Term
| respiratory manifestations of RA |
|
Definition
PULMONARY FIBROSIS
pulmonary effusion
MTX pulmonitis
nodules
bronchiolitis obliterans |
|
|
Term
what is caplans syndrome?
why does it occur? |
|
Definition
massive fibrotic nodules
occurs with occupational coal dust exposure |
|
|
Term
a man with COPD comes in with cyanosis tachycardia and o2 sats 58%
whats the first thing you administer? |
|
Definition
| high flow oxygen. this pt is critically ill and pts die of hypoxia before they die from hypercapnia so it is inappropriate to deny high flow oxygen in acute setting |
|
|
Term
what are the o2 sat targets for an acutely ill person?
what are the o2 sats target for a person at risk of hypercapnia eg COPD pt? |
|
Definition
94-98%
for those at risk for hypercapnia the target is 88-92% |
|
|
Term
| a person with COPD has come in and needs oxygen. Before ABG is available what flow oxygen is recommended? |
|
Definition
28% venture mask at 4litres per min.
the target sats should be 88-92%
if pCO2 are normal start adjusting to 94-98% |
|
|
Term
bacteria often implicated in aspiration oneumonia are aerobic.
give examples of ones that are involved? |
|
Definition
step pneumonia
s. aureus
haemophilus
pseudomonas |
|
|
Term
| in ABG of someone with COPD if it shows a raised bicarbonate what does this suggest? |
|
Definition
| it suggests a chronic compensatory process. |
|
|
Term
| irritation from where to the lungs can be a reason for cough? |
|
Definition
|
|
Term
| what is an acute, chronic and sub acute cough? |
|
Definition
acute <3 weeks
chronic > 8 weeks
subacute = inbetween |
|
|
Term
|
Definition
meds: ACE-i
irritation of lungs in GORD |
|
|
Term
| characteristics of a cough associated with reccurent laryngeal nerve palsy? |
|
Definition
|
|
Term
| causes of a chornic cough |
|
Definition
TB
foreign body
asthma
CF
bronchiectasis
pertussis |
|
|
Term
| what is a loud brassy cough suggestive of? |
|
Definition
| pressure on the trachea e.g from a tumour |
|
|
Term
| why shold you NOT ignore a change of character of a chronic cough? |
|
Definition
| because it may signify a new problem such as infection or malignancy |
|
|
Term
| what are red flags in a chronic cough? |
|
Definition
copious sputum: suggests bronchiectasis
systemic symptoms: suggests TB, lymphoma or bronchial ca
haemoptysis: suggests TB or bronchial cancer
Significant dyspnoea: suggests HF, COPD or fibrotic lung disease |
|
|
Term
| describe PH qualities between coughed up and vomited blood? |
|
Definition
coughed up blood is alkaline
vomited blood is acidic |
|
|
Term
| respiratory causes of haemoptysis? |
|
Definition
infection
neoplasm
vascular
parenchymal
pulmonary HTN
coagulopathies
trauma foreign body |
|
|
Term
| what is serratia marcecens and what can it mimic? |
|
Definition
gram neg bacteria rod shaped.
has red pigment and can mimic haemoptysis |
|
|
Term
| infective causes of haemoptysis |
|
Definition
TB
bronchiectasis
pneumonia
parasites
lung abscesses
fungi
viruses
COPD |
|
|
Term
| vascular causes of heamoptysis |
|
Definition
PE
vasculitis
hereditary hemorrhagic telangiectasia |
|
|
Term
| parenchymal causes of heamoptysis |
|
Definition
|
|
Term
|
Definition
smoking
ACE-i
asthma
post nasal drip
pollution in environment
occupation |
|
|
Term
| how long should a cough due to smoking improve when quit? |
|
Definition
|
|
Term
| how long after stopping ACE-i should the dry cough stop? |
|
Definition
|
|
Term
| what is name of the primary lesion in the lung in TB? |
|
Definition
ghon focus
together with hilar lymph nodes it is called the Ghon complex
the ghon focus is made of TB laden macrophages |
|
|
Term
| in immunocompetent people the primary TB infection usually heals by fibrosis. what may happen in immunocomprimised people? |
|
Definition
| they can develop disseminated disease AKA military TB |
|
|
Term
where does secondary TB generally occur? this happens due to reactivation of the primary infection and can be due to:-
immunosuppressive drugs including steroids
malnutrition
HIV |
|
Definition
| generally occurs in apex of the lungs. |
|
|
Term
| extra pulmonary infection of TB may occur where? |
|
Definition
brain
vertebral bodies (potts disease)
cervical lymph nodes (scrofuloderma)
renal
gi tract |
|
|
Term
|
Definition
| secondary TB in the verbral bodies |
|
|
Term
|
Definition
| TB in cervical lymph nodes. |
|
|
Term
| the inflammatory response in TB is which type of hypersentivity reaction? |
|
Definition
| type 4 - delayed hypersensitivity reaction |
|
|
Term
| what is present in the centre of granulomas in TB? |
|
Definition
|
|
Term
|
Definition
Ziehl-Neelson stain typically used
Mantoux used to screen for latent TB
interferon gamma blood test has also been introduced
HEAF test no longer used. |
|
|
Term
| what is the rx for active TB? |
|
Definition
RIPE for 2 months then RI for next 4 months
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol |
|
|
Term
|
Definition
isoniazid alone for 6 months
those with meningeal TB rx for 12m plus steroids. |
|
|
Term
|
Definition
prevents transcription of DNA into mRNA
SE:enzyme inducer, red secretions, flu symptoms |
|
|
Term
|
Definition
inhibits mycolic acid synthesis
SE: peripheral neuropathy (give vitamin B6 pyridoxine)
Other SE: inducer, hepatitis, agranulocytosis |
|
|
Term
| MOA and SE of pyrazinamide |
|
Definition
inhibits fatty acid synthetase 1
SE:hyperurecaemia causes gout, arthlagia, myalgia, hepatitis |
|
|
Term
fibrosis that predominantly affects the lower zones.
more common causes tend to affect the lower zones |
|
Definition
idiopathic pulmonary fibrosis
connective tissue disorders except ankylosing spondylitis (affects upper zone)
asbestosis
drug induced: amiodarone, MTX, bleomycin |
|
|
Term
fibroses that mainly affect upper zones
apart from TB, sarcoid and ankylosing spond these are the more uncommon ones |
|
Definition
ankylosing spondylitis
TB
sarcoid
silicosis
histiocytosis
coal workers pnemococcis
extrinsic allergic alveolitis |
|
|
Term
| lung cancer can be small cell or non small cell. which one is more common? |
|
Definition
Non small cell. it accounts for 80% of all lung cancers.
