Respiratory

Question 1

What are the signs of the various lobar pneumonias?

Answer 1

Right side has 3 lobes and the left lobe has 2 lobes.

Right upper lobe pneumonia -> consolidation stops at the horizontal fissure

Right middle lobe:
Right heart border is lost ( silhouette sign)
Right hemidiaphragm is visible

Right lower lobe pneumonia:
Right heart border is visible
May lose the right hemidiaphragm

Question 2

Describe how lung collapse looks?

Answer 2

In all collapse should be able to see visible vascular markings

Right UL:
Horizontal fissure goes up

Middle:
Lost right heart border

Question 3

How does a pneumothorax look?

Answer 3

Loss of vascular markings.

Question 3

What are the causes of clubbing

Answer 3

C - cyanotic heart disease, CF
L - Lung cancer, Lung abscess
U - UC
B - bronchiectasis
B - benign mesothelioma
I - infective endocarditis, idiopathic pulmonary fibrosis
N - neurogenic tumours
G - gastrointestinal dis

Question 4

What is extrinsic allergic alveolitis?

Answer 4

Also known as hypersensitivity pneumonitis

• Inflammation of alveoli and bronchioles due to an immune response to inhaled allergens.

-Non-igE mediated

• caused by repeated inhalation of non-human protein such as bird fanciers lung, farmers lung

Acute exposure -> reversible
Chronic low-grade exposure -> can be irreversible -> fibrosis

Question 5

How do you diagnose COPD>

Answer 5

Spirometry

Question 6

what is commonly tested when a person is started on ethambutol?

Answer 6

Visual acuity/Visual fields and colour vision

Question 7

Can COPD cause weight loss?

Answer 7

YES!
A small amount of weight is normal

Question 8

What are some special features you see in pneumonia

Answer 8

You may see **air bronchograms **
- i.e the bronchi is visible becuase the alveoli are filled with debri and gunk

**Air space opacification **
- i.e. the air spaces are filled with debri and white stuff

Question 9

What are the auscultation findings with pneumonia

Answer 9

reduced breath sounds
bronchial breathing ( on expiration).

Percussion is dull

Question 10

What is the CURB-65

Answer 10

Assessing how to manage CAP and score of 4 high 30 day mortality
C = AMTS <=8/10
U= >7mmol (only in hospital)
R= >=30/min
B= Systolic <= 90 and Diastolic <=60
65

Question 11

How do you manage pneumonia

Answer 11

CURB SCORE:
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

0 - home with oral amox for 5 days
2 or more - Hospital admission.
Give dual abx (amox and a macrolide) for 7-10 days

Question 12

what follow up is required for patients with pneumonia

Answer 12

repeat chest-xray at 6 weeks ( ensure no other abnormalitis such as lung tumour)

only in :

With symptoms and signs that persist despite treatment.
Who are at higher risk of underlying malignancy (particularly smokers and people aged more than 50 years).

Question 13

what is the difference between bronchitis and pneumonia on x-ray

Answer 13

Bronchitis - x ray normal
pneumonia- infiltrates

Question 14

Sign of pneumothorax on C-XRAY?

Answer 14

Visible visceral pleural edge ( i.e. the white line showing the part that has collapsed)

No lung markings peripheral to this.

Lung may collapse

Question 15

What features are present in tension pneumothorax?

Answer 15

ipsilateral increased intercostal space
contralateral shift of the mediastinum
depression of the hemidiaphragm

Question 16

what is pneumothorax?

Answer 16

presence of gas in the pleural space

Question 16

What are the signs on auscultation?

Answer 16

It may cause chest pain : often pleuritic because affects pleura.

Signs:
Hyper-resonant lung percussion
reduced breath sounds
reduced lung expansion
tachypnoea
tachycardia

Question 16

Management for pneumothorax?

Answer 16

**Primary **

• < 2 cm:
  –Discharge, repeat CXR
• > 2 cm/SOB:
  –Aspiration
  –If unsuccessful: chest drain

**Secondary **: pre-existing comorbities, if a bullae ruptures.
*< 2 cm:
–Aspiration
*> 2 cm:
–Chest drain

Question 17

What is the follow up for pneumothoax?

Answer 17

Conservative:
- primary cause -> reviewed every 2-4 days as an outpatient
- secondary -> monitor as an inpatient

if stable -> follow up in outpt department in 2-4 weeks

Needle aspiration:
outpatients department in 2-4 weeks

Chest drain:
daily review as an inpatient
remove drain when resolved
discharge and follow-up in the outpatients department in 2-4 weeks

Question 18

what do you do for recurrent pneumothorax?

Answer 18

Video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.

Question 18

How to treat tension pneumothorax?

Answer 18

Tension pneumothorax (one-way air leak into pleural space):
1. Give high flow o2 via a non-rebreather mask
2. Mx with chest decompression
- use open thoracostomy followed by a chest drain if expertise is available.
- Otherwise a needle decompression can be used with a 16-gauge cannula, which is inserted at the second intercostal space, mid-clavicular line, on the affected side. The needle should be inserted just above the third rib, to avoid damaging the neurovascular bundle.
NB: If the cause of the pneumothorax is trauma, ATLS guidelines advise the 5th intercostal space mid-axillary line due to ease of access).
Needle decompression acts as a bridge before insertion of an intercostal chest drain

Question 19

What are the features of pulmonary oedema on x-ray?

Answer 19

Acute pulomonary oedema (secondary to HF):
A -> air space opacificaion
B -> batwing
C -> cardiomegaly ratio >0.5
D -> diversion
E -> Pleural effusion

Question 20

What is COPD

Answer 20

Spectrum of obstructive airway disease.
Includes two key components:
- chronic bronchitis + emphysema

Question 21

What are the radiographic features of COPD?

Answer 21

• increased bronchovascular markings
• lung hyperinflation with flattened hemidiaphragms

Question 22

What are the fissures of the lungs?

Answer 22

Horizontal fissure - right lung
Oblique fissure - Left lung

Question 23

What typically causes upper lobe consolidation

Answer 23

Tuberculosis.

Question 24

What do you see in pneumoperitoneum?

Answer 24

Gas within the peritoneal cavity like a perforated duodenal ulcer

Erect chest x ray – subdiaphragmatic free gas

Question 25

What are the signs of pleural effusion

Answer 25

Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart or renal failure) signs of fluid overload.

Question 26

What are the signs of lung collapse?

Answer 26

Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.

Question 28

How is pleural effusion mx?

Answer 28

as above, ultrasound is recommended to reduce the complication rate
a 21G needle and 50ml syringe should be used

Question 29

What should the fluid be sent for?

Answer 29

pH, protein, lactate dehydrogenase (LDH), cytology and microbiology

Question 30

what determines exudate and trasnduate

Answer 30

exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L