

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5
Q

What imaging investigations should be ordered in ARDS?

What is the defining feature of ARDS?

A

Chest Xray- Bilateral Alveolar Infiltrates- NO OTHER SIGNS OF HEART FAILURE like the Kerley B Lines or Cardiomegaly

CXR will ONLY show the Pulmonary Oedema- nothing else that suggest Heart Failure

CT Scan may help to characterise changes found on X ray

PaO2/FiO2<40 is a Defining Feature of ARDS

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6
Q

What is the management of ARDS?

Where should ARDS be managed?

A

!!!!!!!!!!!!!!!!!!Transfer them to ITU!!!!!!!!!!!!!!!!!!!!!!

1) Mechanical Ventilatory Support- A Low Tidal Volume is associated with better outcomes- Give them OXYGEN!

2) Haemodynamic Support to maintain Mean Arterial Pressure>60mmHg- VASOPRESSORS can be given

3) DVT Prophylaxis

4) Nutritional support through Enteral/ Parenteral if NEEDED

5) Regular Repositioning of Patients for Pressure Ulcer Prophylaxis

6) Antibiotics only needed if an infective cause is suspected (Pneumonia or Sepsis)

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7
Q

What is Asbestosis?

A

It is a LOWER ZONE interstitial lung fibrosis that manifests in patients with Pleural Plaque diseases 10 or more years after they have exposure to Asbestos

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8
Q

What are the signs and symptoms of Asbestosis?

A

History of Asbestos Exposure- usually 20 or more years prior

Symptoms- Dyspnoea and Cough

Signs- Crepitations on Auscultation (cos it is fibrosis) , Finger Clubbing, Cyanosis and Reduced Chest Expansion

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9
Q

What is seen on the Chest Xray for Asbestosis?
What must you remember about the Pleural Plaques?
How do you manage Atelectasis?

A

Linear Interstitial Fibrosis

Pleural Plaques (Pleural Plaques are BENIGN and do NOT undergo a malignant change)

Pleural Thickening

Atelectasis (partial collapse or incomplete inflation of a lung)
- Management- Position them upright and Chest Physiotherapy

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10
Q

What do pulmonary function tests show for Asbestosis?

A

Restrictive pattern (Small Lung)

  • Low FVC
  • Low TLC
  • Normal FEV1/FVC ratio

Can also be Obstructive (Blocked Lung)
- Reduced FEV1

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11
Q

What is needed for the definitive diagnosis of Cancer in Asbestosis?

A

Open Lung Biopsy

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12
Q

What is the management of Asbestosis?

A

CONSERVATIVE, then O2 then Surgery

Smoking Cessation

Pulmonary Rehabilitation

Oxygen if SpO2 <90%

Lung Transplant

If death occurs due to Asbestosis, this must be reported to the coroner

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13
Q

Which conditions cause Aspiration Pneumonia?

A

Anything that may cause an Unsafe Swallow

Neurological Conditions plus Upper GI Conditions plus ALCOHOL and SEIZURE

  • Stroke
  • Myasthenia Gravis
  • Bulbar Palsy
  • Achalasia
  • G.O.R.D.
  • Alcoholics
  • Post Ictal State
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14
Q

What microorganisms cause Aspiration Pneumonia?

A

Streptococcus Pneumoniae

Staphylococcus Aureus

Haemophilus Influenza

Pseudonomas

Enterbacteriaceae

Can Also be Gram Negative Bacteria

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15
Q

What is the treatment of Aspiration Pneumonia?

A

Cover for both Gram Positive and Negative

IV Ceftriaxone and IV Metronidazole

Aspiration= CEF-MET

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16
Q

When must food and water be stopped before a Hernia Surgery?

A

Food- 6 hours before

Only Water until 2 hours before

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17
Q

Which Lung Regions usually mean Aspiration Pneumonia?

A

If the RIGHT MIDDLE and LOWER Lung Lobes are consolidated

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18
Q

When is the Pneumococcal vaccination routinely offered?

A

2 Months

4 Months

12-13 Months

And Over 65 years

2-4-12-65

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19
Q

What groups are at risk of Pneumonia and need the vaccination every 5 years?

What suggests immunocompromisation?

A

Chronic Heart, Lung, Liver or Kidney Disease

Liver Cirrhosis

!!!!!!!!!!!!!Post-Transplant

Renal Failure

Nephrotic Syndrome

Immunosuppression)- AIDS, Chemotherapy, Splenectomy, SICKLE CELL DISEASE

Chronic Lung Conditions- CPD/ Bronchiectasis

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20
Q

What are the causes of Bilateral Hilar Lymphadenopathy?

A

Inflammatory- Sarcoidosis

Infective- Tuberculosis and Mycoplasma

Neoplastic- Bronchial Carcinoma and Lymphoma

Interstitial Lung Disease can also cause this. It can be Inorganic (Silicosis) or Organic (Extrinsic Allergic Alveolitis)

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21
Q

What is Bronchiectasis?

What is the most likely organism that causes it?

A

It is the PERMANENT Dilatation of the Bronchi and Bronchioles due to Chronic Infection/ Inflammation

This is usually caused by (These 4 are the ones associated with ASPIRATION PNEUMONIA AS WELL)

1) Haemophilus Influenzae
2) Pseudonomas Aeruginosa
3) Streptococcus Pneumoniae
4) Staphylococcus Aureus

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22
Q

What are the causes of Bronchiectasis?

What are the 5 main ones to remember?

Also remember YOUNG-KART

A

Post Infection- Tuberculosis, HIV, Measles, Pertussis, Pneumonia

Bronchial Pathology- Obstruction caused by Foreign Body or Tumour

Allergic Bronchopulmonary Aspergillosis (ABPA)

Congenital- Cystic Fibrosis, KARTAGENER’s SYNDROME, Primary Ciliary Dyskinesia, Young Syndrome

Hypogammaglobuminaemia (Low Antibodies)- IMMUNE DEFICIENCY causes Bronchiectasis

Rheumatoid ARTHRITIS

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23
Q

What is the presentation of Bronchiectasis?

