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Clinical Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Signs/Symptoms of Lung Cancer

A

SOB

Hemoptysis

Finger Clubbing

Recurrent Pneumonia

Weight Loss

Lymphadenopathy (Supraclavicular)

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2
Q

Investigations for lung cancer

A

Chest XRAY (Hilar enlargement, Peripheral Opacity, Unilateral Pleural Effusion)

Staging CT (Contrast enhanced)

PET-CT (Areas of increased activity (Warburg’s Effect))

Bronchoscopt with endobronchial ultrasound (EBUS)

Biopsy/histological Analysis

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3
Q

Treatment for non-small cell lung cancer?

A

Lobectomy/Wedge Resection

Radiotherapy (Early DIagnosis)

Adjuvant Chemotherapy

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4
Q

Treatment of small cell lung cancer?

A

Chemotherapy/Radiotherapy

Prognosis is worse for small cell than non-small cell

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5
Q

Extrapulmonary manifestations of Lung Cancer?

A

Recurrent Laryngeal Nerve Palsy => hoarse voice

Phrenic Nerve Palsy => diagpram weakness/SOB

Superior Vena Cava Obstruction => Facial Swelling, difficulting breathing, distended neck veins. Elicited with Pemberton’s Sign in which riading the hands over the head causes facial congestion and cyanosis

Horner’s Syndrome: triad of ptosis, anhidrosis and miosis. Caused by a Pancoast tumor (pulmonary apex) pressing on sympathetic ganglion

Cushing’s Syndrome: ectpic ACTH secretions from Small Cell Lung Cancer

Hypercalcemia: ectopic PTH from Squamous Cell Carcinoma

Limbic Encephalitis: Small Cell Lung Cancer causes immune system to make antibodies targetting the limbic system => memory impairment, hallucinations, confusion/seizures (anti-HU antibodies)

Lambertg Eaton Myasthenic Syndrome: Small Cell Lung Cancer causes immune system to make antibodies targetting voltage gated calcium channels => proximal muscles weakness (better with use)

  • Proximal Muscle Weakness
  • Diplopia
  • Ptosis
  • dysphagia/slurred speach
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6
Q

Characteristics of Lambert-Eaton Syndrome and when to suspect it?

A

Lambertg Eaton Myasthenic Syndrome: Small Cell Lung Cancer causes immune system to make antibodies targetting voltage gated calcium channels => proximal muscles weakness (better with use)

  • Proximal Muscle Weakness
  • Diplopia
  • Ptosis
  • dysphagia/slurred speach

Suspect Small Cell Lung Cancer in older smokers with any of the above symptoms

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7
Q

Presentation/Chest Signs of Pneumonia

A

Presentation
* SOB
* COugh w/ Sputum
* Fever
* Hemoptysis
* Pleuritic chest pain (Sharp chest pain worse on inhalation)
* Delerium (Acute confusion associated with infection)
* Sepsis

Chest Signs
* Bronchial Breath Sounds (harse sounds heard equally on insp/exp. Cuased by consolidaiton in lungs)
* Focal Coarse Crackles
* Dullness to Percussion (Collapse/Consolidation)

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8
Q

Severeity Assessment of Pneunmonia?

A

CRB-65 Out of Hospital (>0 refer to hospital)

CURB-65 in Hospital :
* Confusion
* Urea >7
* Respiratory rate ≥ 30
* Blood pressure <90 systolic or ≥60 diastolic
* Age > 65

CURB-65 predicts mortality (1=5%, 3=15%, 4/5 >25%)
- 0/1: treat at home
- ≥2 hospital admission
- ≥3 ICU Assesment

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9
Q

Typical Common causes of Pneumonia

A

Streptococcous Pneumonia (50%)
Hemophilus Influenza (20%)
Pseudomona (Cystic FIbrosis/Bronchiectasis)
Staphylococcus Aureus (Cystic Fibrosis)

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10
Q

Atypical causes of Pneumonia?

A

Atypical organisms cannot be cultured nromally or detected using gram stain and dont respond to penicillins

  • Legionella
  • Mycoplasma (Milder, ass with rashcalled ertyhma multiforme characterised by target lesions and neurological symptoms in young pts)
  • Chlamydophilia Pneumonea
  • Coxiella Burnetii (Farmer)
  • Chlamydia psittaci (Parrots)
  • PCP (Immunocompromised, low CD4, presents as dry couh without sputum, SOB on exertion and NIGHT SWEATS) - treated with co-trimoxazole

Otehr than PCP trated with Macrolides, Fluroquinilones, Tetracyclines

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11
Q

Pneumonia Investigations?

