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Yr 3: CN2 > Resp II > Flashcards

Resp II Flashcards

1
Q
A
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2
Q

Which type of organisms are most likely to cause HAP? [1]

Which infective organisms are most likely to cause HAP? [4]

A

Gram negative organisms:

PEKA:
Pseudomonas aeruginosa,
Escherichia coli
Klebsiella pneumoniae
Acinetobacter species.

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3
Q

Which organisms are most likely to cause atypical pneumonias? [5]

A

TOM TIP: You can remember the 5 causes of atypical pneumonia with the mnemonic: “Legions of psittaci MCQs”:

Legions: Legionella pneumophila
Psittaci: Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)

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4
Q

State 4 clinical consequences of untreated Mycoplasma pneumonia [4]

A

Haemolytic anaemia
Erythema multiforme
Encephalitis
Peri / myocarditis

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5
Q

How do you treat Mycoplasma pneumonia? [2]

A

1st line:Erythromycin OR Clarithromycin

2nd line: Doxycycline or a macrolide (e.g. )

Because generally there is no diagnosis of the pathogen at the time of treatment, initiation of the treatment is usually empirical

BMJ BP

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6
Q

State and describe this complication of Mycoplasma pneuomia [2]

A

bullous myringitis: painful vesicles on the tympanic membrane

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7
Q

What clinical presentation may indicate COVID caused pneuomonia? [1]

A

Silent hypoxia: Patients may not feel particularly short of breath despite having low oxygen saturations

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8
Q

Alongside CURB65, describe which test is sometimes used to determine Abx therapy in the primary care setting [3]

A

NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:

CRP < 20 mg/L - do NOT routinely offer antibiotic therapy

CRP 20 - 100 mg/L - consider a DELAYED antibiotic prescription

CRP > 100 mg/L - OFFER antibiotic therapy

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9
Q

Describe the treatment algorithm for mild / low severity CAP? [2]

A

First line: 5 day course
- Amoxicillin
- If if penicillin allergic: clarithromycin (macrolide) OR doxycycline (tetracycline)

Second line:
- No respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).

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10
Q

Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | moderate-severity (CURB-65 = 2)?

A

7-10 day course is recommended

1st line:
- ORAL amoxicillin plus a macrolide: clarithomycin
- For patients who are allergic to penicillin in whom oral antibiotics are contraindicated: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone)

PLUS
clarithromycin, or intravenous levofloxacin monotherapy

2nd line:
- Change to doxycycline or a fluoroquinolone: ciprofloxacin AND pneumococcal cover: levofloxacin or moxifloxacin

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11
Q

Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | high-severity (CURB-65 = 3-5)?

DOUBLE CHECK

A

1st line:
- A broad-spectrum beta-lactamase-resistant penicillin: amoxicillin/clavulanate plus a macrolide: clarithromycin
- If allergic to penicillin: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) PLUS a macrolide (e.g., clarithromycin)

2nd line:
- Doxycycline OR
- Cefalexin OR
- Trimethoprim

3rd Line:
- levofloxacin

BMJ BP

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12
Q

In patients with suspected or confirmed Staphylococcus aureus MRSA infection, what are the two treatments? [2]

A

IV Vancomycin
OR
IV teicoplanin

with or without

Rifampicin (orally or intravenously)

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13
Q

State the treatments for these atypical pneumonias [5]

A

A: Clarithromycin (orally or intravenously)

B: Fluoroquinolone (ciprofloxacin) (orally or intravenously)

C: Amoxicillin (orally) or
D: benzylpenicillin
(intravenously)

E: Doxycycline (orally)

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14
Q

In patients with suspected or confirmed Staphylococcus aureus non-MRSA infection, what are the two treatments? [2]

A

Flucloxacillin (intravenously)

with or without

Rifampicin (orally or intravenously)

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15
Q

What is the treatment algorithm for mild to moderate symptoms/signs and not at higher risk of resistance for HAP? [2]

How long for? [1]

A

5 day prescription

ORAL:
- amoxicillin/clavulanate (aka Co-amoxiclax)
- If allergic: Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole

NICE

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16
Q

What is the treatment algorithm for severe symptoms/signs and not at higher risk of resistance for HAP? [2]

How long for? [1]

A

1st line:
- piperacillin/tazobactam OR
- ceftazidime OR
- cefuroxime OR
- meropenem

2nd line:
- levofloxacin

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17
Q

Label the progress expected post-pneumonia from 1 week - 6 months

A

1 week:
- Fever should have resolved

4 weeks:
- Chest pain and sputum production should have substantially reduced

6 weeks:
- Cough and breathlessness should have substantially reduced

3 months
- Most symptoms should have resolved but fatigue may still be present

6 months:
- Most people will feel back to normal.

