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Question 1

What is bronchiectasis?

Answer 1

Increased mucus production and permanent dilation of the bronchi secondary to an underlying cause

Question 2

Which organisms commonly cause bronchiectasis?

Answer 2

H influenzae
S pneumoniae
S aureus
P aeruginosa

Question 3

What are some common causes of bronchiectasis?

Answer 3

Cystic fibrosis
Ciliary dyskinesia
Alpha 1 anti-trypsin deficiency
Obstruction
Immunosuppression
Childhood viral infx
Aspergillus fumigatus

Question 4

What are the symptoms of bronchiectasis?

Answer 4

Persistent cough
Green/rusty cough
SOB
Haemoptysis

Question 5

What are the signs of bronchiectasis?

Answer 5

Crackles on auscultation
Squeaks/pops on inspiration
Signs of underlying disorder
Fever

Question 6

What investigations would you do on a Pt with bronchiectasis?

Answer 6

CXR (first line)
High res CT (gold standard/most appropriate)
Observations (hypoxia)
FBC (raised WCC)
Sputum culture
Pulmonary function (dec FEV1, inc RV/TLC)
Serum alpha-1 antitrypsin levels
Sweat NaCl concentration and genetic testing for CFTR

Question 7

What will you see in a CXR and CT in bronchiectasis?

Answer 7

CXR- dilated thickened walls

CT- signet ring sign

Question 8

What is the management of a Pt with bronchiectasis?

Answer 8

Exercise and nutrition
Airway clearance therapy (postural drainage/percussion)
Inhaled bronchodilator (salbutamol)
Inhaled hyperosmolar agent (hypertonic saline)
ABx

Question 9

What is the prognosis of a Pt with bronchiectasis?

Answer 9

Irreversible

Depends on the severity and recurrence of exacerbations

Question 10

What are the complications of a Pt with bronchiectasis?

Answer 10

Haemoptysis
Respiratory failure
Cor pulmonale

Question 11

What is pneumonia?

Answer 11

Inflammation of the lung parenchyma caused by bacteria, virus, or fungi, resulting in fluid/pus air sacs

Question 12

What are the three types of pneumonia?

Answer 12

Community acquired pneumonia
Hospital acquired pneumonia
Aspiration pneumonia

Question 13

What are the common causes of CAP?

Answer 13

Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus

Question 14

What are the common causes of HAP?

Answer 14

Pseudomonas aeruginosa
Escherichia coli
Klebsiella pneumoniae
MSSA

Question 15

What are the common causes of atypical pneumonias?

Answer 15

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionalla pneumophila
Coxiella burnetti

Question 16

What are the mechanisms of entries for pneumonia?

Answer 16

Inhalation (viral/atypical)
Aspiration of URT secretions
Haematogenous from local infx (endocarditis)
Direct extension from local foci (TB via lymphatics)

Question 17

What are the symptoms of pneumonia?

Answer 17

Productive cough with coloured sputum
SOB
Pain on inspiration (pleuritic)

Question 18

What are the signs of pneumonia?

Answer 18

Fever
Confusion
Dull percussion
Increased fremitus
Bronchial breathing

Question 19

What are the main investigations for pneumonia?

Answer 19

CXR- area of consolidation
FBC- raised WCC
Sputum sample- MC and S
Blood cultures- if severe

Question 20

What is the scoring system for pneumonias?

Answer 20

CURB-65

Question 21

What is CURB-65?

Answer 21

Confusion
Urea >7
Resp rate >=30
Blood pressure (S<90, D<=60)
Age >=65

Question 22

What should you do for a Pt with a CURB-65 of 0-1?

Answer 22

Treat at home

Question 23

What should you do for a Pt with a CURB-65 of 2?

Answer 23

Consider hospital treatment

Question 24

What should you do for a Pt with a CURB-65 of 3+?

Answer 24

Severe pneumonia, treat in ITU

Question 25

What should you treat a low severity pneumonia with?

