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Question 1

Asthma
What?
Presentation?
Common allergens?
Drug cautions?

Answer 1

Chronic inflammatory airway disease characterised by intermittent obstruction and hyperreactivity

Recurrent wheezing, breathlessness, chest tightness, coughing

Allergic: house dust mite, pet fur, grass pollen -> IgE
Non: exercise, cold air, stress, strong emotion, viral infx, smoking

Beta blockers - B2 cause airway constriction
NSAIDS or aspirin block COX-1 -> decrease prostaglandins + overproduction of pro-inflammatory leukotrienes

Question 2

Pathophysiology of asthma

Answer 2

Early phase
Exposure to allergen in presensitised individual
X-link IgE on mast cells
Release inflammatory mediators histamine, leukotrienes and TNFa ->
Increase in vascular permeability and autonomic hypersecretion of mucus -> airway oedema
Increase in airway tone and increased smooth muscle responsiveness
Both lead to narrowed airways
Constriction at 30 mins, inflammation at 3 hours

Late phase: eosinophil mediated (recruited by IL4 and IL5) at 6 hours
Increased goblet cells
Epithelial denudation -> airway hyperresponsiveness
Deposition of matrix proteins and swelling -> airway remodelling and smooth muscle hyperplasia

Question 3

Presentation of Asthma

Answer 3

Worse at night and early morning
Wheeze (polyphonic and expiratory)
Episodic SOB 
Chest tightness
Cough - *worse at night
FHx atopy/nasal polyposis
Diurnal variation - *worse in morning

Question 4

Assessment of asthma control

Answer 4

How often felt SOB?
How often woken from sleep?
How often used reliever?
How often interfered with normal activities e.g. school/work?
How rate asthma control?
Asthma control questionnaire
Inhaler technique

Question 5

Ix for asthma

Answer 5

PEFR (peak flow rate) - diurnal variation >20%, according height/weight
Reversibility testing FEV1 improves by 15% with SABA (or PEF - 20%)
Spirometry
FEV1 < 80% + *FEV1/FVC < 70% = obstructive
CXR: normal or hyperinflation

Question 6

Step wise management of asthma

Answer 6

SABA
\+ low ICS  (800ug)
\+ LTRA (montelukast)
\+LABA (May remove or keep LTRA)
\+ Higher does of ICS (200ug)
\+ 40mg Pred
Hospital admission 

Antimuscarinic agents - Ipratropium/Triotopium can be used as adjuctive therapy.

Question 7

Acute asthma management

Answer 7

Moderate - PEF 50-75%
Severe - PEF 33-50%, RR>25, HR>110, inability to complete sentences (one of)
Life threatening - PEF<33%, SpO2 <92%, PaO2 < 8kPa, silent chest, exhaustion

Steroids within 1 hour
O2 aim 94-98%
Nebulised salbutamol
Reassess severity -> repeat salbutamol (every 20 mins) up to 3
If poor response add nebulised ipratroprium bromide up to 3
Within 1 hour: oral pred (mild) or IV hydrocortisone (sev/lt)

If PEF < 50% 
IV MgSO4
IV theophylline
IV salbutamol 
Intubate + ventilate if exhaustion

Question 8

COPD
What?
Pathophysiology (2 parts)?
Aetiology

Answer 8

Chronic obstruction with irreversible airflow obstruction -> air trapping and hyperinflation

Narrowing of airways and mucosal oedema -> mucus hypersecretion -> cough and excessive mucus for 3M per year for >2y
Elastin breakdown: Permanent destruction and enlargement of alveoli

Cigarette smoking -> inactivation of A1AT
Occupational (particles and gases)
A1ATD

Question 9

COPD
Symptoms
Signs
Pink puffer vs Blue bloater

Answer 9

SOB (initially with exercise but progresses) + cough (morning)

Barrel chest, CO2 flap, hyperresonant percussion, distant breath sounds (over bullae, hyperinflation and trapping), coarse crackles (exacerbation), wheeze (exacerbation)

Pink puffer: emphysema -> CO2 retention -> old and thin, use of accessory muscles

Blue bloater: peripheral oedema and overweight from RHF

Question 10

COPD complications

Answer 10

Cor pulmonale - RHF secondary to long standing COPD - raised JVP, distended neck veins, hepatomegaly - Rx: LTOT + loop diuretic
Pneumonia - pneumococcal vaccine and yearly influenza vaccine
Depression*
Polycythaemia
Respiratory failure:
T1: PaO2 < 8 (Ventilation/perfusion mismatch)
T2: PaO2 < 8 + PaCO2 > 6.0 (Alveolar hypoventilation)

Question 11

Ix of COPD

4 x ray changes.

