Respiratory

Question 1

Empyema

Answer 1

1) Preceding symptoms of pneumonia
2) Subacute presentation (1-2 weeks of symptoms prior)
3) Immunocompromise
4) Pre-existing lung disease
5) Not responding to antibiotics
6) Constitutional symptoms (malaise anorexia wt loss)
7) Fever +/- rigors
8) Productive cough
9) Dyspnoea
10) Pleuritic chest pain
11) Stony dullness to percussion
12) Reduced breath sounds and vocal resonance

Question 2

Asbestosis

Answer 2

1) At risk occupation (shipyard, construction, maintenance, vehicle brake mechanic, asbestos cement, insulation or production of tiles, shingles, gaskets, brakes or textiles) 2) At least 20 years since exposure 3) Smoking risk factor 4) Increasing dyspnoea on exertion 5) Dry cough 6) Inspiratory bibasal crackles 7) Lower zone interstitial fibrosis on CXR and pleural plaques 8) Restrictive pattern on spirometry

Question 3

Asthma

Answer 3

1) Family history 2) Triggers eg cats; dogs; cockroaches; dust mites; fungal spores; tobacco smoke; fumes from chemicals and pollens 3) Atopy history 4) Exacerbation with URTIs 5) Dyspnoea 6) Cough 7) Polyphonic high-pitched wheezes 8) Nasal polyps

Question 4

Extrinsic allergic alveolitis (acute and chronic)

Answer 4

1) Exposure to birds, mouldy ventilation, mouldy hay, grain, wood, or sugar cane; occupational chemicals (epoxy resins, polyurethane foam) 2) Dyspnoea 3) Cough (productive or non-productive) 4) Fever if acute 5) Weight loss (chronic) 6) Bibasal or diffuse crackles 7) Clubbing (chronic)

Question 5

Mycoplasma Pneumonia

Answer 5

1) Close community settings 2) Smoking 3) Age < 30 4) Persistent dry cough 5) Prolonged symptoms 6) Fever 7) Sore throat 8) Rash 9) Headache 10) Mild or absent clinical signs of pneumonia 11) Abnormal LFTs

Question 6

Bronchiectasis

Answer 6

1) Risk factors-cystic fibrosis, immunodeficiency, previous respiratory infections, congenital disorders of the bronchial airways 2) Productive cough (purulent and sometimes haemoptysis) 3) Inspiratory crackles, rhonchi and wheezes 4) Dyspnoea 5) Recurrent fevers 6) Rhinosinusitis

Question 7

Bronchiolitis

Answer 7

1) Age < 3 2) Risk factors congenital heart disease, prematurity, passive smoke exposure and immunodeficiency 3) Cough (wet dry or croupy) 4) Wheeze 5) Crackles 6) Fluctuating clinical signs 7) Preceded by URTI symptoms 8) Increased work of breathing (possible) 9) Fever (possible)

Question 8

Acute bronchitis

Answer 8

1) Productive cough (clear or discoloured sputum) 2) No history of chronic respiratory condition 3) Low grade fever (possible)

Question 9

COPD

Answer 9

1) Smoking history 2) Advanced age 3) Productive cough (worsens with exacerbations) 4) Gradually increasing dyspnoea 5) Barrel chest 6) Hyper-resonant percussion note 7) Reduced breath sounds 8) Wheezing and crackles with exacerbations

Question 10

Croup

Answer 10

1) Age 6 months to 6 years 2) Increase in symptoms with agitation 3) Seal-like barky cough 4) URTI prodrome 12-48 hours (possible) 5) Abrupt onset 6) Symptoms worse at night 7) Stridor (possible) 8) Increased work of breathing (possible) 9) Hoarse voice

Question 11

Cystic fibrosis

Answer 11

1) Family history 2) Failure to pass meconium 3) Failure to thrive 4) Increased appetite (due to pancreatic insufficiency) 5) Wet-sounding cough 6) Recurrent respiratory infections 7) Recurrent sinusitis 8) Bilateral absence of vas deferens in males 9) Steatorrhoea 10) Clubbing 11) GORD

Question 12

Epiglottitis

Answer 12

1) Non vaccination with Hib 2) Immunocompromise 3) Middle age??? 4) Sore throat (adults) 5) Dysphagia 6) Drooling 7) Toxic appearance 8) Acute distress 9) Fever 10) Tripod positioning (head and neck anterior and hands on knees) 11) Muffled voice 12 ) Stridor

Question 13

Glandular fever

Answer 13

1) Cervical or generalised tender lymphadenopathy in second week 2) Pharyngitis exudative or non exudative 3) Petechiae soft palate 4) Malaise 5) Fever lasts up to 2 weeks 6) Splenomegaly up to 4 weeks 7) Elevated aminotransferases 8) Rash 1/3 children up to 1 week

Question 14

Influenza

Answer 14

1) Younger or older age 2) Chronic disease 3) Immunocompromise 4) Pregnancy 5) Household contact with same 6) Fever + cough 7) Sore throat 8) Myalgia

Question 15

Lung abscess

Answer 15

1) Poor dental hygiene 2) Aspiration 3) Immunosuppression 4) Chronic disease 5) Preceding pneumonia 6) Fever 7) Productive cough (purulent) 8) Cardiac murmur (endocarditis with septic embolus to lung) 9) Pleuritic chest pain if preceding PE 10) Constitutional symptoms (night sweats, malaise and weight loss) 11) Pallor and cachexia if chronic 12) Possible haemoptysis