Answer 25

Oral amoxicillin

Question 26

What should you treat a medium severity pneumonia with?

Answer 26

Oral/IV amoxicillin + macrolide (clarithromycin)

Question 27

What should you treat a high severity pneumonia with?

Answer 27

IV co-amoxiclav + macrolide (clarithromycin)

Question 28

What should you after giving a Pt with pneumonia antibiotics?

Answer 28

Repeat CXR in 6 weeks

Question 29

What is the prognosis of a CURB-65 of 0-1?

Answer 29

30 day mortality <1%

Question 30

What is the prognosis of a CURB-65 of 2?

Answer 30

30 day mortality 5-15%

Question 31

What is the prognosis of a CURB-65 of 3+?

Answer 31

30 day mortality 20-50%

Question 32

What are the complications of pneumonia?

Answer 32

Septic shock C difficile from ABx use HF/resp failure in elderly

Question 33

How is Legionella transmitted?

Answer 33

Via aqueous environments such as air conditioners and contaminated water supplies

Question 34

What is the difference between Legionnaire's disease and Pontiac fever?

Answer 34

LD- Legionella pneumonia | PF- non-pneumatic Legionella

Question 35

What are the symptoms of a Legionella pneumonia?

Answer 35

Prodromal flu-like symptoms (fever, malaise, myalgia) Dry cough, can become productive Nausea, DnV

Question 36

Why are atypical pneumonias different from typical pneumonias?

Answer 36

They cannot be detected by Gram stains and cannot but cultured by standard methods

Question 37

What investigations would you do for a Legionella pneumonia?

Answer 37

Sputum culture Urinary antigen detection U+E- hyponatraemia CXR- bibasal consolidation

Question 38

What is the treatment for a Legionella pneumonia?

Answer 38

IV fluoroquinolones OR macrolides | eg. ciprofloxacin OR clarithromycin

Question 39

What are the characteristics of a Pneumocystis jirovecii infection?

Answer 39

Opportunistic fungal infx | AIDS defining illness

Question 40

What is the treatment for a Pneumocystis jirovecii infection?

Answer 40

high dose Co-trimoxazole

Question 41

What are the characteristics of a Pseudomonas aeruginosa infection?

Answer 41

Seen in Pts with bronchiectasis/CF

Question 42

What is the treatment for a Pseudomonas aeruginosa infection?

Answer 42

Treat with piptazobactam (piperacillin + tazobactam)

Question 43

What is the presentation of Mycoplasma pneumonia?

Answer 43

Insidious onset Persistent cough Low grade fever From a close community setting

Question 44

What is seen in the blood film of a Mycoplasma pneumonia infection?

Answer 44

Red cell/cold agglutinins

Question 45

What is the treatment for a Mycoplasma pneumonia infection?

Answer 45

Erythromycin/clarithromycin

Question 46

What type of Pt often presents with a Staph aureus infection?

Answer 46

IVDU

Question 47

What is seen in a CXR of a Pt with a Staph aureus infection?

Answer 47

Patchy consolidation | Forms abscesses

Question 48

What is the treatment for a Staph aureus infection?

Answer 48

Flucoxacillin

Question 49

What is the treatment for an MRSA infection?

Answer 49

Vancomycin

Question 50

What is the modality of transport for TB?

Answer 50

Aerosol droplets

Question 51

What are the two conditions required for a Pt to present with TB?

Answer 51

Infection of Mycobacterium tuberculosis | Inadequate immune system

Question 52

What are the risk factors for TB?

Answer 52

Recent travel to Asia, Latin America, or Africa Immunosuppression Malnutrition Alcoholism

Question 53

What is the pathophysiology of TB?

Answer 53

Droplets enter the lungs Macrophages + T lymphocytes contain the infection, forming a granuloma In weak immune systems, the infection escapes

Question 54

What are the symptoms of TB?

Answer 54

Cough for 2-3 weeks From dry to wet FLAWS especially S Haemoptysis in <10%

Question 55

What are the signs of TB?

