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Finals PACES > Resp > Flashcards

Resp Flashcards

1
Q

Pancoast tumour

A

Ptosis
Miosis
Wasting of 1st webbed space

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2
Q

Clubbing

A

Interstitial lung disease
Malignancy (bronchogenic carcinoma AND mesothelioma)
Suppurative lung disease (bronchiectasis, abscess, empyema, CF)

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3
Q

Consolidation Examination features

A

Percussion: dull
Breath sounds: bronchial or reduced
Vocal resonance: hyper resonant
Mediastinal shift: none

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4
Q

Collapse (or lobectomy/pneumonectomy) Examination features

A

Percussion: dull
Breath sounds: reduced or absent
Vocal resonance: reduced or absent
Mediastinal shift: towards

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5
Q

Effusion (or raised hemidiaphragm due to phrenic nerve palsy) Examination features

A

Percussion: stony dull
Breath sounds: reduced or absent
Vocal resonance: reduced or absent
Mediastinal shift: away if big

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6
Q

Pneumothorax Examination features

A

Percussion: hyper resonant
Breath sounds: reduced or absent
Vocal resonance: reduced of absent
Mediastinal shift: away if tension

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7
Q

Hoover’s sign

A

intercostal indrawing = hyperinflation

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8
Q

Wheeze causes

A

Small airway obstruction = asthma or COPD

Obstruction from object or tumour ==> monophonic and probably collapse further down

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9
Q

Creps causes

A

Secretions (if normal get them to cough and should disappear, if not pneumonia)
Pus (cystic fibrosis, bronchiectasis)
Oedema
ILD

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10
Q

ILD

see extra notes

A

Idiopathic:
Extrinsic allergic alveolitis: bird fancier’s lung; farmer’s lung
Inhaled irritant: asbestosis; silicosis; coal worker’s pneumoconosis
Systemic disease: SLE; RA; sarcoid; systemic sclerosis
Iatrogenic: methotrexate, amiodarone, radiotherapy

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11
Q

Horner’s syndrome

A

Central lesion: stroke/tumour
T1 root lesion: neurofibroma
Brachial plexus lesion: pancoast tumour, cervical rib, trauma (at birth = Klumpke’s)
Neck lesion: tumour, carotid artery aneurysm

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12
Q

Fine creps causes

A

Pulmonary oedema

ILD

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13
Q

Coarse creps causes

A

Bonchiectasis
CF
Bibasal pneumonia

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14
Q

Pleural effusion classification

A

Transdate (<30g/L) = reduced oncotic pressure
E.g. LVF, volume overload, hypoalbuminaemia, Meig’s syndrome
Exudate (>30g/L) = infection (pneumonia, TB); infarction (PE); inflammation (RA, SLE); malignancy (bronchogenic, mesothelioma)

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15
Q

Pneumonia CURB-65

A 
Confusion (< or equal 8)
Urea >7mM
RR >30
BP <90/60
> or equal 65

0-1 –> home Rx
2 –> hospital Rx
3 or > –> consider ITU

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16
Q

Pneumonia Empiric Rx

A

CAP:
Mild - amoxi 500mg TDS for 5 d OR clari 500mg BD 7 d
Moderate - amoxi AND clari 500mg BD for 7 d
Severe - clari 500mg BD IV AND co-amoxi 1.2g TDS IV / cefuroxime 1.5g TDS IV 7-10 d; (add fluclox if staph suspected)
Atypical typically treated with clari:
chlamydia - tetracycline (clari)
PCP - co-trimoxazole
Legionella - clarithromycin + rifampicin

HAP:
mild/<5days/aspiration: co-amoxi 625mg TDS PO for 7 days
Severe: tazocin +/- vanc +/- gent for 7 days

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17
Q

SIRS

A 
> or equal 2 of:
Temp >38 or <36
HR >90
RR >20 or PaCo2 <4.6
WCC >12 or <4
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18
Q

Klebsiella features

A

Cavating pneumonia esp upper lobes

Treated with cefotaxime

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19
Q

Mycoplasma features

A

Dry cough
reticular-nodular shadowing
Flu-like prodrome
Treated with clari

Legionella looks similar but bibasal consolidation and hyponatraemia / deranged LFTs. Also treated with clari and both can be investigated via serology