A

Persistent (DAILY) Productive Cough (+/-Haemoptysis) in a YOUNG person with Resp Issues (that may be the cause of it)

PLUS the 2C’s-
1) Clubbing

2) Coarse Inspiratory Crackles

Dyspnoea

Wheeze

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24
Q

What investigations should be ordered in Bronchiectasis?

What is the best investigation to order?

What are the 2 signs that are seen?

Is Bronchiectasis OBSTRUCTIVE or RESTRICTIVE on Spirometry?

A

Spirometry- Bronchiectasis is OBSTRUCTIVE

Sputum Culture- To identify pathogens and guide management with Antibiotics

High Resolution CT- BEST DIAGNOSTIC INVESTIGATION for Bronchiectasis

Chest Xray- thickened Bronchial Walls and Cystic Appearance- TRAMLINE and SIGNET RING SHADOWS

Bronchoscopy- can locate areas of obstruction and haemoptysis or sample tissue for Culture

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25
Q

What Additional Investigations can be ordered to identify the cause of Bronchiectasis?

A

Serum Immunoglobulins- Hypogammaglobuminaemia

Cystic Fibrosis Sweat Test- Cystic Fibrosis

Aspergillus Precipitins or Skin Prick Test- ABPA

Rheumatoid Factor or ANA- Rheumatoid Arthritis

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26
Q

What is the management of Bronchiectasis?

Remember the 2 conservative managements and the ABC

A

Conservative
- Patient Education
- Support Group
- MOST IMPORTANT- _Chest Physiotherapy _ (Postural Drainage at least Twice Daily to help with Mucous Drainage)
- Smoking Cessation

Medical Management ABC
1) Antibiotics (long term if recurrent- PROPHYLACTIC if 3 or more exacerbations)
2) Bronchodilators (given if Dyspnoea and Wheeze (COPD, ABPA, Asthma))
3) Corticosteroid- Prednisolone if ABPA
- Carbocysteine- a Mucolytic Agent

Surgical Management
- Surgical Excision of Localised Area of Disease or Cessation of the Haemoptysis
- Lung transplant may be indicated

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27
Q

What is Primary Ciliary Dyskinesia (Kartagener’s)?

What is the inheritance?

What is weird about these Kartagener’s patients?

A

PCD is an Autosomal Recessive disorder of dysfunctional cilia.

Cilia are important as they determine the orientation/laterality of internal organs and line the inner walls of bronchi. Consequently, their dysfunction results in bronchiectasis and recurrent infections.

Percussion usually changes at the RIGHT lung base due to movement of the liver during inspiration and expiration. Patients may display this phenomena at their LEFT lung base, suggesting SITUS INVERTUS – a key features of PCD

CHEST XRAY shows DEXTROCARDIA

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28
Q

What are the Musculoskeletal signs of Cystic Fibrosis?

What is HPOA? What 3 conditions is it associated with?

A

Clubbing

Hypertrophic Pulmonary Osteoarthropathy
- Lung disease (CF, Lung cancer or Bronchiectasis) which causes Clubbing and Arthritis

Osteoporosis

Arthritis

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29
Q

What can be ordered for the diagnosis of Cystic Fibrosis?

When can the HEEL PRICK test be ordered?

A

1) Neonatal heel prick day between day 5 and day 9

2) Sweat test: sweat sodium and chloride >60mmol/L

3) Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function.

4) Genetic screening: This can identify CF mutations

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30
Q

What kind of tests should be ordered in patients with KNOWN Cystic Fibrosis?

What is the Spirometry picture in Cystic Fibrosis?

A

~~~~~~~

Aspergillus Skin Prick

Spirometry- Obstructive

Abdominal Ultrasound- Distal Intestinal Obstruction, Liver Cirrhosis, Chronic Pancreatitis

Chest X Ray- Bronchiectasis, Hyperinflation

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31
Q

What is the management of Cystic Fibrosis?

(Read over but memorise the one in PAEDS)

A

~~~~~~

If INFECTIVE EXACERBATION
- Antibiotics
- Nebulised Mucolytics (Dornase Alfa)
- Bronchodilators (Inhaled Corticosteroids or B2 Agonists)

Pancreatic Insufficiency
- Insulin Replacement
- Creon
- Vitamin ADEK

If ABNORMAL LFTs
- URSODEOXYCHOLIC ACID

If Worsening Progressive Lung Disease
- Oxygen
- Non Invasive Ventilation
- Diuretics if Signs of Cor Pulmonale

Surgical Management
- If Cirrhosis- LIVER TRANSPLANT
- Lung Transplant may be needed

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32
Q

What suggests Cystic Fibrosis? (non-standard symptoms)

A

Recurrent Chest Infections

Short

Signs of Diabetes

DELAYED PUBERTY

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33
Q

What are the 4 types of differentials for Haemoptysis?

What is an Aspergilloma and when does it usually present?

What is GOODPASTUREs?

A

1) Vascular Causes
- Pulmonary Embolism

2) Infective Causes
- Pneumonia (dyspnoea)

  • Tuberculosis (systemic symptoms- weight loss, night sweats)
  • Aspergilloma- Ball of fungus in a cavity- usually secondary to TB or Sarcoidosis- No other symptoms
  • Bronchiectasis

3) Immunological Causes
- Goodpasture’s Disease- Pulmonary-renal disease with features of GLOMERULONEPHRITIS- (Haematuria, Proteinuria and Hypertension)- This is due to Autoantibodies against Type 4 Collagen

-Granulomatosis with Polyangiitis- Vasculitis causing Necrotising Granulomatous Inflammation of Small and Medium Blood Vessels- NASAL Obstruction, Saddle Nose, Haemoptysis, Glomerulonephritis (if NOSE is affected)

4) Malignant Causes
- Lung Cancer- Squamous Cell Carcinoma is the most common type of Lung Cancer. Look for Signs of ANAEMIA and Lymphadenopathy

  • Malignant Pleural Effusion
  • Also LUNG ABSCESS if there are Air-Fluid Levels
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34
Q

What are the Xray findings and the main sign of a Lung Abscess?