these include:-
squamous 25% cases
adenocarcinomas 40% cases
large cell carcinoma 10% cases |
|
|
Term
| which is the most common lung cancer experienced in people who have never smoked? |
|
Definition
|
|
Term
small cell lung cancers tend to arise in large airways.
is smoking implicated?
where do cells originate from and what can this result in? |
|
Definition
| they are associated with smoking and compromised of cells with a neuro endocrine differention so hormones may be released from them and are involved in a wide range of paraneoplastic associations. |
|
|
Term
| small cell cancer is AKA? |
|
Definition
|
|
Term
| how much does smoking increase your risk of lung cancer by? |
|
Definition
|
|
Term
| asbestos increases lung cancer by how many times? |
|
Definition
x 5
smoking and asbestos have a synergistic affect.
smoking increases risk by 10 x
asbestos by 5 x
together the risk is increase 50 x |
|
|
Term
| paraneoplastic features of small cell lung cancer |
|
Definition
ADH - SIADH
ACTH -
lambert eaton |
|
|
Term
| paraneoplastic features of squamous cell lung cancer |
|
Definition
PTHr protein causing hypercalceamia
clubbing
hyperthyroidism due to ectopic TSH |
|
|
Term
| paraneoplastic features of adenocarcinoma lung cancer |
|
Definition
|
|
Term
| when to refer pts under 2 week lung cancer pathway? |
|
Definition
aged 40 or more with unexplained haemoptysis
if they have a CXR finding suggestive of lung ca |
|
|
Term
you can offer an urgent CXR to be done in 2 weeks for people aged 40 and over if they they have 2 or > of which symptoms.
if they smoke then they only need one symptom |
|
Definition
cough
fatigue
SOB
chest pain
weight loss
appetite loss |
|
|
Term
| when should you consider urgent CXR in 2 weeks? |
|
Definition
aged 40 or > with :
clubbing
supraclavicular lymphadenopathy
persistant cervical lymphadenopathy
thrombocytosis
chest signs consistent with lung cancer
persistant or recurrent chest infection |
|
|
Term
| features of squamous cell lung ca |
|
Definition
typically central
associated with finger clubbing and PTHr protein causing hypercalceamia
hypertrophic pulmonary osteoarthropathy |
|
|
Term
| features of large cell lung ca |
|
Definition
poorly differentiated and poor prognosis
may secreted bHCG |
|
|
Term
| mx of non small cell lung cancer |
|
Definition
only 20% suitable for surgery
before surgery mediastinoscopy is done to check for mediastinal lymph node involvement as CT does not always capture this.
curative or palliative radiotherapy
poor response to chemo |
|
|
Term
which type of lung cancer
non small cell or small cell has poor response to chemo? |
|
Definition
|
|
Term
| why are stages IIIb or IV contraindications to surgery in non small cell lung ca? |
|
Definition
| because these stages suggest mets are present |
|
|
Term
| staging of T in lung cacm |
|
Definition
T1 <3
T2 >3
T3 >7cm
T4 tumour involves mediastinal contents |
|
|
Term
| effect of paraneoplastic features in small cell lung ca |
|
Definition
ADH causes hypontremia
ACTH causes Cushings and high levels of cortisol can cause hypokalemic alkalosis |
|
|
Term
types of lung biopsy available?
(3) |
|
Definition
percutaneous
transbronchial
open lung |
|
|
Term
| when might you use a radionucleotide bone scan in lung cancer? |
|
Definition
|
|
Term
|
Definition
CF
infection: TB, measles, pertussis,
obstruction: lung ca, foreign body
Immune cause: selective IgA, hypogammaglobinaemia
Ciliary dyskinetic syndromes: Kartegner's syndrome |
|
|
Term
|
Definition
physical training of inspiratory muscles
postural drainage
Abx for exacerbations
bronchodilators
immunisations
surgery in selected cases |
|
|
Term
| gold diagnosis for bronchiectasis? |
|
Definition
|
|
Term
| a person with bronchiectasis has infection with p aueringosa, what is ABx of choice? |
|
Definition
|
|
Term
| common organisms isolated from someone with bronchiectasis |
|
Definition
Haemophilus influenza
pseudomonas
klebsiella
Strep pneumonia |
|
|
Term
| features of Kartegner syndrome |
|
Definition
dextrocardia or situs inversus
bronchiectasis
recurrent sinusitis
subfertility
defect in dynein arm results in immobile cilia |
|
|
Term
|
Definition
Smoking
alpha 1 antitrypsin deficiency
coal
cotton
cement
cadmium used in smelting |
|
|
Term
|
Definition
| pts >35 years who are smokers or ex smokers with symptoms such as exertional breathlessness, chronic cough or regular sputum production |
|
|
Term
|
Definition
post bronchodilator spirometry: FEV1/FEV <70%
CXR: bullae, hyperinflation, flat diaphragm
FBC: exclude secondary polycythaemia
BMI |
|
|
Term
| 4 ix to do in suspected COPD? |
|
Definition
|
|
Term
| what is used to measure the severity of COPD? |
|
Definition
FEV1
>80% predicted = stage 1
50-79% stage 2
30-49 stage 3
< 30% stage 4 |
|
|
Term
|
Definition
smoking cessation
annual influenza
one off pneumococcal
inhalers |
|
|
Term
| what should happen to the dose of theophylline if macrolide or fluoroqunine Abx are prescribed? |
|
Definition
|
|
Term
| most common bacterial organisms causing COPD exacerbations? |
|
Definition
haemophilus influenza
strep pneumonia
Moraxella catarrhalis |
|
|
Term
| if COPD are on O2 therapy how long should they be on O2 for a day? |
|
Definition
|
|
Term
|
Definition
|
|
Term
criteria for long term O2 therapy is
PO2 < 7.3 kPA or pO2 between 7.3 - 8 and which of the following? |
|
Definition
7.3 and 8 pO2 and:-
secondary polycythaemia
nocturnal hypoxemia
peripheral oedema
pulmonary HTN |
|
|
Term
features of idiopathic pulmonary fibrosis
it is 2 x more common in men |
|
Definition
progressive exertional dyspnoea
bibasal crackles
dry cough
clubbing |
|
|
Term
| what pattern on spirometry is seen in idiopathic pulmonary fibrosis? |
|
Definition
|
|
Term
| CXR features in pulmonary fibrosis? |
|
Definition
| ground glass opacities progressing to honey combing |
|
|
Term
| if in an exam question there is an XRAY showing ground glass opacities or honey combing what diagnosis should you be thinking? |
|
Definition
|
|
Term
| what is gold standard to diagnose idiopathic pulmonary fibrosis? |
|
Definition
|
|
Term
| mx of pulmonary fibrosis? |
|
Definition
pulmonary rehab
supplementary O2
lung transplant
pirfenidone is an antifibrotic agent and may be useful in selected pts |
|
|
Term
| which area of the lung would you see reticular opacities and honecombing particularly at the base? |
|
Definition
pulmonary fibrosis
diseases affecting base of lungs are common
pulmonary fibrosis
asbestosis
drug: MTX, bleomycin, amiodarone
most connective tissue disease apart from ankylosing spondylitis |
|
|
Term
| drugs that can cause lung fibrosis |
|
Definition
MTX
amiodarone
bleomycin
nitrofurantoin
ergot derived DA agonists: bromocriptine, carbegoline |
|
|
Term
| diseases that would show an obstructive pattern on spirometry? |
|
Definition
Asthma
COPD
bronchiectasis
bronchiolitis obliterans |
|
|
Term
| diseases that would show a restrictive pattern on spirometry? |
|
Definition
pulmonary fibrosis
asbestos
sarcoid
neuromuscular disorders |
|
|
Term
what test describes the rate of which a gas will diffuse from alveoli into blood?
