Short Case Respiratory Xpress

Question 1

State the causes of lung collapse

Answer 1

• Bronchogenic CA
• TB
• Bronchial adenoma

Question 2

State the causes of lung consolidation

Answer 2

• Bacterial pneumonia
• Bronchogenic CA
• Pulmonary infarct

Question 3

State (2) causes of bibasal crackles with finger clubbing

Answer 3

• Bronchiectasis
• Interstitial lung disease

Question 4

State (2) causes of bibasal crackles without finger clubbing

Answer 4

• Left ventricular failure
• Bronchopneumonia

Question 5

Define asthma

Answer 5

• Chronic inflammatory disorder of the airway characterized by bronchial hyper-responsiveness of the airway to various stimuli, leading to widespread bronchocontriction

Question 6

How would you diagnose bronchial asthma?

Answer 6

• Typical symptoms/signs
• Lung function test

1. > 20% of diurnal variation in PEF on >3 days in a week for 2 weeks
2. FEV1 >15% increase after bronchodilator or oral steroid
3. FEV1 >15% decrease after 6 minutes of exercise (running)

Question 7

What are the indicators of severe asthma?

Answer 7

• Inability to complete 1 sentence in 1 breath
• RR >25/min
• Pulse rate >110/min
• PEF <50% of predicted or best value

Question 8

What are the indicators of life-threatening asthma?

Answer 8

• Exhaustion, confusion, coma
• Bradycardia, hypotension
• Silent chest, cyanosis
• PEF <33% of predicted or best value
• Normal or increased PCO2
• PO2 <60mmHg

Question 9

How do you manage a case of acute asthma?

Answer 9

• ABG
• CXR (to exclude pneumothorax)
• O2, nebuliser - Beta-agonist
• High dose steroid (IV hydrocortisone, prednisolone)
• For severe attack -> IV aminophylline, consider ventilation

Question 10

Define COAD

Answer 10

A disease state characterized by AIRFLOW LIMITATION that is not fully reversible

Question 11

How do you diagnose a case of COAD?

Answer 11

Key indicators:
- Chronic cough with sputum production
- Progressive or persistent dyspnea
- History of smoking
- Exposure to occupational dusts or chemicals

Spirometry (To confirm the diagnosis of COAD)
- Airflow limitation (FEV1/FVC <70%) that is not fully reversible (post-bronchodilator FEV1 <80% of predicted value)

Question 12

What does finger clubbing in COAD superimposed?

Answer 12

Superimposed BRONCHOGENIC CA, chronic infection

Finger clubbing is NOT a feature of COAD

Question 13

State (2) differentials for COAD

Answer 13

• Left ventricular failure
• Chronic asthma

Question 14

What are the additional investigations of COAD?

Answer 14

• Bronchodilator reversibility test (Largely irreversible in COAD)
• Glucocorticoid reversibility test (>15% increase in FEV1 after a course of steroid therapy)
• Chest X-ray (Hyper-inflation, bullous changes, pulmonary hypertension)
• ECG (Cor pulmonale -> Peaked P wave at L2, 3 and AVF)
• ABG
• Alpha-1-antitrypsin deficiency (indicated in young patients <45Y or those with strong family history of COAD)

Question 15

How would you manage a case of acute exacerbation of COAD?

Answer 15

• Nebulized bronchodilator, oxygen
• CXR -> to exclude pneumothorax
• Antibiotics (H. influenza, Strep pneumonia)
• Steroids (Oral or IV)

Question 16

What are the possible findings on PE in a patient with COAD?

1. Face
2. Chest
3. Abdomen

Answer 16

Face
- Central cyanosis
- Polycythemia
- Pursed lips

Chest
- Barrel chest
- Hyper-resonance
- Downward displacement of upper border of liver
- Rhonchi
- Loud S2 (Pulmonary hypertension)

Abdomen
- Palpable liver
Possible cause:
1. Hyper-inflated lungs
2. Bronchogenic CA with liver metastasis
3. Cor-pulmonale

Question 17

State the clinical features of bronchogenic CA

Answer 17

• Primary tumor - Pancoast syndrome
• Mediastinal spread - hoarseness (recurrent laryngeal nerve palsy), superior vena cava obstruction
• Metastasis - pleura, liver, brain, adrenal
• Paraneoplastic syndrome (PNS)
  1. Endocrine - ectopic ACTH secretion (scc), gynecomastia (adc), syndrome of inappropriate ADH secretion/SIADH (scc), hypercalcemia (sqcc)
  2. Neurological - cerebellar syndrome, poly-/dermatomyositis, LEMS
  3. Others - hypertrophic pulmonary osteoarthropathy, clubbing

Question 18

What are the investigations to be done for a case of bronchogenic CA?

