Respiratory - Short Case Flashcards
CXR: calcified lesions in the lung fields
TB
pneumoconiosis
post-chickenpox pneumonia
tularaemia
What is histoplasmosis?
Fungal lung infection
Assoc with immunocompromise
Histoplasma capsulatum is found in soil, often associated with decaying bat guano or bird droppings.
Wheezes/Rhonchi
a. inspiratory wheeze is characteristic of?
b. expiratory wheeze is characteristic of?
c. fixed inspiratory wheeze (monophonic - does not change with respiration) is a sign of?
a. asthma, or upper airway extrathoracic obstruction
b. asthma and COPD
c. carcinoma
ddx Bronchial breath sounds
lobar pneumonia (common)
localised fibrosis or collapse
above a pleural effusion
large lung cavity
Pleural fluid analysis: pH <7.2
Empyema, tuberculosis, neoplasm, RA, oesophageal rupture
CXR: reticular (linear opacities)
fibrosis, brochiectasis
What are the causes of chronic ILD?
- Idiopathic pulmonary fibrosis
- Rheumatological disease
- RA
- Systemic sclerosis
- SLE
- Polymyositis
- Dermatomyositis
- Sjogren’s syndrome
- MCTD
- Ankylosing spondylitis
- Psoriasis
- Eosinophilic lung disease
- Drugs (nitrofurantoin, sulphasazine)
- Aspergillosis
- Other respiratory disease
- Sarcoidosis
- Tuberculosis
- Vasculitis
- Polyarteritis nodosa
- Wegner’s granulomatosis
- Churg-strauss syndrome
- Goodpasture’s syndrome
- Inhaled agents
- Extrinsic allergic alveolitis
- Asbestosis
- Silicosis
- Beryliosis
- Drugs
- Amiodarone
- Nitrofurantoin
- Bleomycin
- Gold
- Methotrexate
- Radiation fibrosis
How do you define an exudate and what are some causes?
Light’s criteria
Pleural fluid protein : serum protein >0.5
LDH >2/3 ULN
Pleural LDH : serum LDH >0.6
Causes
Pneumonia
Neoplasm - lung carcinoma, metastatic carcinoma, mesothelioma
Tuberculosis, sarcoidosis
Pulmonary infarction
Subphrenic abscess
Pancreatitis
CTD - RA, SLE
Drugs - nitrofurantoin (acute), drugs causing lupus, chemotherapeutic agents, bromocriptine
Radiation
CXR: coin lesion ddx
carcinoma
tuberculoma
harmatoma
granuloma
AVF
rheumatoid nodule
lung abscess
hydatid cyst
Stony dullness, bronchial breathing on top, needle marks from previous aspirations
pleural effusion
CXR: miliary calcification ddx
post-chickenpox pneumonia
histoplasmosis
coccidioidomycosis
ectopic calcification in renal failure, hyperparathyroidism
Loose cough, full sputum mug, coarse crackles and wheezes, clubbing
Bronchiectasis
CXR: localised non-homogenous opacity ddx
pneumonia
pulmonary infarct
carcinoma
tuberculosis
Causes of clubbing?
- Respiratory
- lung ca
- chronic pulmonary suppuration (ie. bronchiectasis, lung abscess, empyema)
- IPF, asbestosis
- cystic fibrosis
- pleura fibroma or mesothelioma
- mediastinal disease (thymoma, lymphoma, carcinoma)
- Cardiovascular
- IE
- cyanotic congenital heart disease
- Other
- Inflammatory bowel disease
- Cirrhosis
- Coeliac disease
- thyrotoxicosis
- hemiplegic stroke
**Clubbing does NOT occur with COPD, sarcoidosis, coal worker’s pneumoconiosis, silicosis
Dry cough, crackles, clubbing
ILD
How would you investigate someone with ILD?
Blood tests
- FBC (anaemia in vasculitis or polycythemia in longstanding hypoxia)
- Inflammatory markers
- Immunoglobulins
- Autoimmune profile (ANA, ENA, ANCA, anti-GBM)
- CK (polymyositis, dermatomyositis)
- RF
- ACE
ABG
- T1RF
CXR
- Bilateral basal reticulonodular infiltrates, honeycombing.