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18
Q

All patients with moderate-severe pneumonia should have what investigations? [3]

(NICE & BTS)

A

All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats

Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum

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19
Q

All patients with severe + outbreaks of pneumonia should have what investigations? [3]

(NICE & BTS)

A

All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats

Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum

Severe+:
- Mycoplasma PCR
- Chlamydophilia PCR
- Viral PCR

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20
Q

BTS guidelines:

What are the treatments for

S. aureus non-MRSA? [1]
S. aureus MRSA? [2]

A

S. aureus non-MRSA: flucloxacillin

S. aureus MRSA: vancomycin OR linezolid OR teicoplanin +/- rifampicin

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21
Q

State what is meant by Lofgren’s syndrome [1]

How does Lofgren’s syndrome usually present? [4]

A

Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.

It usually carries an excellent prognosis

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22
Q

Explain what is meant by Heerford’ts syndrome [1]

What is the classical presentation? [3]

A

Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

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23
Q

Describe the clinical features of sarcoidosis if each of the following are effected:

  • Skin [3]
  • Lungs [3]
  • Systemically [3]
A

Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.

24
Q

What treatment might be given to for treating skin sarcoid? [1]

A

Hydroxychloroquine

25
**a prolonged PR interval**
26
Describe the classic triad of yellow nail syndrome [3]
* Yellow fingernails * Bronchiectasis * Lymphoedema ## Footnote TOM TIP: Yellow nail syndrome is characterised by yellow fingernails, bronchiectasis and lymphoedema. Patients are stable and have good clinical signs, making it a good choice for OSCEs. As it is rare, examiners will score high marks if you can combine these features and name the diagnosis.
27
Asides from imaging investigations, describe what else you would investigate for bronchiestasis [7]
**Sputum culture** - Most commonly **Haemophilus** **influenzae** and **Pseudomonas** **aeruginosa** **FBC**: - may reveal **high eosinophil** count in **bronchopulmonary aspergillosis** **specific IgE or skin prick test to Aspergillus fumigatus** **serum alpha-1 antitrypsin phenotype and level** **serum immunoglobulins** - to identify individual immunoglobulin deficiencies as underlying aetiology **Rheumatoid factor** **Serum HIV antibody**
28
Describe the treament algorithm for bronchiestasis for the initial presentation? [5]
**initial presentation** **1ST LINE:** **exercise and improved nutrition**. - Including vitamin D supplementation - Higher BMI has beneficial outcomes - Excercise is considered form of airway clearance **PLUS** – **airway clearance therapy** **(ACT):** - maintenance of oral hydration; percussion, breathing, or coughing strategies - positioning and postural drainage; positive expiratory pressure devices; and oscillatory devices - recommended for 15 to 30 minutes, 2 or 3 times daily **PLUS** – **self-management plan** **CONSIDER** – inhaled bronchodilator: - **salbutamol inhaled** **CONSIDER** – **mucoactive agent** - **hypertonic saline** | BMJ BP
29
acute exacerbation: mild to moderate underlying disease if is first or new presentation of **Pseudomonas aeruginsoa**
**1ST LINE –** **short-term oral antibiotic:** - For adults, prescribe **amoxicillin 500 mg three times a day for 7–14 days** **PLUS – increased airway clearance** **PLUS – continued maintenance therapy**: - Healthy diet & exercise - Higher BMI - Nebulised bronchodilators - Nebulised hyperosmolar agents, such as hypertonic saline,
30
Describe how treatment for bronchiectasis would be escalated in a stepwise manner if they were suffering ≥ 3 exacerbations in one year despite following the initial management?
3 or more exacerbations per year despite maintenance therapy **1ST LINE – reassess physiotherapy ± mucoactive treatment** **PLUS – continued maintenance therapy** - Azithromycin 500 mg three times a week, or - Azithromycin 250 mg daily, or - Offer a minimum of 6 months treatment, but up to 1 year may be required. **CONSIDER – long-term antibiotic** **CONSIDER – surgery**: - Surgical resection is considered in patients with localised disease whose symptoms are not controlled by optimal medical treatment - **Complete resection** of the bronchiectatic area is associated with the **best** **results** **CONSIDER – treatment of respiratory failure**
31
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Streptococcus pneumoniae. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * Ciprofloxacin 500 or 750 mg twice daily
**Amoxicillin 500 mg three times daily**
32
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Haemophilus influenzae****beta lactam negative**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Haemophilus influenzae**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily **Amoxicillin 500 mg three times daily** * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * Ciprofloxacin 500 or 750 mg twice daily
33
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Haemophilus influenzae (beta-lactamase positive)**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * Ciprofloxacin 500 or 750 mg twice daily
**Co-amoxiclav 625 mg three times daily**
34
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Pseudomonas aeruginosa**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Pseudomonas aeruginosa**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * **Ciprofloxacin 500 or 750 mg twice daily**