A

They are causes of MASSIVE HAEMOPTYSIS (Large amounts of Blood)

Central Cavitation with an Air-Fluid Level

FOUL SMELLING Sputum

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35
Q

What are the risk factors for Lung Cancer?

What are the 3 UNUSUAL RISK factors?

A

Smoking
Occupational Exposure (Silica, Asbestosis, Welding Fumes, Coal)

H._O._B.

HIV
Organ Transplantation
Radiation Exposure (Xray, Gamma Rays)
Beta Carotene supplements in Smokers

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36
Q

What are the signs of Lung Cancer?

What are the Paraneoplastic Syndromes?
What type of cancer is associated with Lambert-Eaton and with Hyperparathyroidism?

A

1) Haemoptysis
2) Dyspnoea and Chest Pain
3) NAUSEA and VOMITING
4) Weight Loss and Anorexia

5) Clubbing
6) Hypertrophic Pulmonary Osteoarthropathy
7) Anaemia
8) Horner’s Syndrome (if the tumour is located Apically)

9) PARANEOPLASTIC SYNDROMES (4)- Cushing’s Syndrome, SIADH, Lambert-Eaton (which suggests a Small Cell Carcinoma), Hyperparathyroidism (which suggests Squamous Cell Carcinoma)

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37
Q

What is seen on Examination in Lung Cancer?

4 signs

Which lymph nodes are enlarged in Lung Cancer?

A

1) Consolidation (Pneumonia)

2) Collapse (Absent Breath Sounds, Ipsilateral Tracheal Deviation)

3) Pleural Effusion (Stony dull percussion, Decreased vocal resonance and breath sounds)

4) Supraclavicular and Axillary Lymph Nodes are enlarged

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38
Q

What is Superior Vena Cava Obstruction?

A

Cancer may invade into Surrounding Tissues which compresses the Superior Vena Cava

This leads to Dyspnoea and FACIAL PLETHORA

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39
Q

What are the features of Squamous Cell Carcinoma?

It s typically CENTRAL

How is Squamous on Xray?

How is Squamous with cavitation?

What are the 2 HYPERS of Squamous?

A

1) Usually presents as Obstructive Lesions of the Bronchus leading to Infection

2) It is the lung cancer that MOST COMMONLY CAVITATES

3) On Xray it is not possible to tell whether it is an Abscess or Cancer (as the border’s definition can not be seen). However, the JAGGED BORDER of cancer can be seen on CT

4) Metastasis is late

5) It often causes HYPERCALCAEMIA- bone destruction or production of PTH-LIKE PEPTIDES

6) Also associated with Clubbing and Hypertrophic Pulmonary Osteoarthropathy

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40
Q

What are the features of Adenocarcinoma?

Peripheral

What does it most commonly cause compared to the other lung cancers?

Which lymph nodes are usually affected? Where does it spread to?

What are the Paraneoplastic Syndromes?

A

1) This is the most common type of Lung Cancer in the UK

2) It arises from Mucous Cells in the Bronchial Epithelium

3) It commonly invades Mediastinal Lymph Nodes and the Pleura- it spreads to BRAINS and BONEs

4) It usually does NOT Cavitate (unlike Squamous)

5) It is the LEAST Likely to be linked to Smoking and is the MOST COMMON in NON-Smokers

6) It is also the MOST LIKELY to cause Pleural Effusions

7) Paraneoplastic Syndromes- Gynaecomastia and HPOA

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41
Q

What are the features of Small Cell Carcinoma?

It is a CENTRAL Cancer

What cells does it arise from?

What are the paraneoplastic conditions associated with it?

How quick or late doe they metastasise?

A

1) Arise from Endocrine Cells (Kulchitsky Cells). These are APUD cells- so they will secrete many Polypeptides such as ACTH

  • APUD= (Amine - high amine content. Precursor Uptake - high uptake of amine precursors. Decarboxylase - high content of the enzyme decarboxylase)

2) These can cause various presentations- Addison’s and Cushing’s and Lambert Eaton Myasthenic Syndrome_(Limb weakness- due to VGCC antibodies)

3) Small cell carcinomas spread EARLY- metastatise early

4) These tumours respond to CHEMOTHERAPY

5) In addition to ACTH, these release ADH- which causes HYPONATRAEMIA

6) It causes Central Hilar Lymphadenopathy

7) Paraneoplastic SCLC (Sodium, Cushings, LEMS)
- ACTH- Cushings
- ADH- Hyponatraemia
- Lambert Eaton Myasthenic Syndrome

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42
Q

What are the Paraneoplastic Syndromes in Lung Cancer?

A
  • Small cell (The A_H’s and LAMBERT EATON)
    1) ADH- Hyponatraemia
    2) ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc- look for the METABOLIC SIGNS of CUSHINGs- not the physical ones
    3) Lambert-Eaton syndrome
  • Squamous cell (The 2 HYPERS and Clubbing)
    1) parathyroid hormone-related protein (PTH-rp) secretion causing Hypercalcaemia
    2) Clubbing
    3) Hypertrophic pulmonary osteoarthropathy (HPOA)
    hyperthyroidism due to ectopic TSH
  • Adenocarcinoma
    1) Gynaecomastia
    2) Hypertrophic pulmonary osteoarthropathy (HPOA)
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43
Q

What investigations should be ordered in Lung Cancer?

Which is the investigation of choice and which is first line?

Which blood test is an indicator for lung cancer?

How are biopsies obtained?