what gas is typically used for this test? |
|
Definition
this is the transfer factor test
the gas used is carbon monoxide. |
|
|
Term
| reasons that can result in erranous readings in pulse oximetry |
|
Definition
poor perfusion
motion
xs light
skin pigmentation
nail varnish
CO poisoning |
|
|
Term
| features of pulmonary oedema on CXR |
|
Definition
interstitial oedema
bats wings
upper lobe diversion
kerley B lines |
|
|
Term
| expansion of lung interstial space by fluid is seen on CXR as what lines? |
|
Definition
|
|
Term
| cannon ball mets are mostly due to? |
|
Definition
| renal cell carcinoma mets |
|
|
Term
| smoke ring sign suggests? |
|
Definition
| cavitating lung carcinoma |
|
|
Term
| how might cavitating lung carcinoma show up in CXR? |
|
Definition
|
|
Term
| what might wedge shaped densities on CXR be a sign of? |
|
Definition
| secondary lung cancer mets. |
|
|
Term
| causes of bilateral hilar lymphadenopathy on CXR |
|
Definition
sarcoid
TB
metastatic disease
pneumoconioses |
|
|
Term
| causes of lower zone fibrotic shadowing on CXR? |
|
Definition
idiopathic pulmonary fibrosis
asbestosis |
|
|
Term
| causes of upper zone fibrotic shadowing on CXR? |
|
Definition
TB
ank spond
radiotherapy
sarcoid
extrinsic allergic alveolitis |
|
|
Term
| interventions that improve prognosis in COPD? |
|
Definition
smoking cessation
long term O2 therapy 15 hours a day |
|
|
Term
|
Definition
Amoxicillin
if allergic: doxy or clarithromycin
if staphloccoci suspected then add flucox |
|
|
Term
| pneumonia due to atypical pathogens. Abx of choice? |
|
Definition
|
|
Term
HAP within 5 days of admin
HAP > 5 days of admin |
|
Definition
within 5 days of admin give co-amoxiclav or cefuroxime
> 5 days after admin and HAP then give
pipercillin with tazobactam OR
cephalosporin OR
quinolone |
|
|
Term
| exacerbations of chronic bronchitis |
|
Definition
| amoxicillin or tetracycline or clarithromycin |
|
|
Term
| rx for tumour lysis syndrome? |
|
Definition
IV allopurinol or
IV rasburicase (recombinant urate oxidase)
given immediately prior to and during 1st days of chemotherapy |
|
|
Term
| in any pt presenting with AKI with high phosphate and high uric acid what should you think? |
|
Definition
|
|
Term
| metabolic derangements due to tumour lysis syndrome? |
|
Definition
high k
high phosphate
high uric acid
low calcium |
|
|
Term
| what is the Cairo-Bishop score used for ? |
|
Definition
| grading tumour lysis syndrome |
|
|
Term
| define neutropenic sepsis |
|
Definition
neutrophils <0.5 with one of the following:-
temp >38
other sign consistent with clinically significant sepsis. |
|
|
Term
| prophylaxis for neutropenic sepsis? |
|
Definition
| if anticipated that they may get it as a consequence of their rx they should be given a fluroquinolone |
|
|
Term
| mx for neutropenic sepsis |
|
Definition
start empirical Abx pipercillin and tazobactam
still febrile after 48hours?
alternative such as meropenam +/- vancomycin
if still not responding after 4-6 days order high res CT to look for fungal infection
there may be a role for G-CSF in selected pts |
|
|
Term
causes of avascular necrosis
ix of choice is MRI |
|
Definition
LT steroid use
chemotherapy
alcohol xs
trauma |
|
|
Term
| premature ovarian failure can be due to chemotherapy, AI, radiotherapy but most cases are idiopathic. when is the onset of menopause in this condition? |
|
Definition
before age 40
raised FSH,LH levels |
|
|
Term
in non small cell lung cancers that are peripheral with no mets what is rx of choice?
