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Flashcards in Respiratory Deck (124):
1

Which serum electrolyte is likely to be raised in a patient with active TB?

Increased serum calcium due to activated macrophages which produce calcitriol (active form of vit D)

2

What are causes of shortness of breath?

Respiratory
Cardiac
Anatomical
Shock
Anaemia

3

What is an expiratory wheeze?

Musical / whistling sound
Narrowing / obstruction of small airways
Causes: Inflammation - asthma, COPD, allergic reaction
Secretions blocking lumen - infection
Physical blockage - tumour, foreign body

4

What is stridor?

High-pitched, harsh, vibrating noise
Inspiratory
Turbulent airflow in large airways
Trachea, larynx
Emergency

5

What are your differential diagnoses for SOB?

Bronchial Inflammation: Infection / Pneumonia, Asthma, COPD, Bronchiectasis
Fluid in Airways: Pulmonary Oedema (heart failure)
Non-inflammatory Narrowing / Obstruction: Lung cancer, Pulmonary embolism, Inhaled foreign body

6

What are common pathogens which cause pneumonia?

S.pneumoniae
H.influenzae
Mycoplasma

7

What are symptoms of pneumonia?

Fever
Cough
Dyspnoea (acute / sub-acute)
Purulent sputum

8

What are pathological features of asthma?

Reversible airway obstruction
Bronchial muscle contraction
Mucosal swelling / inflammation
Increased mucus production

9

What are symptoms and features that would make you suspect asthma?

Childhood
Usually episodic, diurnal variation
Wheeze, dyspnoea
Non-productive nocturnal cough

10

What are features of COPD?

Progressive disorder of airway obstruction
Little / no reversibility or diurnal variation
Chronic bronchitis - clinical
Emphysema - histological
SMOKERS, Chronic cough, dyspnoea, wheeze and sputum, Age >35yrs

11

What is bronchiectasis?

Chronic infection of airways
Destroys muscular tissue so held dilated by lung parenchyma
Filled with purulent sputum

12

What are some causes of bronchiectasis?

Congenital: cystic fibrosis
Post-infection: measles, pertussis, TB
Airway obstruction: tumours
Immunosuppression

13

How can heart failure be a cause of SOB?

Impaired left ventricular function –blood backs up in pulmonary
circulation so Pulmonary Oedema

14

What are causes of heart failure?

Ischaemic heart disease
Cardiomyopathy
Myocarditis

15

What are non cardiac causes of fluid overload which could result in pulmonary oedema?

Excessive IV fluids
Renal failure

16

What questions in the history would you want to ask about someone's cough?

When did it first start?
Is it present all the time?
Does it wake you up at night?
Worse at any time of day?
Does anything trigger it?
Work? Exercise? Medication?
Do you cough anything up? What colour? Any blood?

17

What questions in the history would you want to ask about someone's SOB?

When did it first start? How quickly has it come on?
Is it present all the time? Is it only present when you exert yourself?
Before this started, how far could you walk on flat before getting breathless? And now?
Is it worse in certain positions? How many pillows do you use?
Does anything else trigger it?

18

What associated symptoms would you want to ask about in a patient who you suspect has asthma?

Acute onset
Rashes
Itchy skin
Watering eyes

19

What associated symptoms would you want to ask about in a patient who you suspect has bronchiectasis?

Fever
Progressive illness (or acute-on-chronic)
Weight loss

20

What past medical history questions are important in a patient who you suspect has bronchiectasis?

Chest infections? Especially as a child
Cystic fibrosis?
Previous TB?

21

What past medical history questions are important in a patient you suspect has heart failure?

Heart attacks?
Angina?
Kidney disease?

22

Which drugs might be particularly relevant to ask about in a patient presenting with SOB?

Steroids?
Immunosuppressants?
On home nebulisers or oxygen?
Multiple allergies / atopy?

23

What social history questions are important in a patient presenting with SOB?

Occupation?
Change of job?
Moved house?
New pet?
New hobby?
SMOKING!! Pack years?
Occupation?
Time spent living abroad?
TB contacts?
Alcohol?

24

What family history questions are important in a patient presenting with SOB?

Asthma?
Eczema?
Hay fever?
Bronchitis? Emphysema? Especially at an early age
Cystic fibrosis?
TB?
Heart disease?

25

What end of the bed signs might you look for in a patient with SOB?

