Cough Flashcards
bronchiectasis, pneumonia, TB, lung cancer, asbestosis (121 cards)
1
Q
What is bronchiectasis?
A
chronic condition that causes increased mucus production and permanent dilation of the bronchi/bronchioles secondary to an underlying cause
2
Q
Which organisms commonly cause bronchiectasis?
A
H influenzae
S pneumoniae
S aureus
P aeruginosa
3
Q
What are some common congenital causes of bronchiectasis?
A
CONGENITAL Cystic fibrosis Primary ciliary dyskinesia Alpha 1 anti-trypsin deficiency Young's Syndrome
4
Q
What are the symptoms of bronchiectasis?
A
Chronic cough (+ copious green sputum) SOB Haemoptysis Fever Weight loss
5
Q
What are the signs of bronchiectasis?
A
Basal crepitations on auscultation
Squeaks/pops on inspiration
Clubbing
6
Q
What investigations would you do on a Pt with bronchiectasis?
A
Imaging:
- CXR (first line)
- High res CT (gold standard/most appropriate)
Bloods + cultures
- ABG
- FBC (raised WCC
- Sputum culture
- Pulmonary function (dec FEV1, inc RV/TLC)
Underlying cause:
- Serum alpha-1 antitrypsin levels
- Sweat NaCl concentration and genetic testing for CFTR
7
Q
What will you see in a CXR and CT in bronchiectasis?
A
CXR- dilated thickened walls
CT- signet ring sign
8
Q
What is the conservative management of a Pt with bronchiectasis?
A
IRREVERSABLE- SUPPORTIVE MANAGEMENT
Exercise and nutrition
Vaccinations
Airway clearance therapy:
- Chest physiotherapy (postural drainage/percussion)
- High frequency oscillation devices
- Nebulised hypertonic saline (hyperosmolar agent)
- Inhaled bronchodilator (salbutamol)
9
Q
What is the prognosis of a Pt with bronchiectasis?
A
Irreversible
Depends on the severity and recurrence of exacerbations
10
Q
What are the complications of a Pt with bronchiectasis?
A
Haemoptysis
Recurrent infections
Respiratory failure
Cor pulmonale (RHF)
11
Q
What is pneumonia?
A
Inflammation of the lung parenchyma caused by bacteria, virus, or fungi (LRTI)
12
Q
What are the three types of pneumonia?
A
Community acquired pneumonia
Hospital acquired pneumonia
Aspiration pneumonia
13
Q
What are the common causes of CAP?
A
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
14
Q
What are the common causes of HAP?
A
Pseudomonas aeruginosa
Escherichia coli
Klebsiella pneumoniae
Staph aureus
15
Q
What are the common causes of atypical pneumonias?
A
Legionalla pneumophila Chlamydia psittaci Mycoplasma pneumoniae Chlamydia pneumoniae Coxiella burnetti (Q fever)
‘legions of psittaci MCQ’
16
Q
What are the mechanisms of entries for pneumonia?
A
Inhalation (viral/atypical)
Aspiration of URT secretions
Haematogenous from local infx (endocarditis)
Direct extension from local foci (TB via lymphatics)
17
Q
What are the symptoms of pneumonia?
A
Productive cough with coloured sputum Fever SOB (dyspnoea) Chest pain (pleuritic) Confusion
18
Q
What are the signs of pneumonia on inspection
A
Fever Confusion Respiratory distress- use of accessory muscles Cyanosis (peripheral/central) Raised HR/RR reduced chest expansion
19
Q
What are the main investigations for pneumonia?
A
CXR- area of consolidation FBC- raised WCC ABG Sputum MC+S Pleural fluid MCS (via thoracentesis) Blood cultures- if severe
20
Q
What is the scoring system for pneumonias?
A
CURB-65
21
Q
What is CURB-65?