Answer 11

Spirometry: Classification based upon FEV1
Obstructive pattern: FEV1/FVC < 0.7
Non-reversible
Decreased pulse oximetry
ABG: may see hypoxia +- hypercapnia
CXR: 
Flattened diaphragm
Increased intercostal spaces
Hyperlucent lungs
Increased AP diameter
FBC: may see polycythaemia (HCT > 0.55) + Hb rise

Question 12

Management of COPD

Answer 12

Patient education + vaccination + depression screen + COPD nurse
Smoking cessation, exercise, obesity mgmt (pulmonary rehabilitation)
Inhaled therapy
LTOT (*15hrs) IF PaO2 <7.3 or 7.3-8 with SaO2 < 88 or CHF or oedema or PCV

Inhalers if no significant improvement.

Question 13

Infective exacerbation of COPD

Management

Answer 13

SABA + SAMA neb (salbuamol + ipratropium) + O2 (24% venturi aim for 88-92%)
Oral corticosteroid (prednisolone) - prevents recurrence
Airway clearance - mucolytics + physio
BIPAP if respiratory insufficiency
Blood culture and sputum culture + gram stain

Community (less severe)
Narrow spectrum: amoxicillin or doxycycline
Hospital
Broad spectrum: ?IV vancomycin or tazocin

Question 14

Cell differences in COPD vs Asthma

Answer 14

Neutrophils + macrophages = COPD

Mast cells + eosinophils = Asthma

Question 15

CURB 65

Answer 15

CURB 65 
Confusion
Urea > 7
RR > 30
BP < 90 or < 60 diastolic
65

Score
0-1 - low risk, recommend outpatient care
2 - moderate risk - to hospital
3-5 - high risk = to ITU (30 day mortality = 15-40%)

Question 16

Pneumonia Ix & Chest xray changes

Answer 16

FBC, CRP (raised WCC, raised CRP)
ABG: may be low oxygenation
Sputum culture and sensitivity - for causative
CXR - lobar
Air bronchograms
Consolidation: homogenous opacification in lobe
Atelectasis if small airway obstruction (incomplete obstruction)
If atypical = diffuse reticular or reticulonodular opacities (affects interstitium)
Blood culture - for causative organism
*Urinary antigen: for legionella and pneumococcus

Question 17

Pneumonia management
Low/Mod/Severe
Hospital aq
Legionella
Chlamydia

Answer 17

O2 if needed + IV fluids if needed +

Low risk (0-1) CAP: Oral 5 day amoxicillin

Mod (2) CAP: Oral 7-10 days amoxicillin + clarithromycin (doxycycline if allergic)

Mod and high risk (2+) CAP: 7-10 day dual therapy:
Co-amoxiclav + clarithromycin (IV) if penicillin allergic = cefotaxime

HAP: IV cefotaxime + gentamicin
Legionella: Clarithromycin + fluoroquinolone
Chlamydia: Doxycycline

Question 18

Complications of Pneumonia

Answer 18

Septic shock
ARDS - non-cardiogenic pulmonary oedema
Pleural effusion (50%) + empyema
*Hepatisation (histologically)

Question 19

Bilateral hilar lymph enlargement

Answer 19

Sarcoid
TB
Lymphoma

Question 20

TB aetiology
Risk factors
Organisms

Answer 20

Birth endemic (asia etc), immunocompromised (e.g. HIV), exposure (v.infective)
Poor nutrition, overcrowding, IVDU, homeless, prisons
M. tuberculosis, m. bovis