A

1) Sputum cytology

2) FIRST LINE- Chest X-ray: abnormalities that may be seen include nodules, lung collapse, pleural effusion, consolidation, and bony metastases.

3) INVESTIGATION of CHOICE= Contrast-enhanced CT scan: this is used to further confirm the diagnosis and stage (TNM classification) the disease. The CT scan should also include both the adrenals and liver to look for sites of metastases.

4) Bronchoscopy: used to obtain a BIOPSY for histology

5) Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA): allows biopsy of lymph nodes, paratracheal and bronchial lung lesions for histology

6) Cardiovascular review and lung function tests should also be performed to assess patient’s suitability for treatment options.

7) RAISED PLATELETS is an indicator for LUNG CANCER

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44
Q

What is the management of Non-small Cell Lung Cancer?

At what stages are radiotherapy and chemotherapy offered?

A

First Line- LOBECTOMY

Curative Radiotherapy can be offered to Stage 1, 2 and 3 Non-Small Cell Carcinomas

Chemotherapy should be offered if Stage 3 or 4

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45
Q

What is the management of Small Cell Lung Cancer?

A

Chemotherapy and Palliative Care

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46
Q

What is the management of Hypercalcaemia?

A

IV Fluid Replacement first

with NORMAL SALINE

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47
Q

What is the management of Superior Vena Cava Obstruction?

A

Immediate Oral Dexamethasone

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48
Q

What 3 conditions increase the likelihood of a Lung Abscess?

A

1) Lung Malignancy

2) Pneumonia

3) Aspiration of Oropharyngeal Secretions- breathing in stuff that is secreted from mouth/nose

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49
Q

What are the signs of a Lung Abscess?

What most commonly causes a lung abscess and what pathogens?

A

1) Typically following ASPIRATION PNEUMONIA or a STROKE
2) They are typically POLYMICROBIAL

Fever

DENTAL EROSIONS- cos poor dental hygiene increases the risk

SMELLY Productive Cough

Dyspnoea

Lethargy

SYSTEMIC SYMPTOMS-

1) Night Sweats

2) Weight Loss/ Cachexia

CLUBBING

Bronchial Breathing

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50
Q

What investigations should be ordered in Lung Abscesses?

What must be obtained in a lung abscess?

What is seen in a CHEST XRAY?

A

Blood- High ESR/CRP and Leukocytosis- cos it is an INFECTION after all

Sputum Culture and Blood Culture MUST BE OBTAINED

Chest Xray- an Abscess affects ONE SIDE- commonly the POSTERIOR SEGMENT of the UPPER LOBE and the APEX of the LOWER LOBE
- It will show a FLUID-FILLED SPACE with an AIR-FLUID LEVEL

CT Scan

Bronchoscopy- Aspirates can be obtained for Culture and for Drainage

51
Q

What is the management of a Lung Abscess?

A

Conservative- Do NOT forget the Conservative management
- Chest Physiotherapy for Postural Drainage
- Smoking Cessation if Necessary

Medical
- Supportive Treatment- Oxygen, Fluid Regime, Analgesia
- Antibiotic Treatment- IV Therapy for 3 weeks then Oral Antibiotics for 1-2 Months

Surgical
- CT-guided Percutaneous Drainage or Pulmonary Resection

52
Q

What are the signs of Obstructive Sleep Apnoea?

A

if they sleep but it doesn’t help and they snore

Excessive Daytime Sleepiness (so like fatigue)

Lack of Concentration

Snoring

Sleep is not Refreshing

Irritability and Personality Change

53
Q

What are the risk factors for Obstructive Sleep Apnoea?

A

Obesity
Male
Smoking
Alcohol

Neuromuscular Disease
Micrognathia

54
Q

What investigations should be ordered in Obstructive Sleep Apnoea?

What is the gold standard for obstructive sleep apnoea?

A

Polysomnography is the GOLD STANDARD (measuring physiological parameters while the patient is asleep at night)

ALSO Blood Pressure

55
Q

What is the management of Obstructive Sleep Apnoea?

A

BASICALLY manage the risk factors and CPAP

1) Weight Loss
2) Smoking Cessation
3) Avoid Alcohol in the evening

4) CPAP- maintains upper airway patency and it is the GOLD STANDARD

56
Q

What are the signs of Pleural Effusion?

What are the 3 core signs of a pleural effusion?

What are the Chest Expansion, Breath Sounds, Vocal Resonance and Percussion like?

What about Tracheal DEVIATION?

What 3 signs of the cause should you bear in mind?

A

Dyspnoea, NON-PRODUCTIVE cough, !!!!!chest pain

  • Chest Expansion, Breath sounds, Vocal Resonance and Percussion is LOWER on the affected side
  • Trachea MAY be deviated AWAY from the affected side

1) Trachea is NORMAL or DEVIATED away from the affected lung

2) Chest Expansion is REDUCED on the Affected Side

3) Percussion is DULL on the Affected Side

4) Reduced BREATH SOUNDs and VOCAL RESONANCE on Affected Side

///////////////////////////////////////////

Signs of the CAUSE

1) Pyrexia- Infection

2) Cachexia and Clubbing- Malignancy

3) Raised JVP and Ankle Oedema- Heart Failure

57
Q

What are the 4 causes of Exudative Pleural Effusion?

What is the PROTEIN RANGE?

(usually UNILATERAL)

What is the MOST COMMON CAUSE

A

Diseases which increase Permeability

  • REMEMBER IMIP=EXUDATIVE

(Protein>30)

1) Infections (Pneumonia or TB)- PNEUMONIA is the most common EXUDATIVE cause

2) Malignancy

3) Inflammatory Conditions (Rheumatoid Arthritis, Lupus, Pancreatitis)

4) Pulmonary Infarct (secondary to Pulmonary Embolism) and Trauma

58
Q

What are the causes of Transudative Pleural Effusion?

What is the PROTEIN LEVEL?