A
Confusion Urea >7 Resp rate >=30 Blood pressure (S<90, D<=60) Age >=65
22
Q
What should you do for a Pt with a CURB-65 of 0-1?
A
Treat at home (GP)
23
Q
What should you do for a Pt with a CURB-65 of 2?
A
Consider hospital treatment (A+E, short stay)
24
Q
What should you do for a Pt with a CURB-65 of 3+?
A
Severe pneumonia, admission + consider ITU
25
What should you after giving a Pt with pneumonia antibiotics?
Repeat CXR in 6 weeks
26
What is the prognosis of a CURB-65 of 0-1?
30 day mortality <1%
27
What is the prognosis of a CURB-65 of 2?
30 day mortality 5-15%
28
What is the prognosis of a CURB-65 of 3+?
30 day mortality 20-50%
29
What are the complications of pneumonia?
Septic shock
C difficile from ABx use
HF/resp failure in elderly
30
How is Legionella transmitted?
Via aqueous environments such as air conditioners and contaminated water supplies
31
What is the difference between Legionnaire's disease and Pontiac fever?
LD- Legionella pneumonia
| PF- non-pneumatic Legionella
32
What are the symptoms of a Legionella pneumonia?
Prodromal flu-like symptoms (fever, malaise, myalgia)
Dry cough, can become productive
Nausea, DnV
33
Why are atypical pneumonias different from typical pneumonias?
They cannot be detected by Gram stains and cannot but cultured by standard methods
34
What additional investigations would you do for a Legionella pneumonia?
Urinary antigen detection
U+E- hyponatraemia
LFTs- deranged
35
What is the treatment for a Legionella pneumonia?
IV fluoroquinolones OR macrolides
| eg. ciprofloxacin OR clarithromycin
36
What are the characteristics of a Pneumocystis jirovecii infection?
Opportunistic fungal infx
| AIDS defining illness
37
What is the treatment for a Pneumocystis jirovecii infection?
high dose Co-trimoxazole
38
What are the characteristics of a Pseudomonas aeruginosa infection?
Seen in Pts with bronchiectasis/CF
39
What is the treatment for a Pseudomonas aeruginosa infection?
Treat with piptazobactam (piperacillin + tazobactam)
40
What is the presentation of Mycoplasma pneumonia?
Insidious onset
Persistent cough
Low grade fever
From a close community setting
41
What is seen in the blood film of a Mycoplasma pneumonia infection?
Red cell/cold agglutinins
42
What is the treatment for a Mycoplasma pneumonia infection?
Erythromycin/clarithromycin
43
What type of Pt often presents with a Staph aureus infection?
IVDU
44
What is seen in a CXR of a Pt with a Staph aureus infection?
Patchy consolidation
| Forms abscesses
45
What is the treatment for a Staph aureus infection?
Flucoxacillin
46
What is the treatment for an MRSA infection?
Vancomycin
47
What is the modality of transport for TB?
Aerosol droplets
48
What are the two conditions required for a Pt to present with TB?
Quite hard to catch TB- need prolonged exposure and:
1. Infection of Mycobacterium tuberculosis
2. Inadequate immune system
49
What are the risk factors for TB?
Recent travel to South Asians/India/Bangladesh, Latin America, or Africa
Immunosuppression (HIV)
Malnutrition
Alcoholism
50
What is the pathophysiology of TB?
Droplets enter the lungs
Macrophages + T lymphocytes contain the infection, forming a granuloma
In weak immune systems, the infection escapes
51
What are the symptoms of TB?
```
Cough for 2-3 weeks
From dry to wet (green sputum)
FLAWS especially S
Haemoptysis in <10%
SOB
Lymphadenopathy
```
52
What are the signs of TB?
Fever
Crackles
Bronchial breathing
Erythema nodosum
53
What are the investigations you should do for TB?
- Basic obs + bloods
- CXR
- Sputum MCS (x3 samples)
- IGRA = interferon gamma release assay
- Lymph node biopsy
54
What are the 3 buzzwords for a TB sputum smear?