what if the pts respiratory reserve is poor? |
|
Definition
excision
if resp reserve is poor then curative radiotherapy is an alternative
for more advance disease chemo and radiotherapy |
|
|
Term
|
Definition
| SVC stent + radiotherapy + dexamethasone |
|
|
Term
| which primary acid-base disturbance would you see in COPD? |
|
Definition
|
|
Term
| which primary acid-base disturbance would you see in anxiety and panic attacks? |
|
Definition
|
|
Term
| vomiting and burns would cause which primary acid-base disturbance? |
|
Definition
|
|
Term
| causes of respiratory acidosis |
|
Definition
COPD
opiated OD
obesity hypoventilation syndrome
neuromuscular disease
decompensated asthma
BDZ OD |
|
|
Term
| causes of respiratory alkalosis |
|
Definition
PE
anxiety
pregnancy
altitude
CNS disorders e.g stroke, SAH |
|
|
Term
| which pneumonia is associated with high fever, herpes labialis and rapid onset? |
|
Definition
|
|
Term
| this pneumonia is particularly common in those with COPD |
|
Definition
|
|
Term
atypical pneumonia presenting with dry cough, atypical chest signs/xray
erythema multiforme
autoimmune haemolytic anaemia may be seen |
|
Definition
|
|
Term
| this atypical pneumonia can present with hyponatremia and lymphopenia with deranged LFTs |
|
Definition
|
|
Term
| this pneumonia is classically seen in alcoholics |
|
Definition
|
|
Term
this pneumonia presents commonly in HIV pts
dry cough
absence of chest signs
exercise induced desaturations |
|
Definition
|
|
Term
|
Definition
formation of non caseating granulomas
restrictive spirometry
reduced transfer factor |
|
|
Term
pts with chronic COPD typically have compensated respiratory acidos.
explain the physiology |
|
Definition
there is increased renal reabsorbtion of bicarbonate from the renal tubules into the blood.
this means plasma bicarbonate levels will be raised and urine would be expected to be acidic |
|
|
Term
|
Definition
CF
bronchial carcinoma
perussis
Kartegners syndrome
hypogammaglobulinaemia IgA deficiency
TB
GORD |
|
|
Term
|
Definition
can be asymptomatic
tachycardia, hypoxia, hypotension
CXR can be normal or show a wedge shaped infarction |
|
|
Term
| risk factors for developing PE |
|
Definition
pregnancy
previous PE
immobility
lower limb/hip surgery
malignancy
drugs COCP
FHx
thrombotic conditions |
|
|
Term
| which criteria is used to distuinguish a pleural exudate from a transdudate? |
|
Definition
Lights criteria
pleural to serum protein ratio >0.5
plural to serum LDH >0.6
pleural LDH should be > 2/3 the upper limit of normal
meeting anyone of these criteria indicates exudative effusion. remember to calculate the ratios in the question |
|
|
Term
| list characteristic signs of plueral effusion |
|
Definition
there is reduced expansion on the side of effusion
the trachea is deviated away from the effusion
stony dull percussion
reduced or absent breath sounds |
|
|
Term
|
Definition
Cough
cavitation
calcification
caseation |
|
|
Term
| causes of breathlessness in adults |
|
Definition
acute exacerbation of COPD
CCF
anaphylaxis
PE
panick attack
pneumothorax
asthma exacerbation |
|
|
Term
| signs of life threathening Asthma |
|
Definition
silent chest
cyanosis
hypotension reduced consciousness
PEFR <33% predicted |
|
|
Term
| a complication of central venous cathter insertion that may result in SOB? |
|
Definition
|
|
Term
| radiological signs of pulmonary oedema? |
|
Definition
increased perihilar shadowing: bats wings
upper lobe venous diversion
fluid in horizontal fissure
Kerley B lines |
|
|
Term
| afro carribean women with restrictive pattern on spirometry and raised ACE. what are you thinking? |
|
Definition
|
|
Term
| main cause of respiratory alkalosis is a panic attack. name some other rare causes |
|
Definition
brain stem stroke
SAH
fever
hyperthyroid
meningitis |
|
|
Term
| sarcoidosis and fibrosing alveolitis both cause fibrosis of the upper lobes. how can they be distinguished by hand signs? |
|
Definition
sarcoid rarely causes clubbing
unlike fibrosis alveolitis |
|
|
Term
| how is sarcoid diagnosed? |
|
Definition
| by demonstrating non caseating granulomata in bronchial or lymph node biopsy |
|
|
Term
| if someone has obstructive spirometry with evidence of reversibility after bronchodilator what would you be thinking? |
|
Definition
asthma
because it is reversible |
|
|
Term
| features of farmers lung (extrinsicallergic alveolitis) |
|
Definition
restrictive spirometry
reduced TLCO and KCO
in broncheoalveolar lavage: lymphocytes and mast cells
there may be precipitins to micropolyspora faeni |
|
|
Term
| transfer factor (TLCO) measures CO uptake and is affected by loss of functioning alveoli. in a full pneumonectomy what would happen to this result? |
|
Definition
|
|
Term
| in pulmonary haemorrhage which result would be falsely raised? |
|
Definition
| KCO - this is calculatd to correct for lung volume and in pulmonary haemorrhage appears artificially good due to increased binding of CO to the Hb within alveolar sacs |
|
|
Term
| monitoring of pts with GBS |
|
Definition
serial 4-6 spirometry to check any significant reduction in FEV1
this can indicate a need for assisted ventilation |
|
|
Term
|
Definition
needle aspiration if this fails
chest drain |
|
|
Term
| mx of tension pneumothorax |
|
Definition
| immediate needle decompression followed by placement of chest drain |
|
|
Term
| mx ladder of pneumothorax |
|
Definition
observe
needle aspiration
chest drain insertion
pleurodesis/pluerectomy |
|
|
Term
| in a cxr a double left heart border is consistent with what? |
|
Definition
|
|
Term
features of chronic eosinophilic pneumonia?
the rx for this is steroids |
|
Definition
restrictive spirometry
peripheral lung infiltrates on CXR
raised eosinophils
lung biopsy can give definitive diagnosis showing eosinophilic accumulations |
|
|
Term
64 year old man presents with gradual SOB
CXR shows right pleural effusion
what is the next appropriate ix? |
|
Definition
pleural aspirate to check if effusion is exudate or transudate
if exudate: CT or thorascopy to look for malignancy or TB
if transdudate: echo looking for HF or liver imaging for cirrhosis. |
|
|
Term
| tobacco workers are exposed to which antigen that can cause progressive pulmonary fibrosis? |
|
Definition
|
|
Term
| Chlamydia psitacci can be caught from parrots. what is the ABx of choice? |
|
Definition
tetracycline eg
doxycycline 100mg BD for 21 days |
|
|
Term
| risk factors of flash pulmonary oedema |
|
Definition
multiple cardiac risk factors including advanced age, HTN and high lipids
there may be new systolic murmur loudest at apex: mitral regurge
this can be due to rupture of papillary muscle |
|
|
Term
| mesothelioma has a lag period which can be up to? |
|
Definition
|
|
Term
|
Definition
unilateral
present with malignant pleural effusion of exudate
diagnosis: CT
5 year survival <5% |
|
|
Term
|
Definition
oxygen
bronchodilators: can be repeated at 15 min intervals. nebs ipratropium may also be helpful
steroids given ASAP IV 200ml hydrocortisone or PO 40mg pred
those with severe asthma or poorly responding to nebulised bronchodilators may be given Magnesium sulphate IV |
|
|
Term
| causes of bilateral hilar enlargement? |
|
Definition
Sarcoid
TB
lymphoma
lymph node mets |
|
|
Term
| common respiratory complication in a post bone marrow transplant pt |
|
Definition
bronchiolitis obliterans. occurs in first 100 days.