35
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Klebsiella**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as **Klebsiella**. What is the approriate first line treatment * Co-amoxiclav 625 mg three times daily * Amoxicillin 500 mg three times daily * Flucloxacillin 500 mg four times daily * Doxycycline 100 mg twice daily PLUS rifampicin (for adults) * **Ciprofloxacin 500 or 750 mg twice daily**
36
[] is the usual choice for infective exacerbations caused by Pseudomonas aeruginosa
**Ciprofloxacin** is the usual choice for exacerbations caused by Pseudomonas aeruginosa
37
State 5 common causes of T1RF [6] (and the cause of hypoxia)
**Diffusion abnormality:** - Pulmonary fibrosis - Emphysema in COPD **V/Q mismatch: reduced V** - Pneumonia - Pulmonary oedema - Pneumothorax **V/Q mismatch: reduced Q** - Pulmonary embolism **Low inspired oxygen** | Hypxoxia = increased V More CO2 exhaled Hypoxia but not hypercapnic
38
What are common causes of chronic T2FR? [5]
Obstruction to airways: * **COPD** * **Severe asthma** Hyperexpanded lungs: - **COPD** Thoracic cage problems: - **Kyphoscoliois** - **Obesity** Weakness of resp. muscles * **Chronic neurological disorders** (e.g. motor neuron disease) * **Chronic neuromuscular disorders** (e.g. myopathies)
39
Which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
Lobar pneumonia causing V/Q mismatch
40
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Diffusion abnormality**: patient has **sarcoidosis**
41
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Hypoventilation**: patient has **TB**
42
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Hypoventilation**: lobar collapse
43
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Diffusion limitation**: Pulmonary fibrosis
44
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Hypoventilation**: COPD Can be T1 or T2RF
45
Out of which of the following would this cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Hypoventilition**: motor neuron disease - can't use muscles / diaphragm to breathe
46
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**VQ mismatch**: pneumothroax
47
Out of which of the following would this cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
Morbid obesity: **hypoventilation**
48
Out of which of the following would this CXR cause hypoxaemia? V/Q mismatch Shunt Diffusion limitation Hypoventilation Increased dead space
**Shunt**: eisenmenger syndrome
49
How do you manage acute T2RF? [4]
Controlled oxygen: - **0.5 - 2l/min** via **nasal** **cannulae** - **24 to 28% masks** using **venturi valves** **Regular ABG to monitor CO2 levels** Consider **non-invasive ventilation (BIPAP)** if pH and CO2 dont improve | Go over BIPAP - is this correct?
50
Which inherited disorders increase the risk of PE? [5]
**Factor V Leiden mutation**: - Normally used for blood clotting: helps enzyme reaction to form fibrin in blood clot - Once the coagulation process is turned on in people with factor V Leiden, it turns off more slowly than in people with normal factor V **Antithrombin deficiency** - Normally anti-thrombin acts as the inhibitory component to thrombin formation **Prothrombin deficiency** **Protein C & S deficiencies** **Antiphospholiipid syndrome**
51
Describe the treatment algorithm for patients who have PE **confirmed** and are **haemodynamically unstable** [4]
**First line:** - **heparin**: **10,000 units** intravenously as a **loading dose** initially, followed by **18 units/kg/hour intravenous infusion** PLUS: **thrombolysis**: (involves injecting a fibrinolytic (breaks down fibrin) medication that rapidly dissolves clot) - **Alteplase** or - **Streptokinase** or - **Urokinase** PLUS: - **anticoagulation with unfractionated heparin (UFH**) for several hours after the end of thrombolysis before: **switching to apixaban or rivaroxaban**; low molecular weight heparin (LMWH) is an alternative if these are unsuitable - **this is preferable** CONSIDER: **vasoactive drug** if SBP < 90 mmHG after thrombolysis - **noradrenaline** or - **dobutamine** -
52
Describe the treatment algorithm for patients who have PE **confirmed** and are **haemodynamically stable** [4]
Stable, no renal impairment or co-morbidities: **offer apixaban/rivaroxaban**. If not-suitable, **LWMH for 5 days then offer edoxaban/warfarin*** First line: **anticoagulation**: - **apixaban** or - **rivaroxaban** OR - **UFH / LMWH / Fondaparinux** lead AND **warfarin** - **Target INR 2-3 then stop heparin**
53
Describe three subacute complications of PE
**Infarction and lung necrosis** - PE can cause **ischemic injury** to the **lung parenchyma**, leading to **pulmonary infarction, haemorrhage, or lung necrosis.** **Pleural effusion:** - Inflammatory processes triggered by PE may cause pleural effusion, which may be exudative or hemorrhagic. **Pneumothorax**: - Rarely, PE-induced lung infarction may lead to pneumothorax due to the **rupture of a bulla or necrotic lung tissue**
54
PE would cause change to axis deviation? [1]
**Right axis deviation**
55
Which of the following is used to treat chronic PEs unresolved after 3 months * Embolectomy * Mechanical fragmentation with R heart angiography * Pulmonary thombro-endarterectomy * IVC filter
**Pulmonary thombro-endarterectomy** (PTE)
56
Describe the different bridging times for LMWH if using: - Warfarin - Dabigatran or edoxaban - Rivaroxaban or apixaban
**Warfarin**: - Start LMWH and initiate warfarin at same time then after 5-10 days change to just warfarin **Dabigatran or edoxaban** - 5 days of LMWH with both then switch to doac same day **Rivaroxaban or apixaban** - No bridge - only use them
57
Describe the diagnostic pathway for PEs

Yr 3: CN2 (29 decks)

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