Breathlessness
Resp rate
Accessory muscle use
Sputum pots
Inhalers / nebulisers
Oxygen masks/tubing
Cachexia

26

What examination findings might you see in a patient with SOB?

Peripheral cyanosis
Clubbing
Tar staining
CO2 retention flap
Central cyanosis
Pitting oedema

27

What are respiratory causes for clubbing?

A – abscess
B – bronchiectasis (incl CF)
C – cancer (bronchial + mesothelioma)
D – decreased oxygen (hypoxia)
E – empyema
F – fibrosing alveolitis

28

What is cor pulmonale? What are symptoms of this?

Right sided heart failure due to long term pulmonary hypertension or chronic low oxygen conditions - COPD, CF
Symptoms: SOB during activity, tachycardia, palpitations, chest pain, syncope, cyanosis, raised JVP

29

What are the descriptors for abnormal percussion of a lung?

Pleural Effusion: stony dull
Consolidation: dull
Collapse: dull
Pneumothorax: hyper resonant

30

Which conditions may increase or decrease vocal resonance?

Consolidation: increased vocal resonance
Effusion and pneumothorax: decreased vocal resonance

31

What are bronchial breath sounds?

Tubular, hollow sounds heard over large airways
Louder and higher pitched than vesicular breath sounds

32

What are crackles? If they are head in early or late phases of breathing what does that signify?

Early inspiratory and expiratory: chronic bronchitis
Late inspiratory: pneumonia, CHF, atelectasis

33

What is a pleural rub?

Creaking or grating sound like standing on snow
Produced by two inflamed surfaces sliding on one another - pleurisy

34

What is pleurisy?

Inflammation of the pleurae which impairs their lubricating function and causes pain when breathing

35

What additional investigations might you want to do after an examination of a patient with SOB?

Peak flow
Sputum Pot
Oxygen saturation
ABG

36

How might a patient describe pleuritic chest pain?

Usually lateral
Sudden
Sharp, stabbing
On deep inhalation
Severe

37

What are the 5 Ps which might cause pleuritic chest pain?

Pneumonia
Pulmonary embolus (PE)
Pneumothorax
Pericarditis
Pneumomediastinum

38

What are causes for haemoptysis?

Pneumonia, upper respiratory tract infection
Pulmonary embolism
Coagulopathy
Coughing
Malingering
Vasculitis
Bronchial carcinoma

39

What questions in the history would you want to ask about a patients pleuritic chest pain?

Where is it?
When did it start? Over how long? What were you doing?
How would you describe it?
Does it go anywhere else?
Is it there all the time or does it come and go?
Does anything make it worse? Breathing? Position?
Where is it on a scale of 1-10?

40

What questions in the history would you want to ask about a patients haemoptysis?

What exactly happens? Are you really coughing blood?
When did it first start?
How often does it happen? Per day?
Fresh blood or clot?
How much is there? Streak? Teaspoon? More?

41

What additional symptoms would you want to ask a patient about who presents with pleuritic chest pain?

Leg pain?
Leg swelling?
Fever?
Purulent sputum?
Unintentional weight loss?
Longstanding cough?

42

What aspects of a patients past medical history would you want to ask about if they present with pleuritic chest pain?

Previous DVT/PE?
Recent immobility?
Recent surgery?
Recent travel?
Pregnancy?
History of cancer?
Immunocompromise?

43

Which specific drugs would you want to ask about in a patient presenting with pleuritic chest pain?

Oral contraceptive?
Steroids?
Immunosuppressants?

44

What family history would you want to ask about in a patient presenting with pleuritic chest pain?

DVT?
PE?
History of lung cancer?

45

What social history would you want to ask about in a patient presenting with pleuritic chest pain?

Level of activity?
Occupation?
Home environment?
Occupation?
Smoking? Pack years?

46

What signs would you look for from the end of the bed in a patient with pleuritic chest pain?

In pain
Shallow, rapid breaths
Sputum pots
Oxygen
Inhalers
Chest expansion

47

What examination signs might you look for in a patient with pleuritic chest pain?

Peripheries cold
Oxygen saturations
Peripheral cyanosis
Clubbing
Tar staining
Conjunctival pallor
Fever
Calf swelling/ tenderness

48

What is the mechanism that leads to clubbing in lung conditions?