(usually BILATERAL)

A

Conditions that cause Imbalance in the Starling Forces

(Protein<25)

1) High Capillary Hydrostatic Pressure- Congestive Cardiac Failure

2) Low Capillary Oncotic Pressure- Cirrhosis, Nephrotic Syndrome/ CKD, GI Malabsorption or Malnutrition (Coeliac Disease)-

  • Cirrhosis leads to LOW ALBUMIN, Kidney injuries cause LOW PROTEIN in blood, Malabsorption also causes LOW PROTEIN

3) Hypothyroidism and Meig’s Syndrome (Ascites, Pleural Effusion and Benign Ovarian tumour)

  • Suspect Meig’s if patient has an OVARIAN TUMOUR/ ASCITES as well as the Effusion
59
Q

What Investigations should be ordered in Pleural Effusion?

What is seen on Chest Xray

When is Thoracentesis contraindicated for pleural fluid analysis?
What 4 things must you investigate in Thoracocentesis?

A

Blood Tests
- To help identify the cause
- E.g. Low Albumin + High AST/ALT= Cirrhosis- remember low albumin= low oncotic pressure= exudative
- High WCC= Infection

Imaging
- FIRST LINE IMAGING= PA CHEST XRAY
- Blunting of COSTOPHRENIC ANGLE

1) Ultrasound guided THORACENTESIS for Pleural Fluid Analysis needed in ALL Patients unless they have CLEAR HEART FAILURE

2) Pleural Fluid should be sent for Biochemistry- protein level, LDH, Glucose, pH, Amylase, Cytology, Microbiology)

60
Q

If the Protein Content is 25-35, Light’s Criteria is Applied in Pleural Effusion to decide whether it is Transudate or Exudate

What is Light’s Criteria?
- Only 1 needed

A

Exudate if (0.5 for Protein, 0.6 for LDH) plus LDH PF> 2/3 of upper reference for SerumLDH

1) Pleural Fluid Protein: Serum Protein >0.5

2) Pleural Fluid LDH: Serum LDH >0.6

3) Pleural Fluid LDH >2/3 Upper Reference Limit for Serum LDH

61
Q

What are the 4 measured Pleural Fluid Parameters to aid diagnosis?

What 3 things cause LOW GLUCOSE in PF analysis?
What suggests EMPYEMA?
What do the Complement levels suggest?

When should an oesophageal perforation be suspected?

A

1) Glucose- Low in Rheumatoid Arthritis, Tuberculosis or Malignancy (RTM)-
Raytrace my Glucose

2) pH <7.2 if Empyema

3) Amylase is Raised if Pancreatitis/ Oesophageal RUPTURE

4) Immunology- Rheumatoid Factor for Rheumatoid Arthritis. ANA for SLE. LOW COMPLEMENT if Rheumatoid Arthritis or SLE

5) Suspect Oesophageal perforation- HIGH Amylase, LOW Glucose, LOW pH

62
Q

What is the management of Pleural Effusion?

What are the 2 things done on ACUTE PRESENTATION

What should be done if it is LARGE or if there is EMPYEMA?

What is done if it is RECURRENT?

A

1) ABCDE (Oxygen and everything Diuretics for Heart Failure, Antibiotics for Chest Infections)

2) FLUIDS- even if NOT IN SHOCK

//////////////////////////////

1) Intercostal chest drainage if LARGE Pleural Effusion or Empyema

2) If Recurrent or Persistent Effusions- Pleurodesis (Obliteration of Pleural Space) can be chemical (tetracycline or bleomycin) or surgical

63
Q

What is Pneumocystis Pneumonia? Which FUNGUS causes it?
What kind of patients may it present in?

A

It is an infection with Pneumonia Jiroveci

It is a common presentation in HIV patients who are non compliant with cART or Antibiotic Prophylaxis

  • _C_YSTIS
  • _c_ART
  • JIROVECI
64
Q

What are the signs of Pneumocystis Pneumonia?

What is the cough like?

What measurement means the patient are at a high risk of Jiroveci?

What is typically seen JUST in Pneumocystis Pneumonia?

A

Fever

A NON-PRODUCTIVE COUGH (but can be productive if there is superimposed bacteria)

High risk if CD4<200

Exertional Breathlessness is associated with the onset of the infection (this is a specific sign for PCP vs other infections so remember this)

MAY be End-inspiratory Crackles

65
Q

What investigations should be ordered in Pneumocystis Pneumonia? What should be done if it is severe?

What is seen in CXR?

What is DEFINITIVE?

A

1) First LINE- Chest Xray- Bilateral Bihilar Interstitial Infiltrates- Reticular Appearance

2) If the chest Xray is normal however and you still suspect PCP- then High Resolution CT- look for CYSTS and NODULES

3) DEFINITIVE DIAGNOSIS- Bronchoscopy with Bronchoalveolar Lavage
- Samples are stained using Grocott’s Silver Stain which shows a “Mexican Hat” Appearance- Grocott Jiroveci sounds Mexican

4) Blood gas used to define Severity of Disease. If pO2<9.3kPa and arterial alveolar O2 Gradient >4.7kPa- then give CORTICOSTEROIDS

66
Q

What is the management of Pneumocystis Pneumonia? Remember the First Line

A

1) Co-trimoxazole

2) Clindamycin-Primaquine, Dapsone, IV Pentamidine

67
Q

What is the management of Hypoxia?

A

What type of mask do you start them off on?

Non-rebreathe Mask First

(then adjust to Venturi etc.)

68
Q

What are the signs of Pneumonia?

What is the Vocal Resonance like?
What kind of breathing pattern is seen?

remember the 2 highs

A

Fever

Purulent Sputum

PLEURITIC CHEST PAIN

Haemoptysis

Rigors

Tachycardia, Hypotension and Tachypnoea

HIGH VOCAL RESONANCE

  • Bronchial Breathing= Higher Pitch- Expiration and Inspiration are equal. There will be an AUDIBLE PAUSE between Inspiration and Expiration

Pleural Rub may also be heard

69
Q

What are the signs of Hospital-Acquired Pneumonia?