Question 21

TB Pathophysiology

Answer 21

MP @ midzone of lun engulfs bacteria
MP + LC -> granuloma -> Ghon Focus
MP presents antigen to T cell -> caseation
Caseation heals and calcifies -> some bacilli -> regional LN (mediastinal) -> Ghon complex (calcified focus + associated LN)
Secondary lesions form @lung apices -> fewer WBC (usually at year 1 or 2)

Question 22

TB Presentation

Answer 22

Cough (+haemoptysis) + fever + weight loss + night sweats + weight loss + RF
Pleuritic chest pain + erythema nodosum
Crackles, bronchial breathing

Question 23

Ix for TB

Answer 23

CXR:
Primary: consolidation + ipsilateral hilar enlargement (lymphadenopathy)
Healed primary: Ghon focus: large round calcified lesion near hilum
Post primary: fibronodular upper zone opacities with cavitation + calcification + consolidation to hilum

3 x sputum acid fast bacilli smear
Ziehl-Neelsen stain - pink
Sputum culture
No growth or solid medium = 4-8 weeks or liquid medium = 1-3 weeks
FBC - leukocytosis and anaemia
NAAT - +ve for m.tuberculosis

Question 24

Medical TB management

Infectivity TB management

Answer 24

6M Rifampicin: liver tox, orange secretions, induces hepatic enzymes (accelerate oestrogens, steroids, anticoagulants, phenytoin)
6M Isoniazid: liver tox, peripheral neuropathy (give w/ pyridoxine B6)
2M Pyrazinamide: liver tox, hepatitis
2M Ethambutol: *visual disturbance: optic neuritis, loss of acuity

Isolate patient e.g. negative pressure room
Contact tracing and treatment
Decreased infectivity after 2 weeks of treatment + 3 consecutive -ve AFB smears
Screen household and close contacts

Question 25

Extra pulmonary TB (8)

Answer 25

Pleura - pleural TB leads to pleural effusion LN - scrofula - swelling and discharge GU - frequency/dysuria/haematuria Bone - osteomyelitis starting in growth plates of bone Pott's disease - vertebral fracture associated with TB Brain - TB meningitis - Rich foci Abdomen - ascites (peritoneal) and abdominal LN Miliary TB: millet seed appearance on CT: liver/spleen/lung - by haematogenous spread

Question 26

DVT Clot forming triad Risk Factors

Answer 26

Virchow’s triad: venous stasis, vessel injury, activation of clotting system (hypercoaguable state) Thromboembolic risk factors: Cancer, trauma, major surgery, hospitalisation, immobilisation, oral contraception, obesity/preg (high oestrogen), recent flight (immobilisation) Genetic risk factors: (Family history) Factor V leiden, protein C deficiency, protein S deficiency, antithrombin deficiency, antiphospholipid

Question 27

Wells scoring for DVT Ix pathway

Answer 27

``` 0 or 1 = D dimer If D dimer negative = No DVT. D dimer positive/2 or more Wells = USS <4hours If positive = Treat. If negative = Repeat @6-8 days ```

Question 28

Types of pulmonary embolism

Answer 28

``` Thrombus formation in distal veins -> 50% will embolise Amniotic fluid embolus Fat embolus (at long bone fracture) Air embolus Tumour embolus ```

Question 29

X ray appearance of PE

Answer 29

Wedged shaped opacity set against the pleura.

Question 30

PE Wells scores

Answer 30

``` DVT = 3 Most likely = 3 TachyC (>100) = 1.5 Immobilisation (bed > 3 days or surg in 4 weeks) = 1.5 Hx DVT/PE = 1 Haemoptysis = 1 Malig (6 months) = 1 4 points = PE likely ```

Question 31

Ix for PE

Answer 31

``` ECG: sinus tachycardia, S1Q3T3, RBBB D dimer + CTPA CXR: Decreased vascular markings, atelectasis, small pleural efusion Late sign: wedge shape infarction ABG: reduced PaO2, high lactate ```

Question 32

PE management

Answer 32

Haemodynamically stable: LMWH (dalteparin) or fondaparinux (10a inhibitors) then switch to warfarin Haemodynamically unstable (?renal fail): UFH ± thrombolysis (alteplase) For 5 days OR till INR > 2 for 24 hours (longer) Unprovoked - Warfarin/ NOACfor 3 months Provoked - As above but lifelong

Question 33

DVT management

Answer 33

LMWH or fondaparinux (5d) with warfarin (3 months) or LMWH (6 months) *if unprovoked = 6M

Question 34

Pulmonary fibrosis What? FVC? FEV1/FVC? Presentation?