Answer 18

• Serum sodium, calcium
• CXR - hilar mass or coin lesion, rib erosions, raised hemidiaphragm (phrenic nerve paralysis), lymphangitis carcinomatosis
• Pleural fluid cytology
• Bronchoscopy (+ washing and brushing) - endobronchial tumor
• CT scan thorax/abdomen, bone scan - staging
• Lung function test - FEV1

Question 19

Define Pancoast syndrome

Answer 19

Apical lung tumor with
- Invasion of lower trunk (C8 - T1) of brachial plexus -> WASTING OF SMALL MUSCLES OF THE HAND
- Sympathetic chain -> HORNER’S SYNDROME
- 2nd-3rd ribs

Question 20

Define interstitial lung disease

Answer 20

• A.k.a diffuse parenchymal lung disease
• Group of disorders that involve the space between epithelial and endothelial basement membrane

Question 21

State the causes of ILD

Answer 21

• Known cause
  1. Drugs
  2. Connective tissue disease
  3. Occupational exposure - asbestos, silica
• Idiopathic pulmonary fibrosis
• Granulomatous DPLD - Sarcoidosis
• Other forms of DPLD

Question 22

What are the investigations of ILD?

Answer 22

• CXR
• Lung function test
• CTD screen
• High-resolution CT (HRCT)
• Bronchial lavage
• Lung biopsy

Question 23

What is the possible treatment for ILD?

Answer 23

• Steroid/cyclophosphamide
• Treat underlying cause

Question 24

Define bronchiectasis

Answer 24

Chronic suppurative inflammation of the bronchi that results in permanent dilatation of the airways

Question 25

State the etiologies of bronchiectasis

Answer 25

- Post-infectious (Measles, Pertussis, TB, aspergillosis) - Endobronchial obstruction (Bronchial adenoma/carcinoma) - Congenital - Kartagener's syndrome, hypogammaglobulinemia (extremely rare)

Question 26

What are the complications of bronchiectasis?

Answer 26

- Pneumonia - Hemoptysis - Cerebral abscess - Amyloidosis

Question 27

What investigations to be done to diagnose a case of bronchiectasis?

Answer 27

- Sputum AFB/fungal culture - Sputum culture - H influenza, P aeruginosa, Strep pneumonia - CXR - ring-like shadows , tram lines, focal opacities - Aspergillus precipitin test - High-resolution CT 1. BEST tool to diagnose 2. Detects airway changes that are not visible on X-ray

Question 28

List the specific treatment of bronchiectasis

Answer 28

- Bronchopulmonary hygiene - Antibiotics - Surgical resection of damaged segments/lobes that are nidus for infection

Question 29

In diagnostic approach to pleural effusion, what are the (2) important questions?

Answer 29

- Is the fluid a transudate or exudate? - If the fluid is an exudate, what is the etiology?

Question 30

What are the investigations to be done for pleural effusion and the possible findings?

Answer 30

CXR/US/CT scan - Helps in finding the best site for pleural tap Pleural tap and fluid analysis - Protein - Glucose (Decrease in infection and malignancy) - Gram stain, Ziehl-Neelson stain - Culture/cytology - Adenosine deaminase (Increase in tuberculous effusion) Percutaneous pleural biopsy - Indicated in undiagnosed pleural exudates with non-diagnostic cytology and clinical suspicion of TB or malignancy

Question 31

State the laboratory findings of a transudate and its possible cause

Answer 31

- Protein <30g/l - LDH <200IU/L - Pleural : serum LDH ratio <0.6 Possible cause - Cardiac failure - Nephrotic syndrome - Chronic liver disease

Question 32

State the laboratory findings of an exudate and its possible cause

Answer 32

- Protein >30g/l - LDH >200IU/L - Pleural : serum LDH ratio > 0.6 Possible cause - Malignancy - Pneumonia - TB - Pulmonary infection - Connective tissue disease

Question 33

State the laboratory findings of an empyema and its possible cause

Answer 33

- Turbid, foul-smelling - Centrifuged pleural fluid - clear supernatant Possible cause - Lung infection - Chest trauma - Thoracic surgery - Subdiaphragmatic abscess