1. Acid fast bacilli- property of TB
2. Ziehl-Neelson staining (type of stain for mycobacterium)
3. Lowenstein-Jensen agar (used to culture mycobacterium)
55
What are the categories of lung cancer?
Small cell (20%)
Non-small cell (80%)
- Adenocarcinoma (45% of NSCLC, peripheral in lungs)
- Squamous cell carcinoma (25-30%, later mets)
- Large cell carcinoma (10%, central)
Metastases
Mesothelioma
56
What are the risk factors for lung cancer?
Smoking
Exposure to tobacco smoke, radon gas, asbestos
COPD
57
Facts about lung cancer epidemiology
Most common cause of cancer mortality worldwide
| 3rd most common cancer in Europe
58
What are the characteristics of small cell carcinomas?
Strongest association with smoking
Arise in central lung
Rapid growth, highly malignant
May secrete ectopic hormones (ATCH/ADH)
59
What are the characteristics of adenocarcinomas?
Most common lung cancer in non-smokers
Most common lung cancer in females
Arise in peripheral lung
Most have pleural involvement
60
What are the characteristics of squamous cell carcinomas?
Most common lung cancer in male smokers
Strong association with smoking
Arise in central lung
Can produce PTHrP
61
What are the characteristics of large cell carcinomas?
Can arise centrally or peripheral
| Poor prognosis
62
What are the symptoms of a Pt with lung cancer?
FLAWS
SOB
Cough
Haemoptysis
63
What signs can you find in a Pt with lung cancer?
```
Horner's syndrome
Cachexia
Anaemia
Clubbing
Paraneoplastic syndromes
Wheeze, crackles, dull percussion, reduced breath sounds
```
64
What investigations would you do on a Pt with lung cancer?
```
Obs
CXR
CT
Sputum cytology (assessment of lung secretions)
Bronchoscopy
Biopsy (for definitive diagnosis)
```
65
What would you see in a CXR of a SCLC?
Central mass
Hilar lymphadenopathy
Pleural effusion
66
What would you see in a CXR of a NSCLC?
Single/multinodular nodes
Pleural effusion
Lung collapse
Mediastinal/hilar fullness
67
What is a mesothelioma?
An aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis
68
Which environmental exposure puts people at risk of developing a mesothelioma?
Asbestos
69
What 2 conditions can be caused by asbestos exposure?
Asbestosis
| Mesothelioma
70
What is asbestosis?
Diffuse interstitial fibrosis
| Due to inhalation of asbestos fibres
71
What is the difference between asbestosis and asbestos-induced mesothelioma?
Asbestosis- asbestos fibres deposited in the alveoli
| Mesothelioma- asbestos fibres deposited in the lining of the lungs
72
Which of the two (asbestosis and asbestos-induced mesothelioma) has a stronger correlation with smoking?
Asbestosis
73
What are the risk factors for a mesothelioma?
Asbestos exposure (shipyard/construction workers)
74
What are the symptoms and signs for a mesothelioma?
Dry cough
SOB
Muffled breath on auscultation (due to pl effusion)
75
What are the investigations for a mesothelioma?
CXR
| CT
76
What findings would you see in a CXR/CT of a Pt with mesothelioma?
Thickened pleural plaques
Fibrosis
Honeycomb appearance
77
25F presents to A&E with 2/7 Hx of productive cough, SOB and fever. The cough is worse at night. She has brought up green mucus 2/7. O/E you hear crackles throughout. Her PMHx is cystic fibrosis at birth and has had similar symptoms in the past.
What is the most likely diagnosis?
A. Asthma
B. Pneumonia
C. Chronic sinusitis
D. Bronchiectasis
D. Bronchiectasis
Resp symptoms, mucus, Hx of CF
All leads to bronchiectasis being the most likely.
