Respiratory

Question 1

Define pneumonia

Answer 1

Acute LRTI associated with fever, symptoms and signs in the chest, and consolidation visible on chest x-ray

Inflammation of lung parenchyma (alveolar spaces) due to infective agent

Question 2

Predisposing factors to pneumonia

Answer 2

Smoking
Alcoholism
Immunodeficiency
Diabetes
COPD
CKD
CLD
>65 /<16

Question 3

What are the 3 types of pneumonia?

Answer 3

Organising
Broncho
Lobar

Question 4

Signs and symptoms of pneumonia

Answer 4

Signs:
Pyrexia
Cyanosis 
Confusion (can be only sign in the elderly)
Tachypnoea
Tachycardia
Hypotension
Signs of consolidation (reduced expansion, dull percussion, bronchial breathing)
Pleural rub 

Symptoms:
Fever
Rigors
Malaise
Anorexia
Dyspnoea
Cough
Purulent sputum
Haemoptysis and pleuritic pain

Question 5

Complications of pneumonia

Answer 5

T1RF
AF
Pleural effusion
Brain/lung abscess
Pericarditis
Myocarditis
Cholestatic jaundice
Sepsis/septic shock

Question 6

Differentials of pneumonia

Answer 6

LRTI
COPD/obstructive airway diseases
Bronchiectasis

Question 7

Investigations for pneumonia

Answer 7

Bedside:
Sputum, urine sample

Bloods:
ABG, FBC, WCC, CRP, U&Es urea, mycoplasma, serology, cultures

Imaging:
CXR

Consider: 
Pleural tap (culture fluid), chest CT, bronchoscopy

Question 8

What are the elements of CURB-65?

What does it measure?

Answer 8

Measures severity of CAP

1 point for each of:
Confusion of new onset (AMT<8)
Urea >7mmol/L
Respiratory rate >30bpm
Blood pressure <90mmHg systolic/<60mmHg diastolic 
>65

01 - PO antibiotic/home treatment
2 - hospital therapy
>/=3 - consider ITU

Question 9

Management of pneumonia

Answer 9

Antibiotics (oral or IV)
Oxygen (aim for PaO2 >8/sats >94%)
IV fluids 
VTE prophylaxis
Nutrition
Analgesia if pleurisy
Physiotherapy
Consider ITU (shock, hypercapnia, uncorrected hypoxia)
Follow up at 6 weeks + CXR

Question 10

What are the 4 broad categories of pneumonia?

Answer 10

Community acquired pneumonia
Hospital acquired pneumonia
Aspiration pneumonia
Immunocompromised pneumonia

Question 11

Common causative agents of CAP

Answer 11

Bacteria 85% - Viruses 15%

Strep pneumoniae
Haemophilius influenzae
Mycoplasma pneumonia

Question 12

Management of mild CAP

CURB 0-1

Answer 12

Oral amoxicillin 500mg-1g/8hrs 
or
Clarithromycin 500/12hr 
or
Doxycycline 200mg loading then 100mg/day

Question 13

Management of moderate CAP

CURB 2

Answer 13

Oral amoxicillin 500mg-1g/8hrs
AND
Clarithromycin 500mg/12h

Question 14

Management of severe CAP

CURB 3-5

Answer 14

IV co-amoxiclav 1.2g/8h 
or
IV cefuroxime 1.5g/8h 
AND
IV clarithromycin 500mg/12h

Question 15

Define hospital acquired pneumonia

Answer 15

Pneumonia contracted >48hrs after admission

Question 16

What structure is affected in aspiration pneumonia?

Answer 16

Right lower lobe

Question 17

Common causative agents in aspiration pneumonia

Answer 17

Anaerobes and Strep pneumoniae

Question 18

Management of aspiration pneumonia

Answer 18

IV cephalosporin
AND
IV metronidazole

Question 19

Causes of immunocompromised pneumonia

Answer 19

Conventional pathogens + fungi: Pneumocystis, Candida, Aspergillus

Mycobacteria: TB

Viruses: CMV, HSV

AIDs defining infections e.g. PCP

Question 20

Risk factors for aspiration pneumonia

Answer 20

Swallowing dysfunction
Gastro-oesophageal reflux
Neurological disease
Mechanical- and device-related impairment of the upper digestive tract (e.g. tracheostomy, ETT, nasogastric/percutaneous feeding tube)

Question 21

Risk factors for DVT

Answer 21

Increasing age
Pregnancy
Oestrogen (COCP, HRT)
Trauma
Surgery (pelvic, orthopaedic)
Previous DVT
Cancer
Obesity
Immobility
Thrombophilia/coagulopathy (e.g. Factor V Leiden)

Question 22

Signs of DVT

Answer 22

Calf warmth/tenderness/swelling/erythema
Mild fever
Pitting oedema
Dilated superficial leg veins

Question 23

Complications of DVT

Answer 23

Embolism and PE
Pulmonary HTN
Post-DVT syndrome
Budd-Chiari syndromes

Question 24

Differentials of DVT

Answer 24

Cellulitis

Ruptured Baker’s cyst

Question 25

Investigations in DVT

Answer 25

D-dimer
USS
Thrombophilia tests
Underlying malignancy screen

Question 26

What is Wells’ criteria and what does it measure?

Answer 26

Probability of DVT

Likely: >2 points
Unlikely <2 points

Active cancer
Bedridden recently >3 days or major surgery within 12 weeks
Calf swelling >3cm compared to other leg
Collateral superficial veins present
Entire leg swollen
Localised tenderness along deep venous system
Pitting oedema confined to symptomatic leg
Paralysis, paresis or recent plaster immobilisation of lower extremity
Previously documented DVT
Alternative diagnosis to DVT as likely or more likely

Question 27

Management of DVT

Answer 27

Anti-coagulate - LMWH, warfarin
IVC filters
Compression stockings
Thrombolysis
Surgical removal (trellis device)

Question 28

DVT prevention and prophylaxis

Answer 28

All hospital patients on admission
Reassessment within 24h and when clinical situation changes
Prophylaxis - LMWH, TED stockings, early mobilisation

Question 29

Complications of DVT

Answer 29

PE
Bleeding during initial treatment 
Heparin-induced thrombocytopenia (IHT)
Heparin resistance/aPTT confounding 
Post-thrombotic syndrome 
Bleeding during long-term/extended treatment 
Osteoporosis due to heparin treatment

Question 30

Pathophysiology of DVT

Virchow’s triad

Answer 30

Formation of thrombus dependent on any one of Virchow’s triad being present

Stasis of blood flow

Endothelial injury

Hypercoagulability