A

Chest X Ray
FBC (Raised WBC)
U/E’s (Urea)
CRP
Sputum CUltures
Blood Cutlures
Legionella/Pneumococal Urinary Antigens

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12
Q

Treatment of Pneunomia?

A

Mild: 5 days of Amoxicillin OR Macrolide
Moderate/Severe: 7-10 days Amoxicillin AND Macoloide

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13
Q

What pathology causes a reduced FEV1?

A

Obstructive Lung Disease (FEV1:FVC ratio < 75%)
- Asthma
- COPD

Obstruction slowing passage of air getting ouit of the lungs

Test for reversibility by giving bronchodialator (salbutamol) asthma reversible, COPD not

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14
Q

What pathology causes equally reduced FEV1 and FVC?

A

Restrictive Lung Disease (FEV1 and FVC reduced & FEV1:FVC ratio > 75%)
* Interstitial lung disease (Pulmonary Fibrosis)
* Sarcoidosis
* Obesity
* Motor Neuron Disease
* Scoliosis

Lungs are resicted from expanding

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15
Q

Presentation of Asthma

Diagnosis?

A

Dinural variability (Worse at night)
Atopic conditions (Ecsema, hayfever, food allergies)
Bilateral widepread “polyphonic wheeze”

Diagnosis:
- Spriomettry with bronchoduialator reversibility
- Birect bronchial challenge with histamine or metacholine
- Peak Expiratory Flow Rate (PEFR): using a flow meter, 3 attempts and record best result. Recrod as percent of predicted (based off age, sex height)

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16
Q

Long Term Asthma Management

A

SABA (Salbutamol)
- Act on smooth muscles => relaxation
- Reliever/rescue medicaiton
- Monitor Serum Potassium, causes k+ to be absorbed into cells

Inhaled Corticosteroids (Beclomtasone)

  • Reduce inflaamtion/raectivity of airways
  • Maintencne/preventer medications

Leukotriene Receptor Antagonist (Montelukast)
- Leukotrienes produced by imun system =>inflamation, bronchoconstriction and mucus secretion)

LABA (Salmeterol)

  • Act on smooth muscles => relaxation
  • Longer action than SABA

LAMA (Tiotropium)
- Block acytylcholine receptors of ariway => bronchodialation

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17
Q

Grading Asthma?

A

Moderate (Peak Expiratory FLow Rate (PEFR) 50-75% predicted)

Severe
- PEFR 33-50% predicted
- Resp Rate >25
- Heart Rate >110
- Unable to complete sentences

Life Threatening
- PEFR <33%
- Sats <92%
- Tired/Confused
- NO WHEEZE (Silent Chest)
- Shock

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18
Q

Management of Moderate Acute Asthma?

A

Moderate (Peak Expiratory FLow Rate (PEFR) 50-75% predicted)
- Nebulized beta-2 agonist (Salbutamol 5mg repeated asoften as required)
- Nebulized Ipatropium Bromide (LAMA)
- Steroids (oral predisolone or IV hydrocortisone (5 Days)

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19
Q

Management of Severe Acute Asthma?

A

Severe
- PEFR 33-50% predicted
- Resp Rate >25
- Heart Rate >110
- Unable to complete sentences

Managed with:
- Oxygen if required to maintain sats 94-98%
- Aminophylline infusion
- IV Salbutamol (SABA)

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20
Q

Management of Life Threatening Acute Asthma?

A

Life Threatening
- PEFR <33%
- Sats <92%
- Tired/Confused
- NO WHEEZE (Silent Chest)
- Shock

Management
- IV magnesium Sulphate Infusion
- Admission to ICU
- Intubation (Worst case)

21
Q

ABG’s in Asthma?

A

Respiratory Alkylosis (Initial Tachynea => drop in CO2)

Normal PCO2 or Hypoxia VERY concerning, means pt is tiring => life threatening

Respiratory Acidosis due to HIGH CO2 is very bad sign

22
Q

Investigations/Staging of COPD?