What 3 pathogens cause Hospital-Acquired Pneumonia?

A

Develops >2 days after Hospital Admission

Usually due to Pseudonomas Aeruginosa, Staphylococcus Aureus and Enterobacteria

Pseudonomas, Enterobacter and Aureus- PEA

The PEA causes Hospital Acquired Pneumonia

70
Q

What are the signs of Aspiration Pneumonia?

A

Unsafe Swallow- Stroke, Myasthenia Gravis, Bulbar Palsy, Alcoholism and Achalasia

Right Lung is commonly affected as the right bronchus is wider

71
Q

What are the signs of STAPHYLOCOCCAL PNEUMONIA?

What 3 groups of patients are at risk?

A

BILATERAL Cavitating Bronchopneumonia

Seen in
1) Intravenous Drug Users
2) Elderly Patients
3) Patients who already have an Influenza Infection

72
Q

What are the signs of KLEBSIELLA Pneumonia?

Which Lobes are affected?

What is the hallmark feature of Klebsiella?

Which 2 groups of patients are typically affected by Klebsiella (underlined)? What typically occurs before Klebsiella?

A

Usually affects the UPPER LOBES- resulting in Cavitating Pneumonia

This presents with Red-currant Sputum

There is a higher risk of complications such as Empyema, Lung Abscesses and Pleural Adhesions

Risk Factor- Alcoholics and Diabetics, Elderly (weakened Immune System)

Risk Factor- Malignancy, Steroid Use, Renal Failure, COPD

ASPIRATION typically occurs before Klebsiella

73
Q

What are the signs of MYCOPLASMA Pneumonia?

What can it lead to?

A

WORSENING Flu, Dry cough and Erythema multiforme

Presents like a FLU
- Arthralgia
- Myalgia
- Dry Cough
- Headache

It usually affects YOUNGER PATIENTS

It can cause AUTOIMMUNE HAEMOLYTIC ANAEMIA

Complications- Erythema Multiforme, Meningoencephalitis, Steven-Johnsons, Guillain-Barre

Leads to Erythema Multiforme, Meningoencephalitis, Steven-Johnsons, Guillain Barre, Autoimmune Haemolytic Anaemia

74
Q

What are the signs of LEGIONELLA Pneumonia?

Which 2 things should you look for?

What 3 things are low? (one of these things is one of the things you should look out for as well)

What is the HALLMARK Risk Factor for this?

A

Fever, Myalgia, Malaise

with BRADYCARDIA and CONFUSION and LYMPHOPAENIA

Followed by Dyspnoea and a DRY COUGH

Look for 1) HYPONATRAEMIA and 2) DERANGED LFTs

Usually occurs AFTER Hospital Air Conditioning/ Water exposure

THREE THINGS low- Lymphocytes, Heart Rate and Sodium

75
Q

What are the signs of Chlamydophilia Psittaci Pneumonia?

A

It is acquired from contact with INFECTED BIRDS like Parrots, Cattle, Horses and Sheep

  • Lethargy
  • Arthralgia
  • Headache
  • Anorexia
  • Dry Cough
  • Fever

Additional features seen with Chlamydophilia Psittaci
- Hepatitis
- Splenomegaly
- Nephritis
- Infective Endocarditis
- Meningoencephalitis
- Rash

76
Q

What investigations should be ordered in Acute Pneumonia?

A

ABG

Bloods- FBC, U&E, LFT, ESR, CRP

Blood Culture
Sputum for Microscopy & Culture

1) PCR for Mycoplasma Pneumonia

2) Urine Antigen- for Legionella and Pneumococcal Pneumonia

Chest Xrays- Lobar, Multilobar, Cavitation and signs of Pleural Effusion

77
Q

What is the CURB65 Scoring System for Pneumonia?

A

Confusion (8 or less on AMTS)

Urea >7

Resp Rate>30

Blood Pressure <90/60

Age >65

1- Home Treatment
2- Hospital Treatment
3- Hospital Admission with consideration for ITU Referral

78
Q

What is the management of Pneumonia?

A

Oxygen- keep sats above 94%

Fluid Management

Analgesia if there is Pleuritic Chest Pain- Paracetamol

Antibiotics Orally if not NBM (AMOXICILLIN and CLARITHROMYCIN)

Antibiotics Intravenously if Severe Pneumonia

79
Q

What kind of Pneumonia is prevented by the Pneumococcal Vaccine?

A

Streptococcus Pneumoniae

80
Q

What is Streptococcus Pneumonia associated with?

A

Herpes Labialis

81
Q

What bacteria is commonly associated with patients with COPD?

A

Haemophilus Influenzae

82
Q

What can be given as management for Aspiration Pneumonia?

A

Co-Amoxiclav

83
Q

What is the most likely causative organism of Pneumonia AFTER Mechanical Ventilation?

A

Pseudonomas

  • Treat with CIPROFLOXACIN
84
Q

How do you differentiate between Staphylococcus Aureus and Streptococcus Pneumoniae (both Gram Positive and Cocci)?

A

Staph- Clusters

Strep- Chains

85
Q

What is the management of Hospital Acquired Pneumonia?

A

IV Tazocin

86
Q

What are the signs of Empyema in Pneumonia?

A

Recurrent Fever Despite Antibiotic Treatment for Pneumonia

pH<7.3

Manage with CHEST DRAIN under radiological guidance

87
Q

Which 2 Pneumonias are associated with HIV and how can they be differentiated?

A

Streptococcus Pneumoniae and Pneumocystis Jiroveci

Streptococcus- Rust Coloured Sputum and Focal Consolidations

Pneumocystis Jiroveci- Bilateral Bihilar Interstitial Infiltrates

88
Q

What is Pulmonary Hypertension?