VEGF induces vascular hyperplasia, oedema, and fibroblast or osteoblast proliferation at a peripheral level in the nails
In primary pulmonary conditions such as lung cancer, this is the operative mechanism

49

What are the stages of clubbing?

Nail bed fluctuation
Loss of nail bed angle
Increase curvature of nail fold
Thickened distal phalanx/ Drumstick appearance
Hypertrophic osteoarthropathy

50

What is Virchows triad for DVT risk?

Stasis
Endothelial damage
Hypercoagulability

51

What initial investigations might you want to do to determine the cause of a patients pleuritic chest pain?

ECG
D-dimer (Wells score)
White cells (FBC)
C-reactive protein
Urea and electrolytes
Chest X-ray

52

What is your basic management for a patient with a PE?

Stabilise the patient: Oxygen, Fluids, Senior help
Treat the symptoms: Analgesia
Stop further clots: Anticoagulation (e.g. enoxaparin)

53

Which arachidonic acid metabolite is inhibited by montelukast and is used to treat severe asthma and COPD?

Leukotrienes

54

Give reasons for a hemithorax white out on X-ray

Trachea pulled to opacified side: total lung collapse, pneumonectomy, pulmonary agenesis
Trachea central: consolidation, pulmonary oedema/ARDS, pleural mass (mesothelioma), chest wall mass
Trachea pushed away: pleural effusion, diaphragm hernia, large mass

55

What is the acute management for a severe asthma attack?

High flow oxygen
5mg salbutamol nebulised
500 micrograms ipratropium nebulised
100mg IV hydrocortisone

56

What is the acute management for pneumonia?

High flow oxygen
IV fluid as required
Antibiotics according to curb 65 score and local guidelines

57

What are differences between type 1 and type 2 respiratory failure?

Type 1: low pO2 due to ventilation perfusion mismatch
Type 2: high pCO2 due to lack of ventilation

58

What is lights criteria for diagnosing an exudative effusion?

Pleural fluid protein:serum protein >0.5
Pleural fluid LDH:serum LDH >0.6
Pleural fluid LDH >2/3 upper limit normal for serum

59

Name some causes of a transudative effusion

Heart failure
Hypoproteinaemia (nephrotic syndrome)
Constrictive pericarditis
Hypothyroidism
Ovarian tumours producing right sided pleural effusion

60

You have treated a patient for pneumonia but they still appear ill. What could be reasons for this?

Pleural effusion
Empyema
Respiratory failure
Septicaemia

61

Name some causes of an exudative pleural effusion

Bacterial pneumonia
Carcinoma of bronchus
TB
Autoimmune rheumatic disease
Mesothelioma
Sarcoidosis
Familial Mediterranean fever

62

In a patient with a suspected PE, what is the appropriate immediate treatment?

Low molecular weight heparin unless eGFR is less than 30, then unfractioned should be considered

63

What are some features of severe asthma?

Peak flow 33-50% predicted
Resp rate over 25
Heart rate above 110
Inability to complete sentences

64

What are some features of life threatening asthma?

Peak flow

65

Name some causes of atypical pneumonia

Legionella pneumophila
Mycoplasma pneumoniae
Chlamydophila pneumoniae

66

What should be used to treat atypical pneumonia?

Macrolide - clarithromycin, erythromycin
Tetracycline
Fluoroquinolone

67

Name some risk factors for lung cancer

Smoking
Industrial hazards: asbestos, arsenic, uranium
Air pollution

68

Describe the molecular basis of the development of lung cancer

Stepwise accumulation of oncogenic driver mutations until the hallmarks of cancer are acquired

69

What types of lung cancer are there?

Small cell carcinoma and
Non small cell: adenocarcinoma, squamous cell carcinoma, large cell carcinoma
Bronchial carcinoids
Mesenchymal

70

What precursor lesions to SCC in the lung can occur?

Squamous metaplasia
Squamous dysplasia
Squamous cell carcinoma in situ

71

What are patterns of growth of squamous cell carcinoma of the lung?

Exophytic: ulcerate, bleed and obstruct
Endophytic: infiltrate along airways and can present late

72

Where do squamous cell carcinoma of the lung tend to grow?

Central airways
Sometimes in periphery

73

Where do adenocarcinomas of the lung tend to grow?

Peripheries
Tend to be smaller than other forms of lung cancer

74

What are precursor lesions of adenocarcinoma of the lung?