Answer 34

Restrictive interstitial lung damage and fibrosis leading to decreased compliance FVC low, FEV1/FVC high 4Ds: dry cough, dyspnoea, digital clubbing, diffuse inspiratory crackles

Question 35

Types of pulmonary fibrosis (3)

Answer 35

Replacement fibrosis - secondary to lung damage - Infarction, tuberculosis, pneumonia Focal fibrosis: due to irritants Coal dust, silica, aspestosis DPLD: diffuse parenchymal lung disease IPF, Hypersensitivity pneumonitis (Bird fanciers, Farmers, cheese workers)

Question 36

Causes of pul fibrosis (5) | Presentation

Answer 36

Connective tissue disease: RA, SLE, SS, Sjogren’s Occupational exposure: asbestos, coal dust, silica Medication: amiodarone, bleomycin, methotrexate Inhalation of irritants: hypersensitivity pneumonitis, birds, mould Radiation Progressive SOB, non productive cough, finger clubbing, cor pulmonale, fine end inspiratory crackles in bases.

Question 37

Imaging of Idiopathic pulmonary fibrosis

Answer 37

``` CXR: reticular shadowing (net-like) of lung peripheries + bases, shaggy heart border, ground glass and honeycombing appearance. ``` HRCT: Honeycombing, reticular pattern, and reticular septal thickening, no micronodules or cysts

Question 38

Idiopathic pulmonary fibrosis treatment

Answer 38

Pirfenidone - Antifibrotic. Median survival 2-5 years

Question 39

RA lung disease (4)

Answer 39

Interstitial lung disease in middle aged men Rheumatoid nodules may lead to small effusion Methotrexate associated pneumonitis -> stop and Rx with steroids Caplan’s syndrome - pulmonary fibrosis in coal workers with RA

Question 40

Scleroderma lung disease (3) | Antibody detected

Answer 40

Chest wall fibrosis -> restrictive ventilatory defects Diffuse fibrosis of alveolar walls Pneumonia from aspiration from stiff oesophagus ANA - 95%

Question 41

Sarcoidosis lung changes | Treatment

Answer 41

Multisystem granulomatous disorder (non-caseating) Pulmonary fibrosis + BHL Oral prednisolone if BHL persists past 6 months

Question 42

Hypersensitivity pneumonitis Pathology Examples

Answer 42

Non-IgE mediated widespread inflammation of alveoli and distal bronchioles Cellular infiltrate -> *non-caseating granulomas (reticulo-nodular) Farmer’s lung (hay), pigeon fancier’s lung (droppings protein), maltworker’s lung, cheese maker’s lung

Question 43

Clinical features of Sarcoidosis (7)

Answer 43

Chest - Cough, SOB, Wheeze, inspiratory crackles Skin - Erythema nodosum, infiltration of scars with sarcoid Eye - Anterior &; Posterior uveitus, conjunctivial nodules Bone - Arthralgias, bone cysts Metabolic - Hypercalcaemia Neuro - Meningeal inflammation, mass lesions, seizures, diffuse sensoryneuropathy Cardio - Ventricular arrythmia, conduction defects

Question 44

Hypersensitivity pneumonitis Ix

Answer 44

CXR: diffuse micronodular interstitial shadowing - upper zone CT: reticulo-nodular shadowing, ground glass, micronodules LuFT: restrictive, decreased DLco (diffusing lung capacity of carbon monoxide), decreased SpO2

Question 45

Nodular pattern in upper lung zones & Black sputum

Answer 45

Coal workers pneumoconiosis & Silicosis

Question 46

Asbestosis Time delay Presentation Ix

Answer 46

20 - 40 years Dry cough, dyspnoea, diffuse inspiratory crackles: velcro, digital clubbing LuFT: restrictive CXR: ground glass opacification, small nodular opacities (asbestos bodies - in alveoli at lung bases), shaggy cardiac sillhouette Sputum microscopy: asbestos bodies Biopsy

Question 47

Effects of asbestos on the lung

Answer 47

Pleural effusions Plerual thickening - Parietal and viseral. Pleural plaques (benign) Mesothelioma Asbestosis - Breathless, finger clubbing, fine inspiratory crackles Lung cancer

Question 48

Mesothelioma Presentation (4) Stageing

Answer 48

Hx of asbestos exposure, aged 60-85 Dry cough, dyspnoea, dig club + pleuritic chest pain (*recurrent pleural effusion) Symp of pleural effusion: diminished breath sounds, dull to percuss Constitutional symptoms: weight loss, fatigue, fever, night sweats 1a: ipsilateral parietal pleura 1b: ipsilateral visceral pleura 2: diaphragm or lung involvement 3: ipsilateral bronchopulmonary or hilar LN 4: contralateral or distant mets

Question 49

Mesothelioma Ix Management

Answer 49

CXR - Irregular pleural thickening, reduced lung vol, ev asbestosis, unilateral pleural effusion CT - Pleural thickening, pleural plaques, hilar or mediastinal LN enlargement Thoracocentesis - Exudate with malignant cells Pleural biopsy (*epithelioid mesothelioma) Operable: only curative at stage 1 Inoperable: Chemoradio Survival = 1 year

Question 50

Pleural effusion What? Types & Egs

Answer 50

Excessive fluid in the potential space between visceral and parietal pleura Transudate (low protein <30g/L): disruption of hydrostatic and oncotic forces across pleural membranes, - Heart failure, cirrhosis, hypoalbuminaemia, nephrotic syndrome, Meig’s = right pleural effusion + ovarian fibroma + ascites Exudate (high protein >30g/L): increased permeability of pleura from inflammation - Infection (pneumonia, TB, emyema), malignancy, PE, AI disease (RA) comp of MI (Dressler’s)

Question 51

Pleural effusion signs (5)

Answer 51