20
Q

Chlam. pneum features

A

pharyngitis, otitis –> pneumonia

treated with clari and Ix serology

21
Q

Chlam. psittaci features

A 
dry cough
horder's spots - rose spots
splenomegaly
epistaxis
meningo-encephalitis
treated with clari and Ix serology
22
Q

PCP features

A 
Dry cough
Exertional dyspnoea
Bilateral creps
CXR: normal or bilateral perihilar
interstitial shadowing

Ix: BAL, sputum and biopsy
Rx: high dose co-trimoxazole

23
Q

Bronchiectasis causes

A

idiopathic (50%)
Congenital - CF, Kartagener’s (situs inversus), Young’s syndrome
Post-infectious - Measles, pertussis, pneumonia, TB
Immunodeficiency - Bruton’s, CVID
Yellow nail syndrome

24
Q

Bronchiectasis signs

A

O/E: Clubbing, coarse creps and wheeze, purulent sputum
CXR - thickened bronchial walls (tramlines and rings)
Spirometry: obstructive pattern

25
Q

Bronchiectasis Rx

A

chest physio
Abx for exacerbations - e.g. cipro for 7-10 days
bronchodilators (nebulised B agonists)
From CF - GI dysfunction give Creon to replace pancreatic enzymes, insulin and UDCA for bile stimulation

26
Q

Lung cancer complications

A 
Local
 Recurrent laryngeal N. palsy
 Phrenic N. palsy
 SVC obstruction
 Horner’s (Pancoast’s tumour)
 AF

Paraneoplastic
Endo
 ADH → SIADH ( euvolaemic ↓Na+)
 ACTH → Cushing’s syndrome
 Serotonin → carcinoid (flushing, diarrhoea)
 PTHrP → 1O HPT (↑Ca2+, bone pain) – SCC
Rheum
 Dermatomyositis / polymyositis
Neuro
 Purkinje Cells (CDR2) → cerebellar degeneration
 Peripheral neuropathy
Derm
 Acanthosis nigricans (hyperpigmented body folds)
 Trousseau syndrome: thrombophlebitis migrans

27
Q

DDx of pulmonary oedema

A 
Tranusdates:
↑ capillary hydrostatic pressure
 CCF
 Iatrogenic fluid overload
 Renal failure
 Relative ↑ in negative pressure pulmonary
oedema
↓ capillary oncotic pressure
 Liver failure
 Nephrotic syndrome
 Malnutrition, malabsorption, protein-losing
enteropathy
↑ interstitial pressure
 ↓lymphatic drainage: e.g. Ca

Exudates
 ARDS (admit to ITU for organ support and treat underlying cause)

28
Q

Indications for ventilation in ARDS

A

 PaO2<8KPa despite 60% FiO2
 PaCO2>6KPa

Method
 6ml/kg + PEEP (e.g. 10cm H2O)

29
Q

Type 1 resp failure

A

PaO2 <8kPa and PaCO2 <6kPA; caused by V/Q mismatch which can be vascular (PE, pulmonary shunt); asthma; pneumothorax; atelectasis

as well as fluid and fibrosis

30
Q

Type 2 resp failure

A

PaO2 <8kPa and PaCO2 >6kPA; caused by alveolar hypoventilation from obstructive (COPD, asthma, bronciectasis) or restrictive (GBS, fluid and fibrosis) causes

31
Q

A-a gradient

A

 PAO2= (95 x FiO2) – (PaCO2/0.8)

 ↑ (PAO2-PaO2) suggests lung pathology

32
Q

O2 therapy

A

In pts. at risk of hypercapnic resp failure:
 Start O2 therapy at 24% and do an ABG
– Blue Venturi @ 2-4L/min

33
Q

O2 therapy mechanism

A

Nasal Prongs: 1-4L/min = 24-40% O2

Simple Face Mask

Non-rebreathing Mask
 Reservoir bag allows delivery of high concentrations of O2.
 60-90% at 10-15L

Venturi Mask
 Provide precise O2 concentration at high flow rates
 Yellow: 5%
 White: 8%
 Blue: 24%
 Red: 40%
 Green: 60%
34
Q

mMRC dyspnoea score (COPD)