Atypical adenomatous hyperplasia
Adenocarcinoma in situ

75

What type of mutations are found in 10-40% lung adenocarcinomas?

EGFR

76

What is the most aggressive form of lung cancer?

Small cell carcinoma
Typically disseminated at time of diagnosis
High grade

77

Which form of lung cancer are commonly associated with ectopic hormone secretion?

Small cell carcinoma

78

What is the cell type involved in large cell carcinoma?

Undifferentiated malignant neoplasm
Poorly differentiated adeno or squamous carcinoma
Carcinosarcoma
Large cell neuroendocrine carcinoma

79

What patterns of metastasis are associated with lung cancer?

Lymph nodes: hilar, mediastinal, paratrachel, supraclavicular
Haematogenous: liver, brain, bone, adrenals

80

Tumours in the lung cause obstruction to air and mucus flow. What can this cause?

Partial obstruction: focal emphysema
Total obstruction: atelectasis
Infection: severe suppurative bronchitis, bronchiectasis, abscesses

81

What changes can occur in the surrounding tissues of a lung cancer due to infiltration?

SVC obstruction
Recurrent laryngeal nerve compression
Phrenic nerve invasion (pointing sign)
Pulmonary veins and artery
Narrowing of oesophagus (dysphagia)
Vertebral body erosion
Pleural effusion
Pericardial effusion

82

What aspects of a lung tumour are used to stage it?

T: size, pleural involvement, main stem bronchus involvement, multifocal, distal changes
N: hilar/peribronchial, mediastinal/subcarinal, contra lateral/scalene/supraclavicular
M: mets

83

What are the different stages of lung cancer?

I: localised, no nodes
II: local nodes or large tumour
III: extensive nodal disease
IV: presence of mets

84

What clinical presentations might occur with a lung cancer?

Cough
Haemoptysis
Chest pain
Pneumonia, abscess, lobe collapse
Pleural effusion
Hoarseness
Dysphagia
Diaphragm paralysis
Rib destruction
SVC syndrome
Horners
Pericarditis, tamponade

85

What paraneoplastic syndromes can occur with lung cancer?

ADH: hyponatraemia
ACTH: Cushing's
Parathyroid hormone: raised calcium
Calcitonin: hypocalcaemia
Serotonin and bradykinin: carcinoid syndrome

86

In which type of lung cancer is hypercalcaemia most prevalent?

Squamous cell carcinoma

87

In which type of lung cancer is ADH and ACTH ectopic release most prevalent?

Small cell carcinoma

88

What is lambert eaton myasthenic syndrome?

Autoanitibodies to neuronal calcium channel
Mostly as a result of paraneoplastic syndrome from small cell lung cancer

89

What is acanthosis nigricans?

Brown to black, poorly defined, velvety hyperpigmentation of the skin usually found in body folds such as the posterior and lateral folds of the neck, the armpits, groin, navel, forehead, and other areas
Can occur as a paraneoplastic syndrome

90

What is a CT scan used for in lung cancer?

Presence of lesion
Local extent of tumour
Local nodal disease
Distant mets
Suitability for different types of tissue diagnosis
Background changes

91

What different types of tissue diagnosis can be used in lung cancer?

Bronchoscopy: biopsy and bronchoalveolar lavage
Percutaneous needle biopsy
Node biopsy
Sputum cytology if unfit for procedures

92

What can be used to assess a patients fitness for resection in lung cancer?

Pulmonary function tests

93

What can be used for symptom control in lung cancer?

Painkillers
Radiotherapy
Laser ablation
Stenting

94

What are management options for lung cancer?

Surgical resection of early stage disease (N0)
Radical radiotherapy alone for early stage
Surgery plus chemo/radiotherapy for N1
Radical radiotherapy/chemo if unfit for surgery
Palliative chemo
Tyrosine kinase inhibitors if EGFR positive

95

In a patient with a recent influenza infection, which organism is likely to have causes a pneumonia?

Staph aureus

96

In a patient with COPD, which organism is likely to have caused their pneumonia?

Haemophilus influenzae

97

In a patient with a dry cough, atypical chest signs, hyponatraemia and Lymphopenia, what is the likely causative organism of their pneumonia?