78
25F presents to A&E with 2/7 Hx of productive cough, SOB and fever. The cough is worse at night. She has brought up green mucus 2/7. O/E you hear crackles throughout. Her PMHx is cystic fibrosis at birth and has had similar symptoms in the past.
What is the first line investigation for this patient?
A. Bloods (FBC, CRP)
B. CXR
C. CT
D. Pulmonary function
B. CXR
Everyone with these symptoms should get a CXR as a first line investigation. CT is the gold standard but only used when you have a high suspicion of bronchiectasis.
79
50M smoker with diabetes + HTN presents to A&E with 1/7 confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHg, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base. His urea is 5 mmol/L.
What is the most likely causative organism in this case?
```
A. Staphylococcus aureus
B. Mycoplasma pneumoniae
C. Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Legionella pneumophila
```
C. Streptococcus pneumoniae
80
50M smoker with diabetes + HTN presents to A&E with 1/7 confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHg, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base. His urea is 5 mmol/L.
How should we treat this patient?
A. Admit and give IV co-amoxiclav + macrolide
B. Admit and give oral amoxicillin
C. Admit for observations
D. Give him a smoke cessation leaflet
E. Send home with oral amoxicillin and advise to return if he becomes severely unwell
E. Send home with oral amoxicillin and advise to return if he becomes severely unwell
His CURB-65 score is only 1, due to the confusion.
81
General differentials for a productive cough
ACUTE
- pneumonia
- TB
CHRONIC
- Lung cancer
- Bronchiectasis
- Cystic fibrosis
MIXED
- Heart failure
- COPD
82
What is the most common bacterial cause of community-acquired pneumonia (CAP)?
Streptococcus pneumoniae
83
Which atypical organism is associated with faulty air conditioning systems?
Legionella
84
What scoring system is used to assess CAP severity?
CURB-65
85
What non-invasive test(s) can be used to identify the causative organism
Sputum culture
| also urinary antigen testing – atypicals
86
What organisms are found in aspiration pneumonia?
anaerobes from gut flora
87
Which pathogen causes atypical pneumonia in bird owners?
Chlamydia psittaci
88
Which pneumonia may be present in alcoholics?
Klebsiella
89
Which pneumonia causes hyponatraemia + abnormal LFTs?
Legionella pneumophilia
90
Which HAP causes cavitating lesions on CXR?
S. Aureus
| Klebsiella
91
Which pneumonia is associated with transverse myelitis?
Mycoplasma pneumonia
| Causes inflammation of spinal cord
92
green sputum is a sign of what?
bacterial pneumonia
93
What are the signs of pneumonia on percussion/auscultation?
Dull to percussion over area of consolidation
Basal coarse crepitations
Bronchial breathing (harsh, loud, high pitched)
Increased vocal resonance
94
Signs/symptoms of atypical pneumonia
- Dry cough
- Headache
- Diarrhoea
- Myalgia
- Hepatitis
95
A 35 year old man presents to his GP with shortness of breath and a dry cough. Upon further questioning, he admits to generalised muscle aches and a fever. He suffers from eczema and takes potent steroid medications. The patient lives at home with his dog and pet parrots.
What is the most likely causative organism?
```
A Streptococcus pneumoniae
B Chlamydia psittaci
C Mycobacterium tuberculosis
D Haemophilus influenzae
E Legionella pneumophila
```
Chlamydia psittaci
Dry cough and muscle aches suggest atypical organism
Parrots are a risk factor for chlamydia psittaci (usually doesn’t cause infection but this patient is immunocompromised due to the steroids)
96
what would an ABG show in pneumonia?
Type 1 respiratory failure
| low oxygen, normal CO2
97
2 types of pneumonia on CXR
1. lobar pneumonia (strep pneumoniae)
| 2. bronchopneumonia (patchy, heterogenous consolidation in numerous zones)
98
What causes air bronchograms?