A

An Increase in Mean Pulmonary Arterial Pressure (around 15mmHg)

89
Q

What are the signs of Pulmonary Hypertension?

A

Shortness of Breath and ANKLE SWELLING (if COR PULMONALE)

Fatigue

Syncope

RAISED JVP

Parasternal Heave

Loud P2

Presence of an S3 Sound

Pansystolic Murmur (Tricuspid Regurgitation)

End Diastolic Murmur (Pulmonary Regurgitation)

90
Q

What are the causes of Pulmonary Hypertension?

A

1) Parenchymal Lung Disease
- COPD
- Asthma
- etc.

2) Pulmonary Vascular Disease (Pulmonary Embolism, Portal Hypertension)

3) Hypoventilation
- Kyphosis/ Scoliosis
- Neuromuscular Conditions (Myasthenia Gravis)

4) Left Heart Disease
- Mitral Stenosis/ Regurgitation
- Left Ventricular Failure

91
Q

What investigations should be ordered in Pulmonary Hypertension?

A

ECG- P Pulmonale, Right Ventricular Hypertrophy, Right Axis Deviation

Echocardiogram

Right Heart Catheterisation (GOLD STANDARD)- which will show a MEAN PULMONARY ARTERY PRESSURE >25mmHg

92
Q

What is the management of Pulmonary Hypertension?

A

Treat the underlying condition

Reduction of Pulmonary Vascular Resistance
- Long Oxygen Therapy
- NIFEDIPINE
- Sildenafil
- Prostacycline analogues
- BOSENTAN (Endothelin Antagonist)

Manage the Heart Failure

Heart-lung transplant for selected cases

93
Q

What are the possible causes of Pulmonary Fibrosis?

A

Lung Damage- Pneumonia, Infraction, Tuberculosis

Irritants- Coal or Silica

Diffuse Parenchymal Lung Disease- Idiopathic Fibrosis and Extrinsic Allergic Alveolitis

Connective Tissue Disease- Rheumatoid Arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, Sjogren’s Disease

Medications- AMIODARONE, NITROFURANTOIN, BLEOMYCIN

Hypersensitivity Pneumonitis- Exposure to BIRDS or MOULDS

94
Q

When does Idiopathic Pulmonary Fibrosis present?

A

In 70 year olds

95
Q

What are the signs of Idiopathic Pulmonary Fibrosis?

Suspect if RESTRICTIVE LUNG DISEASE with Shortness of Breath and Non-Productive Cough- especially if Elderly

A

Dry cough and Shortness of Breath

Fatigue

ARTHRALGIA is seen in Idiopathic Pulmonary Fibrosis

Cyanosis and Clubbing

FINE End-Inspiratory Crackles

96
Q

What are the complications of Idiopathic Pulmonary Fibrosis?

A

Type 2 Respiratory Failure

Increased chance of Lung Cancer

COR PULMONALE

97
Q

What investigations should be ordered in Idiopathic Pulmonary Fibrosis?

A

Blood Tests- CRP, ANA and Rheumatoid Factors to find a cause

ABGs- Hypoxia and Hypercapnia are likely

Chest Xray- Bilateral LOWER ZONE Reticulo-nodular Shadowing

High Resolution CT- Reticulonodular Shadowing and Honeycomb Lung

Spirometry- RESTRICTIVE Deficit with Reduced Transfer Factor

98
Q

What is the management of Idiopathic Pulmonary Fibrosis?

A

Stop Smoking, Pulmonary Rehabilitation

Lung term Oxygen Therapy

Antifibrotics (Pirfenidine)

Symptom control in Right Heart Failure

Cure- Lung Transplant is the only cure

99
Q

What are the ABGs in Respiratory Alkalosis?

A

High pH

Low pCO2

Low HCO3

100
Q

What are the causes of Respiratory Alkalosis?

A

CNS Infection

Subarachnoid Haemorrhage

Panic Attack

Pulmonary Emboli (through Reflex Hyperventilation)

Aspirin Overdose (then it becomes Metabolic Acidosis)

Hypoxia (like Hyperventilation)

Anaemia

101
Q

What is Type 1 Respiratory Failure?

A

It it is when there is a NORMAL PaCO2 with LOW O2

This is due to V/Q Mismatch- The volume of air entering the lung is TOO LOW to keep up with the amount of blood perfusing the lungs

102
Q

What are the causes of Type 1 Respiratory Failure?

A

Congestive Cardiac Failure
Asthma
Pulmonary Embolism
Pneumonia
Pneumothorax

103
Q

What are the V/Q levels for the different causes of Type 1 Respiratory Failure?

A

Low V/Q- Poor Ventilation but Well Perfused
1) Bronchoconstriction (Asthma)
2) Airway Collapse (Emphysema)
3) Mucus Plug
4) Congestive Cardiac Failure

High V/Q- Ventilation is fine but Perfusion is bad
1) Pulmonary Embolism

104
Q

What is Type 2 Respiratory Failure?

A

Low PaO2 (<8)

but PaCO2 is HIGH (>6)

This occurs due to Alveolar Hypoventilation- The lungs are NOT ABLE to Oxygenate the blood and Decarbondioxify the blood

(so Low O2 and High CO2)

105
Q

What are the causes of Type 2 Respiratory Failure?

A

1) COPD

2) Idiopathic Pulmonary Fibrosis

3) Opiates (as they cause Depression of the Respiratory Centers)

4) Neuromuscular Diseases- Guillain-Barre Syndrome and Motor Neuron Disease

5) Thoracic Wall Disease- Rib Fracture

106
Q

What is Sarcoidosis?

1) Suspect if Afro-Caribbean

2) High ESR/ Calcium

3) Red Lesions

4) Joint Pain

A

It is a multisystem disease characterised by Granuloma formation

This results in Widespread Inflammatory Changes and Complications

107
Q

What are the Acute signs of Sarcoidosis?