Legionella pneumophillia

98

In a patient with a history of HIV, dry cough, exercise induced desaturations and the absence of chest signs, what is the likely causative organism of their pneumonia?

Pneumocystis jiroveci

99

What would protein concentrations be in transudate and exudate?

Transudate: less than 25g/L
Exudate: >35g/L

100

What is lights criteria for transudates and exudates?

If protein concentration falls between 25 and 35, fluid is likely to be exudate if:
Pleural fluid protein/serum is >0.5
Pleural fluid LDH/serum is >0.6
Pleural fluid LDH is >2/3 upper limit of normal for serum

101

What are causes of exudate?

Malignancy
Infection: parapneumonic or empyema
Oesophageal rupture
Inflammatory: SLE or RA

102

What are causes of transudate?

Cardiac failure
Renal failure
Liver failure
Hypoalbuminaemia

103

Under what circumstances is atelectasis commonly seen?

After prolonged operations
After upper abdominal surgery
Elevated intra abdominal pressure
Obese patients
Smokers

104

In which patients is pneumonia a common problem following major surgery?

Smokers
Obese
COPD
Emergency operations

105

What type of wheeze is present in asthma?

Expiratory

106

What is lofgrens syndrome?

Sarcoidosis triad of bilateral hilar lymphadenopathy, acute polyarthritis, erythema nodosum

107

Why would a patient with active TB have raised plasma calcium levels?

Activated macrophages produce calcitriol (active vit D) which increases absorption in the small intestine and increase reabsorption of calcium in renal parenchyma

108

What are some transudative causes of a pulmonary effusion?

HF
Nephrotic syndrome
Constrictive pericarditis
Hypothyroidism
Ovarian tumour

109

What are some exudative causes of pleural effusion?

Bacterial pneumonia
Carcinoma of bronchus
TB
Autoimmune rheumatic disease
Post MI
Acute pancreatitis
Mesothelioma
Sarcoidosis
Familial Mediterranean fever

110

What can cause a chylothorax?

Leakage from thoracic duct following trauma or infiltration by carcinoma

111

What are 3 important differentials for mediastinal lymphadenopathy?

TB
Sarcoidosis
Lymphoma

112

What are some causes of pneumothorax?

Spontaneous: pleural bleb
COPD
Bronchial asthma
Carcinoma
Lung abscess breakdown leading to bronchopleural fistula
Pulmonary fibrosis with cyst formation

113

At what rate will a pneumothorax be reabsorbed?

1.25% of hemithorax volume per day

114

Why are copd patients at risk of clots?

Polycythaemia

115

What are differentials for chronic cough?

COPD
Asthma
GORD
Catarrh / post nasal drip
Drugs - ace inhibitors
Lung cancer

116

What are differentials for chronic cough?

COPD
Asthma
GORD
Catarrh / post nasal drip
Drugs - ace inhibitors
Lung cancer

117

What are some clinical features of legionella?

Diarrhoea
Pneumonia
Confusion
Hyponatraemia

118

What is the likely organism responsible for hospital acquired pneumonia?

Staph aureus

119

A 32 year old female smoker presents with acute severe asthma. Sats are 91% on 15L oxygen. pO2 is 8.2. There is widespread expiratory wheeze throughout chest. She is given IV hydrocortisone, 100% oxygen, 5mg nebulised salbutamol and 500 micrograms nebulised ipratropium with little response. Nebs are repeated back to back but she remains tachypnoeic with wheeze but good air entry. What is the next step in your management?

IV magnesium

120

What can differentiate mycoplasma pneumoniae from other causes of pneumonia?

Slow progression of symptoms
Positive blood test for cold haemagglutinins

121

What are causes of clubbing?

Bronchial ca
Lung fibrosis
Bronchiectasis
Mesothelioma
Atrial myxoma
Infective endocarditis
Cyanotic heart disease
Cirrhosis
Inflammatory bowel disease

122

What are some causes for CO2 retention?

Alveolar hypoventilation
Hypercapnia
Acute resp failure: pulmonary oedema, pneumothorax, PE, sepsis
Chronic resp failure: COPD

123

How do you manage respiratory acidosis?

Treat cause: nebs, naloxone, chest drain, diuretics
Non invasive ventilation: BIPAP
Invasive ventilation
Chronic: CPAP

124

How do you treat acute pulmonary oedema?

Oxygen
IV furosemide
IV morphine
IV nitrates