BRONCHOPNEUMONIA
| bronchi filled with air, and surrounded by alveoli that are filled with pus (i.e. consolidation)
99
Which antibiotics would you use to treat pseudomonas?
Tazocin + gentamicin
100
Which antibiotics would you use to treat CAP?
amoxicillin (co-amoxiclav if sevre)
101
Which antibiotics would you use to treat atypical pneumonia infections?
Clarithromycin
102
Which antibiotics would you use to treat aspiration pneumonia?
Metronidazole
103
Pneumonia is most commonly treated with which to Abx?
Amoxicillin + clarithromycin
104
symptoms of lung abscess as complication of pneumonia
Swinging fevers
Persistent pneumonia
Foul-smelling sputum
105
Complications of pneumonia
Pleural effusion
Lung abscess (often Staph aureus)
Empyema (puss in pleural cavity)
Sepsis
106
Define TB
Infection by Mycobacterium tuberculosis, which causes multi-systemic disease
107
Explain the progression of TB disease
Primary: initial infection (often asymptomatic, can be pulmonary)
Latent: asymptomatic infection
Post-primary: reactivation usually when immunocompromised (severe symptoms)- may present decades after primary infection
If severe disease --> miliary = lymphohaematogenous dissemination of TB
108
State some extra-pulmonary manifestations of TB
- meningitis
- Erythema nodosum
- clubbing
- peritonitis, ascites
- constrictive pericarditis, effusion
- normocytic anaemia
- Pott's disease
- epidydimo-orchitis, infertility
- renal failure
- Addison's disease
109
What would you see on lymph node biopsy in TB
caseating granulomas
110
What is the Mantoux test?
TST injects purified protein derivative intradermally into skin.
If you have TB, you will form a larger radius of induration due to T-cell activity
Can't distinguish between active and latent TB
111
What would you see on CXR in a person with TB?
- Consolidation (patchy/heterogenous)
- Bi-hilar lymphadenopathy
- Upper lobe scarring- typically affects upper lobes
- Cavitating lesions
- Pleural effusions- like any pneumonia
- Nodular shadowing in miliary (severe) TB
112
A 42 year old woman presents to A&E with cough, haemoptysis and a fever. She has had worsening shortness of breath and has been losing weight unintentionally after returning from her holiday to Bangladesh.
SaO2 = 91%
RR = 22
HR = 99
What is the next best step in her management?
A Oxygen, 2L via nasal cannula
B Rifampicin, isoniazid, pyrazinamide and ethambutol
C Amoxicillin and clarithromycin
D Oxygen, 15L via non-rebreather mask
Oxygen, 15L via non-rebreather mask
Sats are low so treat her low oxygen first before treating the TB itself
Best way to reach target sats of 94-98% is with high flow oxygen (when she has reached her target sats, she can use a nasal cannula to keep her topped up on oxygen)
This is the ABCDE approach for acute conditions
113
acquired causes of bronchiectasis
Childhood/recurrent/persistent viral infx:
- Pneumonia
- TB
- Measles
- Pertussis
- Aspergillus fumigatus
Lung cancer
114
triad of Primary ciliary dyskinesia
Bronchiectasis
Sinusitis
Situs inversus (organs on wrong side)
115
What might discern pneumonia from bronchiectasis?
bronchiectasis = copious, large volumes of sputum
116
4 causes of respiratory clubbing (BILT)
Bronchiectasis
IPF
Lung cancer
TB
117
Gold standard test for bronchiectasis. What does this show?
HR-CT
| classic feature = signet ring sign
118
What is the pharmacological management of a Pt with bronchiectasis?
```
IV ABx (if acute infection)
Oral ABx (prophylactic)(e.g. azithromycin)
```
119
What might differentiate bronchiectasis from COPD?
presence of clubbing
120
most common lung cancer in non-smokers + females
adenocarcinoma
121
which lung cancer has the strongest association with smoking?
small cell/ non-small cell squamous