``` Reduced chest wall movment Dull to percussion Absent breath sounds Reduced vocal resonance Mediastinum shift ```

Question 52

Unilateral pleural effusion management

Answer 52

Clinical picture transudate? Yes -> treat cause (LVF, hypoalbuminaemia) No -> USS guided pleural aspiration/thoracentesis Pleural fluid for: cytology, MC+S, AFB stain, LDH, protein, glucose, amylase, RF PH - normal = 7.6, <7.2 = empyema, RA, SLE, TB, malignancy Glucose < 3.3 = empyema, RA, SLE, TB, malignancy

Question 53

Types of pneumothorax (3)

Answer 53

Primary spontaneous: tall thin males, smoking, Marfan’s, family history Secondary spontaneous: pre-existing lung disease: COPD (bullae), CF, TB, Pneumocystis Pneumonia Traumatic

Question 54

Pneumothroax presentation | X ray changes

Answer 54

Pleuritic CP + dyspnoea (size and sev) Hyper-resonant Reduced expansion Decreased breath sounds Visceral pleural line identified Dark area with no lung markings Diaphragm pushed downwards

Question 55

Tension pneumothorax Signs Management

Answer 55

``` Respiratory distress with rapid shallow breathing Distended neck veins Tracheal deviation away Hyperexpanded ipsilateral hemithorax TachyC/TachyP Hyper-resonant Reduced expansion Decreased breath sounds ``` Immediate needle thoracostomy: 2nd IC mid clavicular 100% O2

Question 56

Pneumothorax maagement

Answer 56

O2 If haemodynamically unstable insert chest drain Primary >2cm/SOB - Fine needle aspiration - No success then chest drain and admit. <2cm - Discharge, review in 2 weeks, avoid strenuous Secondary >2cm/SOB - Chest drain and admit 1-2cm - Fine needle aspritation 1cm - Admit, O2 and observe for 24 hours

Question 57

Chest drain placment

Answer 57

Lateral border pectoralis major Anterior border latissimus dorsi Horizontal line at nipples Mid axillary IC 4-6 with pain relief

Question 58

Pleuritic chest pain DDx

Answer 58