usually irreversible |
|
|
Term
| which cancer of the lung most commonly causes cavitations? |
|
Definition
squamous cell carcinoma
they also produce PTHr causing hypercalceamia |
|
|
Term
| reasons why a CXR must be done in an asthmatic that presents with worsening SOB and whheze |
|
Definition
| to exclude pneumothorax and consolidation/lobar collapse |
|
|
Term
| list the criteria used to asses the severity of asthma? |
|
Definition
Speech
Pulse
RR
pulsus paradoxus
PERF
Ox sats/ABG
cyanosis |
|
|
Term
| mx of acute asthma exacerbations |
|
Definition
sit pt up
o2 60-100% via mask
nebulised sal and ipratropium
IV access
oral/IV steroids
oral/IV amoxicillin +/- erythromycin |
|
|
Term
| signs of mild/moderate asthma |
|
Definition
pulse: normal/tachy
BP: pulsus paradoxicus
RR: >25/min
Speech: normal stilted sentences
ABGs: normal to 8kPA
CO2: normal or low
PERF: >50%
cyanosis: not present |
|
|
Term
PR?
Bull Shit!
APC gene
have i gone cray? not really this is a mneumonic to remember the criteria to assess asthma severity what is it? |
|
Definition
pulse
RR
BP
speech
ABG
PERF
cyanosis |
|
|
Term
| criteria for sever asthma |
|
Definition
pulse: bradycardia
RR: < 10
BP: maybe hypotensive
Speech: cant talk
ABG: <7.6-8
PEFR: < 30% normal
Cyanosis:late/sinister sign |
|
|
Term
| in pts with severe signs of asthma how should management proceed? |
|
Definition
| they should be considered for elective assisted ventilation |
|
|
Term
loud P2 is a sign of?
Pulmonary HTN or
PE? |
|
Definition
|
|
Term
| if PE is suspected, providing there are no CI when should heparin be given? before or after the CTPA scan? |
|
Definition
before the scan
rx also involves giving analgesia and o2. |
|
|
Term
| a stonemason presents with progressive SOB and clubbing. what has his occupation probably exposed him to? |
|
Definition
Silica causing silicosis
dx: High Res CT |
|
|
Term
CF fibrosis gene
long or short arm of chromosome 7? |
|
Definition
|
|
Term
| on CT a ground glass opacity surrounded by denser lung tissue is known as which sign? |
|
Definition
Atoll sign - Maldives sign lol
suggestive of cryptogenic organising pneumonia |
|
|
Term
| which sign on CT suggests invasive aspergillosis? |
|
Definition
|
|
Term
| in which condition is signet sign found in? |
|
Definition
|
|
Term
| features of allergic pulmonary aspergiloosis |
|
Definition
high serum IgE
peripheral eosinophilia
positive skin test for aspergillosis protein
recurrent pulmonary infiltrates on CXR
CT: central cystic bronchiectasis in multiple lobes |
|
|
Term
| triad of yellow nail syndrome |
|
Definition
deformed nails
lymphedema
exudative pleural effusion or other respiratory involvement
2 of 3 features needed for diagnosis
associated with protein losing enteropathy |
|
|
Term
diagnosis of pulmonary TB is by sputum microscopy that can take up to 6 weeks
how can you diagnose renal or military TB? |
|
Definition
early morning urine testing
primary TB causes ghon focus in lings. reactivation of this causes secondary TB |
|
|
Term
| features of pulmonary histiocytosis |
|
Definition
AKA eosinophilic granuloma
pneumothorax
respiratory distress
diabetes insipidus
progressive fever
bone cysts that can cause pathological fractures |
|
|
Term
| what type of hypersensitive reaction does TB cause? |
|
Definition
|
|
Term
| which bacteria causes pneumonia in elderly after influenza and can cause cavitating lesions in the upper lobes of the lungs? |
|
Definition
|
|
Term
| causes of transdudate pleural effusions |
|
Definition
protein <30g
HF
liver cirrhosis
nephrotic
Meigs |
|
|
Term
| RA causes exudate plural effusion and which other common finding ? |
|
Definition
|
|
Term
| which organism is associated with an air crescent sign? |
|
Definition
invasive aspergillosis
it is a sign of recovery from the infection |
|
|
Term
| types of non small cell lung ca? |
|
Definition
squamous 35%
adeno 20%
large cell 20% |
|
|
Term
| type II respiratory failure with raise bicarbonate is likely to be due to? |
|
Definition
| COPD. chronic condition results in metabolic compensation thus the bicarb is high and urinary PH is low because the renal tubules reabsorb more bicarb |
|
|
Term
| features of pleural plaques |
|
Definition
can be asymptomatic
are not premalignant
you cannot get compensation for them
no specific treatment is required |
|
|
Term
a women with RA has been started on TNF antibody rx.
she presents with chornic cough, weightloss and haemoptysis
CXR shows calcified hilar lymph nodes and left upper lobe fibrosis.
is this due to her RA?
is it due to something else?
what is your explanation? |
|
Definition
RA fibrosis occurs in lower lobes.