Answer 55

Fever Crackles Bronchial breathing Erythema nodosum

Question 56

What are the investigations you should do for TB?

Answer 56

``` Obs CXR Sputum smear Sputum culture Nucleic acid amplification test (NAAT) Biopsy- caseating granulomas ```

Question 57

What are the 3 buzzwords for a TB sputum smear?

Answer 57

Acid fast bacilli Ziehl-Neelson staining Lowenstein-Jensen agar

Question 58

What are the types of lung cancer?

Answer 58

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

Question 59

What are the risk factors for lung cancer?

Answer 59

Smoking Exposure to tobacco smoke, radon gas, asbestos COPD

Question 60

Facts about lung cancer epidemiology

Answer 60

Most common cause of cancer mortality worldwide | 3rd most common cancer in Europe

Question 61

What are the characteristics of small cell carcinomas?

Answer 61

Strongest association with smoking Arise in central lung Rapid growth, highly malignant May secrete ectopic hormones (ATCH/ADH)

Question 62

What are the characteristics of adenocarcinomas?

Answer 62

Most common lung cancer in non-smokers Most common lung cancer in females Arise in peripheral lung Most have pleural involvement

Question 63

What are the characteristics of squamous cell carcinomas?

Answer 63

Most common lung cancer in male smokers Strong association with smoking Arise in central lung Can produce PTHrP

Question 64

What are the characteristics of large cell carcinomas?

Answer 64

Can arise centrally or peripheral | Poor prognosis

Question 65

What are the symptoms of a Pt with lung cancer?

Answer 65

FLAWS SOB Cough Haemoptysis

Question 66

What signs can you find in a Pt with lung cancer?

Answer 66

``` Horner's syndrome Cachexia Anaemia Clubbing Paraneoplastic syndromes Wheeze, crackles, dull percussion, reduced breath sounds ```

Question 67

What investigations would you do on a Pt with lung cancer?

Answer 67

``` Obs CXR CT Sputum cytology (assessment of lung secretions) Bronchoscopy Biopsy (for definitive diagnosis) ```

Question 68

What would you see in a CXR of a SCLC?

Answer 68

Central mass Hilar lymphadenopathy Pleural effusion

Question 69

What would you see in a CXR of a NSCLC?

Answer 69

Single/multinodular nodes Pleural effusion Lung collapse Mediastinal/hilar fullness

Question 70

What is a mesothelioma?

Answer 70

An aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis

Question 71

Which environmental exposure puts people at risk of developing a mesothelioma?

Answer 71

Asbestos

Question 72

What 2 conditions can be caused by asbestos exposure?

Answer 72

Asbestosis | Mesothelioma

Question 73

What is asbestosis?

Answer 73

Diffuse interstitial fibrosis | Due to inhalation of asbestos fibres

Question 74

What is the difference between asbestosis and asbestos-induced mesothelioma?

Answer 74

Asbestosis- asbestos fibres deposited in the alveoli | Mesothelioma- asbestos fibres deposited in the lining of the lungs

Question 75

Which of the two (asbestosis and asbestos-induced mesothelioma) has a stronger correlation with smoking?

Answer 75

Asbestosis

Question 76

What are the risk factors for a mesothelioma?

Answer 76

Asbestos exposure (shipyard/construction workers)

Question 77

What are the symptoms and signs for a mesothelioma?

Answer 77

Dry cough SOB Muffled breath on auscultation (due to pl effusion)

Question 78

What are the investigations for a mesothelioma?

Answer 78

CXR | CT

Question 79

What findings would you see in a CXR/CT of a Pt with mesothelioma?

Answer 79

Thickened pleural plaques Fibrosis Honeycomb appearance

Question 80

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

Answer 80

D. Bronchiectasis Resp symptoms, mucus, Hx of CF All leads to bronchiectasis being the most likely.

Question 81

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

Answer 81

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.

Question 82

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 ```

Answer 82

C. Streptococcus pneumoniae

Question 83

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

Answer 83

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.