``` ACS Aortic dissection Pneumothorax PE Pneumonia Malignancy ```

Question 59

Bronchiectasis Pathology Presentation Causes (5)

Answer 59

Failure of mucociliary clearance and impaired immune function -> continued insult to bronchial wall -> chronic inflammation -> Permanent dilatation and thickening Recurrent (chronic daily) cough, excessive sputum, bacterial colonisation, recurrent infection ``` Post infectious: measles/flu/pertussis, aspergillus fumigatus (ABPA), pneumonia Immunodeficiency: HIV, Ig deficiency Genetic: CF, ciliary dyskinesia, A1ATD Connective tissue disease: RA, Sjogren’s IBD: CD, UC ```

Question 60

Early inspiratory: airway disease | Late inspiratory: interstitial disease

Answer 60

Early - Bronchiectasis | Late - IPF

Question 61

Bronchiectasis Symptoms/Signs Sputum culture and sensitivity Chest X ray

Answer 61

``` Cough and daily sputum Intermittent haemoptysis Obstructive symptoms: dyspnoea + wheeze Weight loss and fatigue Inspiratory coarse crackles (shift on cough), high pitched inspiratory squeaks and pops, low pitched rhonci (snoring sounds), clubbing ``` ``` G- = pseudomonas aeruginosa (high risk if CF) G+ = s.aureus, s.pneumonia ``` Normal/dilated bronchi with thickened walls + cysts (cystic shadows)

Question 62

Cystic fibrosis pathology

Answer 62

Genetic disease with mutations in CFTR gene, a Cl channel in Lungs, bowel, pancreatic duct, sweat glands, reproductive organs Failure of Cl channel opening in response to cAMP in epithelial cells Decreased excretion of Cl to lumen, increased reabsorption of Na to cells Decreased excretion of H20 Thick, sticky secretions

Question 63

Cystic fibrosis Screening Presentation

Answer 63

Serum immunoreactive trypsinogen on 5d heel prick (Guthrie). Neonates + infants: failure to pass meconium, failure to thrive, large appetite (pancreatic insufficiency), chronic wet cough Resp - Recurrent infection, chronic cough, wheeze, thick mucus, nasal polyps GI - Gallstones, decreased motility Panc - Insufficiency -> bulky, greasy, foul smelling stool Reproductive system - Absent VAS - infertility Digital clubbing

Question 64

Infective organisms in CF

Answer 64

Pseudomonas aeruginosa (70%) - *highly transmissible Burkholderia cepacia S.aureus

Question 65

CF management

Answer 65

Oral/IV ABX (oral = co-amoxiclav, if IV = gentamicin + cover for pseudomonas/staphylococcus tazocin) Chest physio Inhaled bronchodilator Inhaled mucolytic: Segregate in hospital Vaccination: influenza and pneumococcal Prophylactic ABX: fluclox or amoxi Pancreatic enzyme replacement, fat soluble vitamins DEAK, GORD = H2 antag + PPI Treat CF diabetes, fertility and genetic counselling

Question 66

Pulmonary hypertension Definition Presentation

Answer 66

Mean pulmonary artery pressure >25mmHg at rest with pulmonary capillary wedge pressure <15mmHg Dyspnoea Accentuated P2 (pulmonary component of second heart sound) Tricuspid regurgitation murmur (high pitched holosystolic) Pulmonary regurgitation murmur (Graham Steell) - high pitched early diastolic at pulm area (normally if pul HTN secondary to mitral stenosis) RHF: oedema, exertional syncope, visible RV heave, pulsatile hepatomegaly, ascites, raised pulsatile JVP

Question 67

Pul Hypertension | Management

Answer 67

CCB (nifedipine or amlodipine) or sildenafil (PDE5 inhibitor - augments pulmonary vascular response to nitric oxide) Anticoagulant: warfarin target 1.5 to 2.5 Lifestyle: low level graded exercise Oedema: furosemide and low salt diet Supplemental O2 if needed

Question 68

Types of lung cancer

Answer 68