it is well known that use of TNA antibody meds can cause reactivation of TB
TB affects upper lobes. the CXR suggests fibrosis in upper lobes and not lower lobes so therefore it would TB reactivation and not her RA |
|
|
Term
| features of bronchiectasis on examination |
|
Definition
clubbing
cyanosis
florid crepitations at both bases which change with coughing
copious amounts of sputum
recurrent chest infections |
|
|
Term
| causes of unilateral pleural effusions |
|
Definition
infection: pancreatitis,
PE
trauma
lobar pneumonia
bronchial cancer
TB
Malignancy mets
RA
SLE
Dresslers syndrome |
|
|
Term
| what tests should be done on a diagnostic aspirate of plural effusion? |
|
Definition
macroscopic inspection
cytology
protein
LDH
pH
gramstain |
|
|
Term
| if a firm diagnosis is not reached after doing testing on aspirate of pleural effusion what other tests can be done if we suspect mesothelioma? |
|
Definition
CT with contrast
video assisted thorascopic surgery
CT or USS guided needle biopsy |
|
|
Term
| sings of tension pneumothorax |
|
Definition
tachypnoea
tachycardia
hypotension
elevated JVP
deviation of trachea away from the side of the pneumothorax
sweating and cyanosis |
|
|
Term
| mx of tension pneumothorax |
|
Definition
high flow O2
needle decompression into 2nd intercostal space
chest drain into plural space: 4th/5th ICS midaxillary line and connect to underwater seal
once tension relieved and drain is bubbling remove cannula from 2nd ICS and arrange CXR
admit to hospital
remove chest drain when it stops bubbling
repeat chest xray |
|
|
Term
| when can uncomplicated pneumothorax be treated conservatively? |
|
Definition
if rim of air is <2cm on CXR and minimal or no breathlessness
mx: inhale high concentration o2 |
|
|
Term
| features of extrinsic allergic alveolitis AKA farmers lung |
|
Definition
| caused by Saccharopolyspora rectivirgula: used to be called micropolyspora faenia |
|
|
Term
| how would you describe the granulomas in farmers lungs and sarcoid? |
|
Definition
non caseating
farmers lung aka extrinsic allergic alveolitis: respiratory distress, fever and basal crackles with spontaneous recovery within 12-24hours |
|
|
Term
| disorders associated with CF |
|
Definition
bronchiectasis
diabetes mellitus
steatorrhoea and malabsorbtion |
|
|
Term
|
Definition
nutritional support
diabetic education
physio of chest
rapid rx of infective exacerbations
sputum viscocity reduction
genetic counselling of parents
consider for heart lung transplant |
|
|
Term
asthma is a type 1 hypersensitivity reaction
MOA of ipratropium?
montelukast?
what class of drug is theophylline? |
|
Definition
muscarinic antagonist ipratropium
montelukast: leukotriene receptor antagonist
theophylline: xanthine |
|
|
Term
features of obstructive sleep apnoea
rx of this condition? |
|
Definition
affects 1% of males
associated with obesity
oronasal factors are important and may be correctable
rx: nasal CPAP and weight loss. |
|
|
Term
| reasons for treating obstructive sleep apnoea include? |
|
Definition
to relieve day time sleepiness
there is evidence that untreated pts have a increased cardiovascular mortality |
|
|
Term
|
Definition
recent major surgery
FHx of coagulopathy or thromboembolic disease
recent fracture pelvic or lower limb
malignancy
coagulopathy
pregnancy
smoking
immobility |
|
|
Term
features of obstructive sleep apnoea
rx of this condition? |
|
Definition
affects 1% of males
associated with obesity
oronasal factors are important and may be correctable
rx: nasal CPAP and weight loss. |
|
|
Term
| reasons for treating obstructive sleep apnoea include? |
|
Definition
to relieve day time sleepiness
there is evidence that untreated pts have a increased cardiovascular mortality |
|
|
Term
|
Definition
recent major surgery
FHx of coagulopathy or thromboembolic disease
recent fracture pelvic or lower limb
malignancy
coagulopathy
pregnancy
smoking
immobility |
|
|
Term
|
Definition
FBC, clotting screen
ABGs
CXR
ECG
CTPA or VQ scan |
|
|
Term
|
Definition
sit pt upright
O2
IV access and analgesia
SC LMWH 1.5mg/kg/OD
confirm diagnosis: provoked 3month warfarin, if unprovoked 6 months warfarin,
INR 2-3 |
|
|
Term
| in clotting screen for someone presenting with PE what should it include? |
|
Definition
protein C
protein s
anti thrombin III
anticardiolipin antibody
Factor V leiden mutation |
|
|
Term
| type of respiratory failure in PE? |
|
Definition
|
|
Term
| features of lambert eaton syndrome |
|
Definition
muscle weakness
depressed reflexes
autonomic dysfuction e.g postural hypotension
in myasthenia gravis the reflexes are normal |
|
|
Term
| pericarditis causes positional pain made worse when lying? |
|
Definition
|
|
Term
medications used in COPD
beta 2 agonist: salbutamol
anticholinergics: tiotropium and ipratropium
steroids: inh, oral iv
theophylline: aminophylline
these are meds used in COPD but do not have an effect on prognosis. which 2 things can affect prognosis of COPD? |
|
Definition
smoking cessation
Long term O2 therapy for 15 hours a day |
|
|
Term
| how can pts qualify for home o2 therapy? |
|
Definition
2 sets of ABGs and spirometry with the patient stable.
o2 <7.3 or
o2 >8 with one or more of the following
2ndary polycythaemia
nocturnal hypoxemia
peripheral oedema
pulmonoary HTN |
|
|
Term
| if a women who ha shad PE was treated with full dose heparin and now discharged on warfarin develops DVT what is the underlying cause due to? |
|
Definition
Heparin induced thrombocytopenia.