A

Spirometry (Obstructive Picture):
- FVC: Total lung capacity
- FEV2: forved air expiration in 1 second
- FEV1/FVC < .7
- Staging with FEV1: Stage 1 >80%, Stage 2 50-79%, Stage 3 30-49%, Stage 4 <30%

Other Investigations
- Chest XRay (cancer)
- FBC (Polycythemia, raised Hemoglobin, secondary to chronic hypoxia)
- Sputum Culture
- ECG/Echo
- CT Thorax (Fibrosis, cancer, bronchiectasis)
- Serum 1 antitrypsin
- Trasnsfer Factor for Carbon Monoxide (TLCO reduced in COPD, severity indicator)

23
Q

Management of COPD

A

Step 1: SABA (salbutamol/Terbutaline) or SAMA (Ipratropium Bromide)
Step 2: LABA + Inhaled Corticosteroid Combo (Fostair, Symbicort)

Long term oxygen therapy for severe COPD causing polycythemia, cyanosis of hcor pulmonary

24
Q

ABG’s in COPD?

A

Repiratotoary Acidosis (low pH with raised pCO2)

Raised bicarb indicated chronic retention of CO2

25
Q

Types of Respiratory Failure?

A

Low pO2 indicates Hypoxia + Respiratory Failure

Type 1 Respiratory Failure: NORMAL pCO2 with LOW pO2 (1 Affected)

Type 2 Respiratory Failure: RAISED pCO2 with LOW pO2 (2 Affected)

26
Q

Causes of Type 1 Respiratory Failure?

A

NORMAL pCO2 with LOW pO2 (1 Affected)

Pulmonary Edema

Pneumonia

PE

Pulmonary Fibrosis

27
Q

Causes of Type 2 Respiratory Failure?

A

RAISED pCO2 with LOW pO2
COPD
Resp center depression
Resp muscle weakness

28
Q

Considerations when delivering O2 to pt with COPD

A

Cannot have oxygen when smoking

Too much O2 => depressed respiratory drive

Venturi Masks deliver specific O2 percentages
- Retaining CO2 (88-92%)
- Not retaining CO2 (>94%)

29
Q

Indications for BiPAP

A

Used for Type 2 Respiratory Failure (RAISED pCO2 with LOW pO2)

Criteria for initiating BiPAP: Repiratory Acidosis (pH < 7.35, PaCO2 > 6) despite medical treatment

Contraindidations: phenomothorax

30
Q

Indications for CPAP

A

Obstructive Sleep Apnea

Congestive Cardiac Failure

Acute Pulmonary Edema

31
Q

Diagnosis of Instersitial Lung Disease?

A

CT Scan: Ground Glass Apearance

Finger Clubbing

Bibasal fine inspiratory crackles

32
Q

Casues of pulmonary fibrosis?

A

Drugs:
* Amiodarone
* Cyclophosphamide
* Methotrexate
* Nitrofuratoin

Seconary Pulmonary Fibrosis:
- Alpha1-antitrypsin deficiency
- Rehamatoid Arthritis
- SLE
- Systemic Sclerosis

Hypersensitivity Pneumonitis (Diagnosed with bronchoalveolar lavage showing INC WBC and Mast Cells)

Asbesthosis

33
Q

Pleural Effusion w/ >30 g/L of Protein?

A

Exudative (Inflamation=> protein leaking out of tissue into pleural space):
- Lung Cancer
- Pneumonia
- Rheamatoiid Arthritis
- TB

34
Q

Pleural Effusion w/ <30 g/L Protein

A

Transudative (Fluid moving across into pleural space)
- Congestive Heart Failure
- Hypoalbuminemia
- Hypothyroidism
- Meig’s Syndrome (right sided plerual effusion w. Ovarian Malginancy)

35
Q

Presentation of Pleural Effusion?

A

SOB
Dullness to Percussion
Reduced brachial Sounds
Tracheal Deviations AWAY from large effusion

36
Q

Investigations for Pleural Effusion
- XRAY
- Aspirate

A

XRay FIndings
- Blunting of costophrenic angle
- FLuid in lung fissures
- Meniscus (curving where it meets chest wall/mediatinum)
- Tracheal Deviation (Massive effusion)

Aspiration Sample
- Protein Count (>30 Exudative, <30 Transudative)
- Cell Count
- pH
- Glucose
- LDH
- Culture

37
Q

Criteria to determine if plerual effusion is transudative or exudative?

A

Light’s Criteria More likely to be EXUDATE if:
- Pleural Fluid/protein ratio >.5
- Pleural fluid LDH >200
- Pleural fluid::Serum LDH >.6

38
Q

When to suspect empeyema?