A

Fever

Polyarthralgia

Erythema Nodosum

Bilateral Hilar Lymphadenopathy

This is also known as LOFREN SYNDROME

108
Q

What are the Chronic Signs of Sarcoidosis?

A

Pulmonary (most common manifestation)
1) Dry Cough
2) Dyspnoea
3) EXERTIONAL DYSPNOEA
4) Examination may reveal CREPITATIONS

Constitutional
1) Fatigue
2) Weight Loss
3) Arthralgia
4) Low-grade Fever
5) There will also be Lymphadenopathy and ENLARGED PAROTID GLANDS

Neurological
1) MENINGITIS
2) Peripheral Neuropathy
3) Bilateral BELL’s PALSY

Ocular
1) Uveitis
2) Keratoconjunctivitis Sicca

Cardiac
1) Arrhythmias
2) RESTRICTIVE CARDIOMYOPATHY

Abdominal
1) HEPATOSPLENOMEGALY
2) Renal Stones

Dermatological
1) Erythema Nodosum
2) Lupus Pernio

109
Q

What Investigations should be ordered in Sarcoidosis?

A

(Any) Tissue Biopsy is DIAGNOSTIC- you would see NON-CASEATING GRANULOMAs on Biopsy

Bloods
1) HIGH ESR
2) Raised ACE
3) Raised Calcium
4) LOW Lymphocytes

CXR or CT
1) Stage 1- Bilateral Hilar Lymphadenopathy (BHL)
2) Stage 2- BHL with PERIPHERAL INFILTRATES
3) Stage 3- ONLY Peripheral Infiltrates
4) Stage 4- Pulmonary Fibrosis

110
Q

What is the management of Sarcoidosis?

A

Stage 1- usually self-resolving

Acute Sarcoidosis- Bed Rest/ NSAIDs

Steroid Treatment- Either Oral or IV depending on the severity

If SEVERE- give IMMUNOSUPPRESSANTS

111
Q

What are the Spirometry results for Restrictive Lung Diseases?

A

Decrease in both FEV1 and FVC

So FEV1/FVC will be normal and GREATER than 0.7

This is seen where the Lung Volume is reduced

112
Q

What are the causes of Restrictive Lung Disease?

A

Respiratory
1) Pulmonary Fibrosis
2) Acute Respiratory Distress Syndrome
3) Pneumoconiosis

Neuromuscular
1) Myasthenia Gravis
2) Motor Neurone Disease

Thoracic
1) Obesity
2) Kyphosis

113
Q

What are the Spirometry results for Obstructive Lung Diseases?

A

FEV1 is lower than the FVC

So FEV1<0.7

114
Q

What are the causes of Obstructive Lung Diseases?

A

Asthma and COPD

Bronchiectasis

Cystic Fibrosis

115
Q

How is TB Spread and what are the risk factors for TB?

A

Spread through Droplets

Risk Factors
1) Sub-saharan Africa/ South Asia
2) Homeless
3) Drug and Alcohol Abuse
4) Contact with Infected Patient
5) IMMUNOSUPPRESSION
6) Young or Old Age

116
Q

What are the signs of Tuberculosis?

A

General
- Night Sweats
- Fever
- Weight Loss

Pulmonary (Most Common)
- Chronic Cough and Purulent Sputum (with or without Haemoptysis)
- Bronchiectasis, Pneumonia, Pleural Effusion
- INSPIRATORY CHEST PAIN

Genitourinary (Second Most Common)
- “Sterile” Pyuria
- Kidney Pathology
- Abscesses
- Salpingitis and Infertility
- Epididymo-Orchitis

CNS Presentation
1) TB Meningitis or Tuberculoma
2) Headache
3) Meningism
4) Focal Neurological Signs
5) Decreased Consciousness

Musculoskeletal
1) Arthritis/ Osteomyelitis
2) PSOAS Abscess
3) Pott’s Disease of the Spine

Gastrointestinal
1) Abdominal Pain
2) Appendicitis due to Ileocaecal Lesions- Can get to Peritoneum which causes ASCITES

Pericardial
1) Pericardial Effusions
2) Constrictive Pericarditis

Lymph Nodes
1) Tender and Firm

Cutaneous
1) Erythema Nodosum and Bazin’s Disease

117
Q

What investigations should be ordered in Tuberculosis?

A

1) Chest X ray

2) Early Morning Sputum samples for culture and sensitivity- ACID FAST BACILLI

3) Samples from Non-pulmonary sites- May need Biopsy and Needle Aspiration

4) Ziehl-Neelsen or Auramine Staining

5) PCR with drug sensitivity

6) Interferon-Gamma Release Assays- Use this if the patient has had a PRIOR BCG INFECTION

7) Mantoux Test- it is AFFECTED by a PRIOR BCG INFECTION

118
Q

What is the management of Tuberculosis?

A

RIPE for 2 months then just RI for 4 months

If Multidrug Resistance- Macrolides, Quinolones, Capreomycin

119
Q

What are the side effects of Isoniazid (TB)?

A

Peripheral Neuropathy (Pyridoxine is given to prevent this)

Gout

LIVER TOXICITY

120
Q

What are the side effects of Rifampicin (TB)?

A

Body Fluids become ORANGE

It induced Liver Enzyme P450

LIVER TOXICITY

121
Q

What are the side effects of Ethambutol (TB)?

A

Visual Disturbances (Colour blindness, Loss of Acuity)

Avoid in CKD

122
Q

What are the side effects of Pyrazinamide (TB)?

A

LIVER TOXICITY

123
Q

What is the only TB Drug that does NOT have the LIVER TOXICITY Side Effect?

A

Ethambutol

124
Q

What are the Chest Xray Findings in Tuberculosis?

A

Fibro-Nodular Opacities (Usually Upper Lobe)