this can happen as a SE of full dose heparin and also when warfarin is started it initially reduces hepatic synthesis of protein C
mx: stop warfarin and give direct thrombin inhibitors like ARGATROBAN |
|
|
Term
| chronic exposure to which type of asbestos causes asbestosis?? |
|
Definition
|
|
Term
| cavitating lung tumours are most likely to be? |
|
Definition
|
|
Term
|
Definition
phosphodiesterase inhibitors
potentiate the effect of cyclic AMP
this results in airway dilatation |
|
|
Term
| conditionas associated wit idiopathic pulmonary fibrosis? |
|
Definition
RA
SLE
IBD
Primary Biliary Cirrhosis |
|
|
Term
| investigations and findings to confirm idiopathic lung fibrosis? |
|
Definition
CXR - lower zone
ABG - type I
Lung fx: restrictive with reduced transfer coefficient
high res CT: confirms distribution of fibrosis |
|
|
Term
|
Definition
|
|
Term
| painful ankles and clubbing in lung cancer is due to? |
|
Definition
| hypertrophic pulmonary osteoarthropathy which is associated with clubbing |
|
|
Term
| hypokalemia in lung cancer is due to? |
|
Definition
ACTH secretion
hyponatramia due to ADH secretion |
|
|
Term
features of normal CXR
T/F
the left diaphragm and left hilum are both lower than the right? |
|
Definition
FALSE
left hemidiaphragm lower than right because the right is pushed up by liver
BUT
left hilum higher than right hilum |
|
|
Term
| median survival for mesothelioma? |
|
Definition
|
|
Term
| when can xray detect pleural effusion? |
|
Definition
if > 200ml is present
USS can detect small one 3-5 ml |
|
|
Term
| causes of atypical pneumonia |
|
Definition
mycoplasma
legionella
chlmaydia psittaci
coxiella burnetti |
|
|
Term
| abnormalities in atypical pneumonias |
|
Definition
FBC: haemolytic anemia, thrombocytopenia
Uand E: hyponatremia
LFT: transient hepatitis
ABG: type I resp failure
antibody titres rising |
|
|
Term
| what skin manifestation may atypical pneumonia due to Clamydia psitacci cause? |
|
Definition
|
|
Term
|
Definition
confusion
urea >7
RR >30
BP SBP<90 DBP<60
Age >65
3 or more = severe |
|
|
Term
| egg shell calcification of nodes is strongly suggestive of? |
|
Definition
|
|
Term
| diagnosis of histiocytosis on CXR would show? |
|
Definition
scattered nodules of Langerhans cells
associated eosinphils, macrophages and giant cells
Langerhans cells contain racket shaped Birbeck granules |
|
|
Term
| a question says racket shaped birbeck granules in Langerhans cells. what diagnosis are you thinking? |
|
Definition
|
|
Term
| Vitamin d deficiency findings in someone on anti TB drugs? |
|
Definition
Low Calcium
Low phosphorus
Raised Alk Phos
both rifampicin and isoniazid can cause vit D deficiency |
|
|
Term
centriacinar emphysema seen in COPD
panacinar emphysema seen in? |
|
Definition
| alpha 1 anti trypsin deficiency |
|
|
Term
| features of plastic bronchitis |
|
Definition
coughing out tubular gelatinous materials
found in asthma, bronchiectasis, CF
AKA Hoffmans bronchitis
rx: bronchial washing, prevention of infection
bronchoscopy to exclude malignancy and remove casts manually |
|
|
Term
peak flow <50% is severe asthma
what is life threatening? |
|
Definition
|
|
Term
| T/F histoplasmosis and Allergic bronchopulmonary aspergillosis are both associated with bronchiectasis? |
|
Definition
True
as well as TB, measles, pertussis |
|
|
Term
| hypercalceamia is associated with type of lung cancer? |
|
Definition
|
|
Term
| what is the name of the chemical pneumonia cause by aspiration of gastric contents during general aneasthesis? |
|
Definition
|
|
Term
| when you insert a needle into the lung for aspiration or drainage in order to avoid the neurovascular bundle should you insert the needle above or below the rib? |
|
Definition
Insert above the rib
this is because the neurovascular bundle lies just below. |
|
|
Term
| when you insert a needle into the lung for aspiration or drainage in order to avoid the neurovascular bundle should you insert the needle above or below the rib? |
|
Definition
Insert above the rib
this is because the neurovascular bundle lies just below. |
|
|
Term
| when to repeat someone for cxr under 2 week rule for hoarseness? |
|
Definition
| age 45 or more with unexplained and persistent hoarseness for CXR to ENT |
|
|
Term
| why do we do a CXR in hoarseness? |
|
Definition
| to exclude apical lung tumour |
|
|
Term
|
Definition
lung ca
overuse
laryngeal cancer
GORD
smoking
viral illness
hypothyroid |
|
|
Term
|
Definition
| obstruction of windpipe or larynx |
|
|
Term
| compression stockings are used to prevent VTE which condition are they CI in? |
|
Definition
|
|
Term
| strategies to prevent VTE in hospitalised pts |
|
Definition
mechanical VTE: compression stockings, intermittent pneumatic compression, foot impulses devices
therapeutic agents: LMWH, unfractionated heparin and Digabatrin in hip and knee prophylaxis surgery |
|
|
Term
| digabatrin is used as VTE prophylaxis in which types of surgery? what is its MOA? |
|
Definition
used in hip and knee surgery
MOA: direct thrombin inhibitor |
|
|
Term
ix in pregnant women with ?PE
D-dimer is unreliable because it can be raised with pregnancy. |
|
Definition
start LMWH
CXR - if normal do
Compression Duplex Doppler
if both are negative women needs to have V/Q scan or CTPA
if these are all normal but suspicion remains high, keep her on LMWH and repeat tests in 1 week |
|
|
Term
| dilemas of V/Q and CTPA scanning in pregnancy |
|
Definition
| V/Q scan has increased risk of childhood cancer than CTPA but reduced risk of maternal breast cancer. |
|
|
Term
| if it is bright red or pink with alkaline pH what is it most likely to be? |
|
Definition
haemoptysis
haematemesis: brown to black with acidic PH |
|
|
Term
| gingival thickening, saddle nose, nasal perf and haemoptysis. what are you thinking? |
|
Definition
| Wegeners AKA granulomatosis with Polyangitis |
|
|
Term
| fine inspiratory rales may be associated with haemoptysis. what does this sign suggest |
|
Definition
| it is associated with alveolar blood. |
|
|
Term
| how to nurse a palliative patient with haemoptysis |
|
Definition
lie them on the side of their tumour
cover blood with red or green towels
give parental opioid and fast acting BDZ |
|
|
Term
|
Definition
ABC
tranexamic acid
balloon tamponade |
|
|
Term
|
Definition
| 10 second pause in breathing activity |
|
|
Term
| how is day time sleepiness assessed in obstructive sleep apnoea? |
|
Definition
