Chest medicine

Question 1

Commonest cause of pneumonia?

Answer 1

Steptococcus pneumoniae

Question 2

Chlamidophila psittaci, how would you contract this bacteria?

Answer 2

Birds, this is a zoonosis

Question 3

CURB-65 breakdown?

Answer 3

C - confusion
U - urea >7mmol/L
R - resp rate >30/min
B - BP (sys <60)
Age - greater than 65

Question 4

SARS - what type of pathogen is it?

Answer 4

Coronavirus

Question 5

Atypical cause of pneumonia in HIV +ve patients with CD4 less than 200/mm3?

Answer 5

Pneumocystis pneumonia caused by Pneumocystis jiroveci

Question 6

Common causes of HAP?

Answer 6

G-ve bacteria (E coli & P aerunginosa) 50%
Staph aureus 20%
Strep pneumoniae 15%

Question 7

Typical features?

Answer 7

Cough, purulent sputum, fever with pleuritic chest pain and breathlessness

Localised chest signs: crackles, dullness, bronchial breathing

Resp failure indicated by cyanosis and tachypnoea

Question 8

Investigations?

Answer 8

CXR - consolodation
Haematology and biochem tests
Pulse oximetry & ABG

Sputum gram stain
Sputum culture
Blood culture
Pleural fluid aspiration

Question 9

Antibiotics in CAP and HAP?

Answer 9

CAP - amoxicillin (plus clarithromycin if atypical)

HAP - aminoglycacide and 3rd gen cephlasporin

Question 10

What is ARDS?

Answer 10

a form of acute respiratory failure by PULMONARY OEDEMA

resulting from ENDOTHELIAL DAMAGE

due to a cascade of INFLAMATORY EVENTS

developing in responce to an INTIATING INJURY/ILLNESS

Question 11

ARDS - pathogensis?

Answer 11

Usually pulmonary oedema results from increased hydrostatic pulmonary capillary pressure (e.g. left ventricular failure), but in ARDS it is a result of increased alveolar capillary PERMIABILITY

Question 12

Prognosis of ARDS?

Answer 12

50% mortality

Survivors often left with fibrosis

Question 13

ARDS - clinical features?

Answer 13

Occurs in response to:
DIRECT injury - aspiration, severe pneumonia

INDIRECT injury - sepsis, major trauma, pancreatitis

12 - 24hrs after precipitating events. First signs are of dyspnoea and tachypnoea

Question 14

How to differentiate causes of pulmonary oedema?

Answer 14

Pulmonary capillary wedge pressure is typically <18mmHg in ARDS.

In cadiogenic pulm oedema, the pulmonary artery pressure increases above 18mmHg

Question 15

What are the two disease of large airways?

Answer 15

Asthma and COPD

Question 16

What are the three RCP question regarding asthma?

Answer 16

1. Have you had trouble sleeping?
2. Have you had any symptoms during the day time?
3. Has your asthma interfered with your usual activities?

Question 17

Finding of asthma o/e?

Answer 17

Freq normal
Hyperinflation
Wheeze: exp., diffuse and polyphonic (‘musical’)
Signs of atopy: exzema, conjunctivitis

Question 18

Differential of asthma?

Answer 18

COPD
Heart Failure
Bronchiectasis 
GORD
Pulm fibrosis

Question 19

What findings would lead you away from asthma?

Answer 19

cough no wheeze
no variation of symtpoms
no relief with B2 agonist
voice disturbances

Question 20

Two key investigations?

Answer 20

PEFR
Spirometry

(Also, cultures, bloods, imaging)

Question 21

Steps in the management of asthma?

Answer 21

Step 1 - B2 agonist
Step 2 - add steroid
Step 3 - add LABA
Step 4 - trial of increased steroid dose. Leukotriene antagonist. Theophiline.
Step 5 - daily steroid tablet and specialist care referal.

Question 22

Acutely unwell patients can be managed with MOVE acronym- standing for…?

Answer 22

M - monitor (cardiac, BP, pulse ox, ect.)
O - oxygen
V - venous access
E - ECG

Question 23

Specifically for asthma, the OSHIT acronym can be used, it stands for:

Answer 23

O - oxygen
S - salbutamol
H - hydrocortisone
I - Ipratropium bromide
T - theophiline/magnesium

& MONITOR

Question 24

Severity scale for asthma:

Answer 24

Moderate:
worsening symptoms
PEFR 50-75% best

Acute severe:
PEFR 33-50%
RR >25
HR >110
Unabble to speak in sentences 

Life threatening:
PEFR <92%
silent chest
cyanosis
poor resp effort 
arrythmia
exhaustion 

Near fatal:
increased PaCO2 requiring ventilaiton

Question 25

In a suspected chest infection what does a swinging fever suggest?

Answer 25

Indicative of a collection of pus outside of the pneumonia I.e. empyema or para-pneumonic infection

Question 26

CXR findings in pneumonia?

Answer 26

Walled off cavity lesion with fluid level

Question 27

With every admission of asthma,what should be done?

Answer 27

Follow up within 30 days Review of self-medication skills and inhaler programme

Question 28

In an admission of asthma, if a severely unwell patient recovers to >75% PEFR what should you do?

Answer 28

Send patient home

Question 29

What might you see in a person who is losing control of their asthma management?

Answer 29

Waking at night with wheeze, cough, chest pain Increase use of bronchodilator therapy Decreased effectiveness of bronchodilators Missing work days Change in exercise tolerance

Question 30

If a patient comes in with an acute asthma attack, when can you discharge them home?

Answer 30

When they have been stable of their regular medication for 24hrs, prior to discharge or if PEFR is >75% best

Question 31

What advice should you give to a patient about how they should act if they suffer an asthma attack?

Answer 31

1. Take inhaler (B2) immediately 2. Sit down loosen clothing 3. Take the inhaler every minute for 5 minutes. 4. No improvement call 999 5. Continue step 3 until ambulance arrives.

Question 32

What is the pathological process that occurs in CF that allows for easy infection of the lungs?

Answer 32

CF results in permanent dilatation of the bronchioles, allowing for repeated infections of the airways

Question 33

What signs would you find in a young adult with CF? and in a neonate?

Answer 33

Finger clubbing; bilateral coarse crackles; cyanosis Failure to thrive; meconium ileus; rectal prolapse.

Question 34

Patients with COPD are prone to developing hypercapnia when they are on oxygen therapy, how would this present and how would you treat it?

Answer 34

Increasing confusion and tiredness/lethargy after being on oxygen therapy Trial NIV (BiPAP) in these patients

Question 35

A patient with lung tumours can secrete PTH, leading to hypercalaemia. What are the symptoms of primary hyperthyroidism?

Answer 35

'Bones' - pain and sometimes pathological # (ostitis fibrosa cystica) 'Stones' - renal stones 'Groans' - abdo pain from ulcers, nausea, indigestion and constipation 'Psychic moans' - lethagy, fatigue, depression

Question 36

A patient presents with a likely lung cancer but she is hyponatraemic, what is going on?

Answer 36

The lung cancer is a small cell cancer which can cause SIADH leading to low sodium levels.