``` Small cell (least common) 15% Non-small cell (most common) 85% -Adenocarcinoma -Squamous cell carcinoma -Large cell carcinoma ```

Question 69

Non Small cell carcinomas (3)

Answer 69

Adenocarcinoma - 40% - peripheral lung - From mucus cells at bronchial epithelium - Mets: brain, adrenal bone - Most common LC with aspestos Squamous cell carcinoma - 20% - central airways, metastasise late - Present as obstructive lesion - Local spread common - Well differentiated cells Large cell carcinoma - 10% - central airways, appear undifferentiated Metastasise early very large

Question 70

LC presentation General Locally invasive (3)

Answer 70

Cough + dyspnoea + haemoptysis (new or persistent) Requires imaging Chest pain (lung has no pain fibres therefore this suggests invasion of pleura or chest wall) Constitutional symptoms: Weight loss, fatigue Local invasive symptoms Pancoast tumour - Invasion of brachial plexus -> weakness, parasthesia, pain in C8-T1, shoulder pain - Invasion of sympathetic chain -> Horner’s syndrome Ptosis, miosis, ipsilateral anhydrosis Recurrent laryngeal nerve -> hoarseness Mediastinal invasion/shift -> dysphagia, arrhythmia, facial swelling (compression of superior vena cava)

Question 71

NSCLC staging

Answer 71

T1: < 3cm T2: 3-7cm, assoc atelectasis, involves main bronchus >2cm to carina, invades visceral pleura T3: >7cm and directly invades chest wall, diaphragm, phrenic, mediastinal pleura, parietal pericardium T4: invasion of mediastinal organs: oesophagus, trachea, great vessels, heart, malignant pleural effusion, recurrent laryngeal N1: ipsilateral bronchopulmonary or hilar N2: ipsilateral mediastinal or subcarinal N3: contralateral mediastinal, hilar or any supraclavicular M1: mets present, contralat lung or malignant pleural effusion

Question 72

Goodpasture’s What Presentation Antibody

Answer 72

Anti-glomerular basement membrane disease Pulmonary renal syndrome Usually as an AKI caused by rapidly progressive glomerulonephritis. Kidney symptoms: oedema, *reduced urine output Lung symptoms: cough + haemoptysis + SOB + fever AntiGBM aB: autoantibody to type IV collagen (alveoli and glomeruli)

Question 73

Respiratory failure

Answer 73

Type 1: hypoxia (<8kPa) without hypercapnia (>6kPa) T1: COPD (pink puffer), pneumonia, pulmonary oedema, fibrosis, asthma, PE, ARDS Type 2 hypoxia + hypercapnia 2: COPD (blue bloater), asthma, myasthenia gravis, polyneuropathy

Question 74

ARDS What? Cause

Answer 74

Dyspnoea and hypoxaemia caused by non-cardiogenic pulmonary oedema and diffuse lung inflammation which may progress to respiratory failure Most common: SEPSIS OR PANCREATITIS

Question 75

Location of pulmonary fibrosis Upper Lower

Answer 75

hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) coal worker's pneumoconiosis/progressive massive fibrosis silicosis sarcoidosis idiopathic pulmonary fibrosis most connective tissue disorders drug-induced: amiodarone, bleomycin, methotrexate asbestosis

Question 76

Kelbsiella pneumonia

Answer 76

Causes cavitating upper lobe mass & infective symptoms

Question 77

Small cell para neoplastic

Answer 77

ADH, ACTH, Lambert-Eaton syndrome (muscle weakness - NMJ) SIADH - hyponatraemia ACTH - HTN, hyperglycaemia, hypokalaemia, alkalosis, muscle weakness LES - weakness that improves with muscle contraction

Question 78

Squamous cell para neoplastic

Answer 78

PTH-rp, clubbing, TSH PTHrp - bone pain and hypercalcaemia Hyperthyroidism

Question 79

Adenocarcinoma para neoplastic

Answer 79

Gynaecomastia