Breathlessness

Question 1

Definition of sepsis

Answer 1

Infection + adverse host reaction (organ failure, SOFA >=2)

Question 2

Quick assessment of organ f(x) for sepsis

Answer 2

Lungs: O2 sats

Heart: MAP

Liver: Bilirubin

Haem: Platelets

Kidneys: Creatinine

CNS: GCS

Question 3

Differential for wheeze

Answer 3

Asthma

COPD

Heart failure

Anaphylaxis

Question 4

Differential for stridor

Answer 4

Epiglottitis

Anaphylaxis

Trauma

Foreign body/tumour

Question 5

Differntial for reduced air entry + clear chest

Answer 5

Pneumothorax

Pleural effusion

Question 6

Differential for crepitations

Answer 6

Pneumonia

Pulmonary oedema

Bronchiectasis

Pulmonary fibrosis

Question 7

Differential for SOB + clear chest

Answer 7

PE

DKA

Pneumocystis jirovecii pneumonia

CNS causes

Anaemia

Drugs e.g. salicylates

Hyperventilation (e.g. panic attack)

Question 8

Signs and symptoms of anaphylaxis

Answer 8

Itching, urticaria

Angioedema

D+V

Wheeze, laryngeal obstruction

Tachycardia, hypotension (SHOCK)

Question 9

Mimics of anaphylaxis

Answer 9

Carcinoid

Phaeochromocytoma

Systemic mastocytosis

Hereditary angioedema

Question 10

Acute management of anaphylaxis

Answer 10

Secure airway, ?intubate, 100% O2

adrenaline IM

chlorphenamine and hydrocortisone IV

Saline IV (titrate against blood pressure)

Question 11

Long-term management of anaphylaxis

Answer 11

Mast cell tryptase at 1-6h

Monitor 4-6h for biphasic reaction + safety net (more likely if happened before)

2-3d course of oral prednisolone TTO

Allergy clinic F/U if first episode

Question 12

Adrenaline dose anaphylaxis

Answer 12

0.5mg (0.5ml of 1:1000) IM

Repeat every 5 min

Question 13

Hydrocortisone dose anaphylaxis

Answer 13

200mg IV

Question 14

Chlorphenamine dose anaphylaxis

Answer 14

10mg IV (of 1:1000)

Question 15

Features of severe asthma attack

Answer 15

PEF 33-50% of expected

Unable to complete sentences

RR >25

Pulse >110

Question 16

Features of life-threatening asthma attack

Answer 16

PEF <33%

Feeble/absent respiratory effort

Cyanosis

Altered consciousness

Hypotension, arrhythmia

Normal/high PaCO2

PaO2 <8; sats <92%

Question 17

Management of acute asthma

Answer 17

Salbutamol nebuliser

Hydrocortisone/prednisolone

Fluids

If infx suspected, abx

If severe, ipratropium bromide

Reassess every 15min, incl. ECG/ABG

If unresponsive to therapy, magnesium sulfate (senior consultation)

If remains unresponsive, consider aminophylline (ICU)

Question 18

Salbutamol dose acute asthma

Answer 18

5mg nebulisedrepeated every 15-30min or 10mg/h continuously

Question 19

Steroid doses acute asthma

Answer 19

100mg IV hydrocortisone

OR

40-50 mg PO prednisolone

Question 20

Ipratropium bromide dose acute asthma

Answer 20

0.5mg/4-6h nebulised

Question 21

TTO for asthma

Answer 21

5-7d of 40-50mg oral prednisolone

GP f/u

Respiratory clinic f/u

Question 22

Management of acute exacerbation of COPD

Answer 22

Salbutamol + ipratropium bromide

O2 > titrate to sats of 88-92%

Prednisolone

Antibioticsif infective

If unresponsive, consider aminophylline/NIV (not intubation unless haemodynamically unstable/unable to protect airway)

Question 23

Steroid dose acute COPD

Answer 23

30mg PO prednisolone (7-14d)

Question 24

Nebuliser doses COPD

Answer 24

5mg/4h salbutamol

0.5mg/4-6h ipratropium

Question 25

Causes of pneumothorax

Answer 25

**Idiopathic:** Young, tall, thin **Secondary:** Significant smoking Hx, age \>50, underlying lung disease e.g. asthma, COPD, infx, fibrosis **Traumatic:** incl iatrogenic **CTD:** E.g. Ehlers-Danlos, Marfan's

Question 26

Presentation of pneumothorax

Answer 26

Asymptomatic Pleuritic chest pain Dyspnoea Reduced expansion/breath sounds Hyper-resonance Sudden deterioration in COPD/asthma/ventilated patients

Question 27

Indictions for chest drain in pneumothorax

Answer 27

SOB and/or size \>2cm Atempt aspiration first in 1ry pneumothorax

Question 28

Management of tension pneumothorax

Answer 28

Large-bore (orange/grey) cannula in midlavicular line, 2nd intercostal space Consider finger thoracostomy if suspicion of pus/blood (e.g. trauma)

Question 29

Risk factors for PE

Answer 29

Immobilisation (flights, illness) Surgery (esp pelvis/legs) Pregnancy, OCP, HRT Coagulopathy, previous DVT/PE Malignancy, inflammation

Question 30

Presentation of PE

Answer 30

Tachycardia, gallop rhythm, loud P2, raised JVP, RV heave SOB, pleuritic chest pain, haemoptysis, pleural rub RV strain, RBBB, S1Q3T3, tachycardia

Question 31

Management of PE

Answer 31

**M**orphine + metoclopramide 10mg **O**xygen **C:** Dalteparin 200U/kg OR fondaprinux 7.5mg **A**lteplase 10mg over 1-2 min if haemodynamic instability Consider IR/ITU referral Dobutamine if BP remains low

Question 32

qSOFA score for sepsis

Answer 32

RR \>=22 SBP \<100 GCS \<15

Question 33

Wells scoring for PE

Answer 33

Clinical signs and symptoms of DVT PE is #1 diagnosis OR equally likely Heart rate \> 100 Immobilization at least 3 days OR surgery in the previous 4 weeks Previous, objectively diagnosed PE or DVT Hemoptysis Malignancy w/ treatment within 6 months or palliative

Question 34

Indication for CXR in acute asthma attack

Answer 34

Life-threatening (**NOT SEVERE!** i.e. PEF \<33%) Suspected pneumothorax, pneumomediastinum Suspected consolidation