using the Epworth Sleepiness Scale
if score is >10 then ix is recommended. |
|
|
Term
| difference between apnoea and hypoapnoea? |
|
Definition
apnoea: respiration ceased for 10 seconds
hypoapnoea: 10 secons where ventilation is reduced by at least 50% |
|
|
Term
| gold standard investigation to diagnose obstructive sleep apnoea? |
|
Definition
Polysomnography (PSG)
it gives an apnoea/hypoxia index score AHI |
|
|
Term
| mx of obstructive sleep apnoea |
|
Definition
conservative: weight loss, stop smoking, avoid alcohol and sedative drugs in evening
medical: CPAP for a minimum of 4 hours per night
surgery: uvuloparatopharyngoplasty
tonsillectomy |
|
|
Term
| other methods to manage obstructive sleep apnoea |
|
Definition
tennis ball technique to the back or supine alarms
mandible splints that keep it in a forward position |
|
|
Term
| obstructive sleep apnoea complications |
|
Definition
independent risk factor for stroke
can cause driving accidents
HTN CHD CCF |
|
|
Term
| driving and obstructive sleep apnoea |
|
Definition
if they have day time sleepiness they need to cease driving until symptoms are under control
for group 2 license holder stop driving until symptoms under control and assessed by a consultant or specialist
you don't have to stop driving or inform the DVLA if you are being investigated for the condition or have the condition but not day time sleepiness
pts should tell DVLA but not stop driving if they are using CPAP or mandible splint. so long as they are compliant it shouldn't affect their license |
|
|
Term
| classification of obstructive sleep apnoea |
|
Definition
mild 5-14 episodes per hour
moderate 15-30 episodes per hour
severe >30 episodes per hour |
|
|
Term
CURB 65
score of 0 = mx in community |
|
Definition
confusion <8/10 on amst
urea >7
rr >30
BP <90SBP or DBP<60
age 65 or > 1 |
|
|
Term
CURB score of 1
WHAT TO DO ? |
|
Definition
measure o2 sats. if >92% then can mx in community but do a CXR
if CXR shows bilateral multilobar shadowing then admit to hospital |
|
|
Term
| pts with a CURB score of 2 or more? |
|
Definition
| manage in hospital as it suggests a severe CAP |
|
|
Term
| if pneumonia due to staph aureus what ABX should you add to amoxicillin? |
|
Definition
|
|
Term
| what are the CI to lung cancer surgery? |
|
Definition
SVC obstruction
FEV < 1.5
malignant plueral effusion
vocal cord paralysis |
|
|
Term
| spirometry pattern in restrictive lung diseases |
|
Definition
FEV1 is reduced
FVC is significantly reduced
FEV1/FVC is normal or increased |
|
|
Term
| spirometry pattern in obstructive lung diseases |
|
Definition
FEV1 signifincantly reduced
FVC reduced or normal
FEV1/FVC reduced |
|
|
Term
| indications where chest drain should be put in |
|
Definition
PH <7.2
purulent effusion
gram staining that indicates an infection is present |
|
|
Term
| adenocarcinomas may not be detected on bronchoscopy why is that? |
|
Definition
they are peripheral lesions.
they are the commonest in non smokers |
|
|
Term
| tram track opacities are seen in which resp condition? |
|
Definition
|
|
Term
| vaccinations that someone with COPD should receive include? |
|
Definition
| annual influenza and one off pneumococcal |
|
|
Term
| SIGN guidelines on how to escalate care in asthma exacebation |
|
Definition
o2
salbutamol nebs
ipratropium bromide nebs
hydrocortisone IV or PO pred
Mg sulphate IV
aminophylline or IV salbutamol |
|
|
Term
| 71 year old man 2 month hx of cough and weightloss has a CXR and a mass suggestive of cancer is noted. what is the next ix? |
|
Definition
|
|
Term
| NICE suggest we do not prescribe ABx immediately but can do under which circumstances? |
|
Definition
child <2 with bilateral otitis media
child with ottorhea and acute otitis media
pts with sore throat and 3 or more on centor criteria |
|
|
Term
| symptom control in non-CF bronchiectasis? |
|
Definition
| inspiratory muscle training and postural drainage |
|
|
Term
pleural plaques are premalignant?
T/F |
|
Definition
False.
they are benign and do not undergo malignant change |
|
|
Term
| NICE recommendations for COPD exacerbations? |
|
Definition
increase frequency of bronchodilator use and consider giving it nebs
pred 30mg for 7-14 days
abx only if sputum is purulent or clinical signs of pneumonia |
|
|
Term
| in acute asthma exacerbations how long should you give oral pred for and what dose? |
|
Definition
|
|
Term
| paraneoplastic features of small cell and squamous lung ca? |
|
Definition
small cell: ACTH:cushings and ADH: hyponatreamia
squamous: PTHrP : hypercalceamia |
|
|
Term
| Abx of choice for HAP within 5 days of administration? |
|
Definition
Co-amoxiclav or cerufoxime
after 5 days
pipercillin with tazobactam
or
broad spec cephlasporin
or
quinolone |
|
|
Term
|
Definition
| broad spec cephalosporin or quinolone |
|
|
Term
how to remember obstructive lung conditions?
A BBC |
|
Definition
Asthma
Bronchiectasis
Bronchiolitis obliteran
COPD
the rest are restrictive |
|
|
Term
|
Definition
|
|
Term
| when to use CPAP and when to use BIPAP? |
|
Definition
BIPAP used in COPD
CPAP not as good at BIPAP in COPD
CPAP used in type I respiratory failure and pulmonary oedema |
|
|
Term
| why does mycoplasma pneumonia not respond to penicillins or cephalosporins? |
|
Definition
it lacks a peptidoglycan cell wall
mx: erythromycin, clarithromycin
tetracyclines are an alternative |
|
|
Term
| what needle to use for diagnostic aspiration |
|
Definition
|
|
Term
in someone with CKD stage 4 who comes in with ?PE which ix would you do and why?
V/Q or CTPA? |
|
Definition
V/Q because of their renal failure.
CTPA has contrast which wold be nephrotoxic in someone with already established CKD. |
|
|
Term
| a CXR shows cannon ball mets. what is the next line of ix? |
|
Definition
CT abdo
this is because mets are usually from renal cancer and this ix can confirm this |
|
|
Term
|
Definition
| high calorie high fat with pancreatic enzyme supplements with every meal |
|
|
Term
| what are the most frequently isolated organisms in bronchiectasis? |
|
Definition
| pneumococcas and h influenzae |
|
|
Term
| farmers lungs is an example of? |
|
Definition
extrinsic allergic alveolitis AKA hypersensitivity pneumonitis
causes: aspergillus, penicillum, birds |
|
|
Term
| what type of plueral effusion is seen in meigs syndrome? |
|
Definition
|
|
Term
| dry itchy red eyes in sarcoid? |
|
Definition
| keratoconjunctivitis sicca |
|
|