Pleural aspiration findings?

A

Improving pneumonia w/ New/Ongoing Fever

Aspirations:
- Pus
- Acidic (pH<7.2)
- LOW Glucose
- HIGH LDH

39
Q

Investigations for Pneumonthorax?

A

Erect XRay (Area w/ no lung markings)

CT Thorax (Smaller/ asses size)

40
Q

Management of Pneumothrorax?

A

No SOB and <2cm air then no treatment required

SOB and >2cm air (Aspiraton and Re-Assesment)

Unstable (Chest Drain)

41
Q

Danger/Signs/ Management of Tension Pneumothorax

A

Tension pneumothorax caused by trauma creating one-way valve. Pushes mediateiunum across, kinking large vessels => Cardiovacular Arrest

Signs:
- Tracheal deviation AWAY from side of pneumothroax
- Reduced air entry on affected side
- Increased resonance to percussion on affected side
- Tachycardia
- Hypotension

Management:
- “Insert a large bore cannula into the 2nd intercostal space in the midclavicular line”
- once perssure relieved, then chest drain is required for definitive management

42
Q

Chest Drain Insertion?

A

Inserted into the Triangle of Safety
- 5th intercostal space (inferior to nipple line)
- Mid Axillary Line (lateral edge of Latissimus Dorsi)
- Anterior Axillary Line (lateral edge of Pectoralis Major)

Inserterd ABOVE rib to avoid neurovascular bundle running beneath, after insertion chest xray to check positioning

43
Q

Risk Factors for DVT/PE?

A

Immobility (Long Flights)
Recent Surgery
Pregnangy
Estrogen Therapy
Malignangy
Polycythemia
SLE
Thrombophilia

44
Q

Prophylaxis for VTE?

Contraindications?

A

LMWH (Enoxaparin) (Unless Active bleeding or on Warfarin/DOACs)

Compression Stocking (Unless Peripheral Artery DIsease)

45
Q

Presentation/Diagnosis of PE?

A

SOB
Pleuritic Chest Pain
Hypoxia
Tachycardia
Raised Resp Rate
Low grade fever

Perform Well’s Score (Predicts risk of pt having PE)
- Likely => CTPA (VQ if contraindicated)
- Unlikely => d-dimer (95% sensitive, not specific), if positive then CTPA

Deifinitive Diagnosis of PE:
- CT Pulmonary Angiogram (CTPA): chest CT w/ intravenmous contrast highlighting pulmonary arteries
- Ventilation-Perfusion (VQ) Scan) radioactive isotypes and gama camera to compare ventilation with perfusion of lungs. Used in pts with renal impairment, contrast allergy or at risk of radiation

46
Q

Conditions leading to elevated d-dimer?

A

VTE
Pneumnonia
Malignancy
Heart Failure
Surgery
Pregnancy

47
Q

Management of PE

A

Initital:

  • LMWH Imediately started if delay w/ scan
  • If Massive PE w/ hemodynamic compromise => Catheter-Directed Thrombolysis (Streptokinase, Altepolase, Tenectoplase)

Long term: Warfarin, DOAC, LMWH

48
Q

Pulmonary Hypertension
- Signs/Symptoms
- Investigations?
- Mangement

A

Signs/Symtoms
- SOB
- Syncope
- Tachycardia
- Raised JVP
- Hepatomegaly
- Peripheral edema

ECG Changes
- Right Ventricular Hypertrophy (Large R-waves on right chest leads (V1-3); Large S-waves on Left leads (V4-6))
- Right Axis Deviation
- Right BBB

Chest XRay Changes
- Dialated Pulmonary Arteries
- Right Ventricular Hypertrophy

Others
- Raised NT-proBNF= Right heart failure

Poor prognosis (30-40% 5 year survival). Treatable with IV Prostanoids, Phosphodiesterase Inhibiots (Sildenafil)

49
Q

Investigations for Sarcoidosis?

A

Blood
- INC serum ACE
- Hypercalcemia
- INC serum coluable interleukin-2 recepto
- Raised CRP

Imaging
- Chest XRay: Hilar Lymphadenopathy
- HIgh Resolution CT: Hilar Lymphadenopathy and Pulmonary Nodules
- MRI: CNS Involvement
- PET Scan: shows areas of active inflamation

Histology (GOLD STANDARD)
- Non-Caseating granulomas w/ epitheliod cells)

Clinical Medicine (8 decks)

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