Question 16

Lung cancer

Answer 16

1) Older age 2) Smoking history 3) New or persistent cough 4) Dyspnoea 5) Haemoptysis 6) Chest or shoulder pain 7) Weight loss 8) Possible signs - wheeze, crackles, dull percussion, decreased breath sounds 10) Possible - hoarse voice, weakness paraesthesia or pain in C8/T1 distribution, supraclavicular or cervical lymphadenopathy, Horner’s syndrome, finger clubbing

Question 17

Obstructive sleep apnoea

Answer 17

1) Obesity 2) Male gender 3) Family history of condition 4) Chronic snoring 5) Maxillomandibular anomalies 6) Daytime somnolence 7) Witnessed apnoeas 8) Episodic gasping 9) Restless sleep 10) Insomnia 11) Macroglossia 12) Endocrine disorders (T2 diabetes, PCOS, hypothyroidism & acromegaly) 13) Erectile dysfunction 14) Nocturia 15) Morning headaches 16) Dry mouth

Question 18

Pertussis

Answer 18

1) Age < 6 months 2) Household contact 3) Teacher or healthcare worker 4) Incomplete immunisations 5) Cough 1-2 weeks post infection 6) Inspiratory whooping (3-10 weeks post infection) 7) Rhinorrhoea early stages 8) Post-tussive vomiting

Question 19

Pneumoconiosis

Answer 19

Risk factor - mining, exposure to silica, coal or beryllium KEY FACTOR* *Dyspnoea on exertion - gradual onset *Cough - dry, non-productive *Crepitations on chest auscultation

Question 20

Pneumonia (CAP)

Answer 20

*Risk factors - >65 yo, healthcare resident, COPD, smoking, alcohol abuse, contact with kids *Cough with increasing sputum *Fever, rigors *Dyspnoea *Pleuritic pain *Abnormal auscultation - asymmetric breath sounds, pleural rubs, vocal resonance/fremitus changes

Question 21

Pneumothorax

Answer 21

*Risk factors: smoking, family history, tall & thin, <40 yo, acute asthma, COPD, CF *Chest pain *Dyspnoea *Hyperexpanded chest *Hyper resonant, reduced breath sounds *Trachea may be shifted to opposite side

Question 22

Pulmonary embolus

Answer 22

*Risk factors: Increasing age, DVT, recent surgery, convalescence, FHx, malignancy, previous embolus, pregnancy/postnatal, trauma/fracture *Chest pain, dyspnoea, tachypnoea - key features *Cough *Tachycardia *Fever *Other features: haemoptysis, elevated JVP, accentuated pulmonary S2, unilateral calf swelling/tenderness

Question 23

Pulmonary fibrosis (idiopathic)

Answer 23

*Risk factors: advancing age, male, smoker, FHx (also inorganic dust, diabetes, GOR, viral infection) *Dyspnoea - typically reproducible *Cough - non-productive, poor response to anti-tussives *End expiratory fine basilar crackles - Velcro-like quality *Weight loss, fatigue, malaise *Finger clubbing, may be present

Question 24

Pulmonary hypertension

Answer 24

*Pulmonary artery pressure >25 mmHg measured on catheterisation *Idiopathic, Inherited, Drug-induced or secondary to: L heart disease, lung disease/hypoxia, thrombo-embolic disease *20-50 yo females predominant in idiopathic group *Progressive SOB *Fatigue *Chest pain *Ankle and abdominal swelling *Raised JVP, parasternal heave *Loud P2 and/or pansystolic tricuspid murmur

Question 25

Rhinitis, allergic

Answer 25

*Risk factors: FHx of atopy, <20 yo, Western lifestyle, little exposure to animals in early life *Sneezing and nasal pruritus *Palate, throat, ear & eye itching *Fatigue and irritability *Nasal congestion/rhinorrhoea *Conjunctival injection *Ocular mucoid discharge *Mucosal pallor and swelling of nasal mucosa and turbinates *Allergic shiners (bluish discolouration of infra-orbital region)

Question 26

Sarcoidosis

Answer 26

*Risk factors: 20-40 yo, FHx, Scandinavian, female, non-smoker *Cough *Dyspnoea *Fatigue *Arthralgia *Wheezes/rhonchi *Lymphadenopathy *Photophobia *Red painful eye *Blurred vision *CXR - hilar/paratracheal adenopathy *Hypercalcaemia

Question 27

Sinusitis, acute

Answer 27

*Risk factors: viral URTI, allergic rhinitis *Purulent nasal discharge *Nasal obstruction *Facial pain/pressure *Cough, sore throat *Myalgias

Question 28

Sinusitis, chronic

Answer 28

*Risk factors: Allergic rhinitis, Asthma, Sinus surgery, sinus/septal deformities *Facial pain/pressure *Nasal obstruction/discharge *Purulent discharge *Headache *Fatigue *Cough *Anosmia *Halitosis

Question 29

Tuberculosis, pulmonary

Answer 29

*Risk factors: exposure to this condition, from endemic country, HIV, immunosuppression *Cough *Fever & night sweats *Anorexia & weight loss *Malaise *Haemoptysis (uncommon)