A
  1. Dyspnoea only on vigorous exertion
  2. SOB on hurrying or walking up stairs
  3. Walks slowly or has to stop for breath
  4. Stops for breath after <100m / few min
  5. Too breathless to leave house or SOB on dressing
35
Q

COPD Severity

A

Spirometry should show FEV1:FVC <0.7 for COPD and usually FEV1 <80%

Assess Severity
 Mild: FEV1 >80% (but FEV/FVC <0.7 and symptomatic)
 Mod: FEV1 50-79%
 Severe: FEV1 30-49%
 Very Severe: FEV1 < 30%
36
Q

PE score system

A

For PE assess probability from Well’s score
If low probability perform D-dimer (if negative excludes PE, if positive do CTPA)
If high probability perform CTPA
NB. -ve D-dimer has 95% NPV for PE

NB review management of PE

37
Q

Pleural effusion classification

A

 Effusion protein < 25g/L = transudate
 Effusion protein >35g/L = exudate
 Between 25-35g/L: apply Light’s Criteria

Light’s Criteria
 An exudate has one of:
 Effusion : serum protein ratio >0.5
 Effusion : serum LDH ratio >0.6
 Effusion LDH is 0.6 x ULN
38
Q

Pleural effusion Ix

A

Diagnostic Tap
 Percuss upper boarder and go 1-2 spaces below
 Infiltrate down to pleura with lignocaine.
 Aspirate with 21G needle
Send for:
 Chemistry: protein, LDH, pH, glucose, amylase
 Bacteriology: MCS, auramine stain, TB culture
 Cytology
 Immunology: SF, ANA, complement

39
Q

Sarcoidosis features

A 
GRANULOMA
General (FLAWS)
Respiratory - dry cough SOB, chest pain
Arthralgia
Neurological (Bell's palsy)
Urine (renal stones from hypercalcaemia)
Low hormones (amenorrhoea)
Ophthalmological (uveitis, Sjogren's)
Myocardial (restrictive cardiomyopathy)
Abdominal (hepatosplenomegaly + cholestatic LFT)
Skin (erythema nodosum/lupus pernio)
40
Q

Stages of sarcoid

A

 Stage 1: BHL
 Stage 2: BHL + peripheral infiltrates
 Stage 3: Peripheral infiltrates alone
 Stage 4: Progressive mid-zone fibrosis with bullae

41
Q

Granulomatous Disease Differential

A

 Infections: TB, leprosy, syphilis, crypto, schisto
 AI: PBC
 Vasculitis: GCA, PAN, Wegener’s, Takayasu’s
 Idiopathic: Crohns, Sarcoid
 Interstitial lung: EAA, silicosis

42
Q

Sarcoidosis Rx

A

Acute sarcoidosis
 Usually resolves spontaneously
 Bed rest and NSAIDs

Chronic sarcoidosis
 Steroids: pred 40mg/d for 4-6wks
 Additional immunosuppression: methotrexate,
ciclosporin, cyclophosphamide

43
Q

ILD causes by location

A 
Upper Zone: A PENT
 Aspergillosis : ABPA
 Pneumoconiosis: Coal, Silica
 Extrinsic allergic alveolitis
 Negative, sero-arthropathy
 TB

Lower Zone: STAIR
 Sarcoidosis (mid zone)
 Toxins: BANS ME (bleomycin, amiodarone, nitrofurantoin, sulfasalazine, methotrextrate)
 Asbestosis
 Idiopathic pulmonary fibrosis
 Rheum: RA, SLE, Scleroderma, Sjogren’s, PM/DM

44
Q

Quitting smoking advice

A

Referral to NHS stop smoking service
Nicotine gum/patches
Varenicline (C/I depression)
Bupropion (C/I epilepsy)

45
Q

Obstructive sleep apnoea

A

Daytime Features:
morning headache, somnolence, reduced memory, irritability, depression

Polysomnography is diagnostic
Rx:
weight loss, avoid smoking and EtOH
CPAP during sleep
surgery to relieve obstruction (tonsillectomy or uvulopalatpharyngoplasty)
46
Q

COPD X-ray

A 
Hyperinflation (>6 ant ribs)
Decreased cricosternal distnace
Flat hemidiaphragms
Large central pulmonary arteries
Decreased peripheral markings
Bullae

Finals PACES (12 decks)

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