- Bilateral hilar lymphadenopathy - sarcoidosis
- Calcified pleural plaques in asbestosis
Lung function tests
- Reduction in lung volumes (TLC, FRC)
- Restrictive pattern of defect
- Reduced gas transfer factor and gas transfer coefficient
HRCT
MRI
Broncho-alveolar lavage
Lung biopsy
6 minute walk test
How do you define a transudate?
What are causes of transudates?
Light’s criteria
- Pleural protein : serum protein = <0.6
- pleural LDH <2/3 ULN
- pleural : serum LDH <0.6
Causes
Cardiac failure
Nephrotic failure
Liver failure
Meig’s syndrome - ovarian fibroma and pleural effusion
Hypothyroidism
Please present someone with advanced ILD secondary to systemic sclerosis with evidence of pulmonary HTN and on steroid therapy.
This patient is/isn’t breathless at rest. There is evidence of peripheral and central cyanosis. The fingers are clubbed. The skin over the fingers and face is smooth, shiny and tight. There is sclerodactyly, atrophic nails, and evidence of Raynaud’s phenomenon. There is no evidence of nicotine staining. There is steroid purpura peripherally. There are no palpable lymph nodes. On examination of the chest, there are no scars. The trachea is central and the cricoid-notch distance is not reduced. Chest expansion is equal but reduced bilaterally. The percussion note is dull and vocal fremitus is reduced at both bases. On auscultation, there are fine end-inspiratory crackles at both bases. There are no audible squawks and there is no wheeze.
In addition, the venous pressure is elevated. There is a prominent parasternal heave, and a loud pulmonary component to the second heart sound. There is peripheral edema.
Overinflated chest, possible cyanosis, pursed lipped breathing, reduced breath sounds and wheezes, Hoover’s sign
COPD
CXR: diffuse opacities ddx
miliary <2mm: miliary TB, miliary metastases, sarcoidosis, pneumoconiosis, lymphoma, lymphagitis, pneumonia, vasculitis, pulmonary haemorrhage
nodular 3-10mm: pneumonia, pneumoconiosis, TB, met carcinoma, sarcoidosis
CXR: cavitated lesion ddx
lung abscess
carcinoma (usually squamous cell) or Hodgkin’s
TB
fungi
Causes of upper lobe lung fibrosis?
SCHART
- Sarcoidosis/silicosis
- Coal-worker’s pneumoconiosis
- Histiocytosis
- Ankylosing spondylitis/allergic bronchopulmonary aspergillosis
- Radiation
- Tuberculosis
often young patient with signs of bronchiectasis and cachexia
cystic fibrosis
CXR: homogenous opacity ddx
Pneumonia - lobar or segmental
Collapse
Effusion
What is the treatment for pulmonary fibrosis?
- Treatment generally ineffective
- Anti-fibrotic agents Nintedanib or Pirferidone
- Consider Sildenafil if pHTN
- Lung rehabilitation, consider lung transplant
sometimes clubbing, scar, radiotherapy marks, signs of effusion or collapse, lymph nodes
treated carcinoma
Pleural fluid analysis: chylous
Tumour (usually lymphoma), thoracic duct trauma, tuberculosis, tuberous sclerosis
gross unilateral chest deformity, big scar
thoracoplasty
What are the causes of lower lobe fibrosis?
Lower lobes (RASCO)
- rheumatoid arthritis
- asbestosis
- scleroderma
- cryptogenic fibrosing alveolitis
- other (drugs, e.g. busulphan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone)
ddx Reduced breath sounds
emphysema
large lung mass
collapse, fibrosis, or pneumonia
effusion
pneumothorax
Crackles/crepitations
- Late or pan inspiratory crackles
- Fine ddx
- Medium ddx
- Coarse ddx
- Early inspiratory crackles
* Coarse
Fine late inspiratory crackles: fibrosis - dry
Medium late inspiratory crackles: caused by LVF
Coarse late inspiratory crackles: bronchiectasis or retained secretions
Early inspiratory crackles: coarse - caused by COPD
