Week 3 Flashcards
(94 cards)
1
Q
What are the 4 main groups of mediastinal lymph nodes?
A
Superior mediastinal lymph nodes
Aortic nodes
Inferior mediastinal nodes
N1 nodes
2
Q
Name 1-4 in this diagram
A
- Oblique fissure
- horizontal fissure
- posterior costophrenic recess
- sternal recess
3
Q
What has happened here?
A
Middle lobe collapse
4
Q
What has happened here?
A
Left lower lobe collapse, due to a carcinoid tumour
5
Q
Clinical signs of lung cancer
A
Cough for more than 3 weeks
Feeling breathless for no reason
Chest infections that don’t clear up
Haemoptysis
Weight loss
Chest/shoulder pain
Unexplained tiredness/lack of energy
Hoarse voice
6
Q
What (paradoxical) sign can be seen in a lung that has a tumour growing in it? Why does this occur?
A
As the tumour grows larger, the lung will lose volume and get smaller.
This is due to proximal obstruction of the bronchial tree, causing all the air beyond the obstruction to be absorbed by the tissues.
7
Q
What is Stridor? What is it usually accompanied by?
A
Stridor is a difficulty breathing in, usually accompanied by a coarse audible wheeze during inspiration.
8
Q
Where might you see local invasion in lung cancer? How might these present?
(ROB PPS)
A
- Recurrent pharyngeal nerve - hoarse voice
- Pericardium - breathlessness, AF, pericardial effusion
- Oesophagus - dysphagia
- Brachial plexus - wasting of the small muscles in the hand
- Pleural cavity - pleural effusion, resulting in breathlessness
- SVC - puffy eyelids, headache, distended ext. jugular vein and veins of the abdomen and thorax
9
Q
Where are pancoast tumours seen? What is it a sign of and what are the effects?
A
Apices of the lung.
Sign of invasion of the brachial plexus, presents as a “missing” 1st rib as it has been eroded through, and wasting of the small muscles in the hand.
10
Q
A patient with lung cancer has localised chest pain that they describe as being worse on movement and at night.
Where might the cancer have invaded?
A
Invaded the chest wall and passed through the intercostal spaces, destroying parts of the neighbouring ribs.
11
Q
What are some common sites for metastasis from a primary lung cancer?
A
- Liver
- Brain
- Bone
- Adrenal glands
- Skin
12
Q
How might cerebral metastasis present?
A
- Weakness, may mimic a stroke but occurs over a much longer time
- Visual disturbance
- Headaches that are worse in the morning and unrelated to light. These are due to raised ICP
- Fits, if the cortex is involved
13
Q
How might liver metastasis present? What LFT is likely to be particularly abnormal?
A
- Weight loss
- Loss of appetite
- Weakness and fatigue
- Nausea and vomiting
- Upper abdo pain
- Jaundice
LFTs will likely be abnormal, especially Alkaline Phosphatase (ALP)
14
Q
What are some paraneoplastic signs of lung cancer? (Non-metastatic)
A
- Finger clubbing (lung cancer is one of the most common causes)
- Weight loss
- Thrombophlebitis (vein inflammation due to thrombus)
- Hypercalcaemia
- Hyponatraemia
- Weakness - Eaton Lambert Syndrome
15
Q
Causes of finger clubbing
A
- Lung cancer (most common)
- Bronchiectasis
- Bacterial endocarditis
- Liver disease, especially Chronic Hep C infection
- Congenital
16
Q
Respiratory red flags (7)
A
- Cough for more than 2 weeks
- Weight loss
- Haemoptysis
- Chest pain
- Hoarseness
- Breathlessness
- Wheeze
17
Q
What investigations would you perform if you suspected lung cancer?
A
- CXR
- FBC, including Na, K, Ca and Alk Phos
- Spirometry
- Coagulation screening
- CT scan of thorax, and CT guided biopsy
- PET scan
- Bronchoscopy
18
Q
What does a PET scan do?
A
Assesses function rather than structure. Areas of high metabolic activity (i.e. tumours) light up
19
Q
Tissue is the issue for confidently diagnosing lung cancer! How is this best acquired?
A
- Bronchoscopy
- CT-guided biopsy (for peripheral tumours)
- Endobronchial ultrasound
20
Q
Clinical picture - smoker, haemoptysis and abnormal CXR
Think lung cancer? Differentials first please!
A
- TB
- PE
- Vasculitis (inflammation of the blood vessels)
- Secondary cancer
- Lymphoma (blood cell tumours)
- Bronchiectasis
21
Q
Benign primary lung cancers are rare/common
Malignant and metastatic lung cancers are rare/common
A
Benign - rare
Malignant - common
22
Q
What ectopic hormone production would you see in squamous cancer?
A
PTH (parathyroid hormone)
23
Q
What ectopic hormone production would you see in small cell cancer?
A
ACTH (adrenacorticotrophic hormone)
24
Q
What are the 4 common smoking-associated types of cancer?
A
- adenocarcinoma (gland forming) - 35%
- squamous carcinoma (keratinising) - 30%
- small cell carcinoma - 25%, worst type to get!
- large cell carcinoma - 10%, worse than squamous and adeno.
25
What are the treatments of choice for small cell and non-small cell lung cancers?
Small cell - chemotherapy, although resistance is emerging rapidly
Non-small cell - surgical resection
26
Immunohistochemistry - what do adenocarcinomas express? What do small cell cancers express?
Adenocarcinomas - thyroid transcription factor (TTF) 1
SCC - mutated p53 and high molecular weight keratins
27
Knowing the mutation in lung cancer can guide treatment. What mutations are seen almost exclusively in adenocarcinomas (especially in non-smokers and asian ppn.), and what treatment can be used?
Mutations in the EGFR, making it active even in the absence of a ligand
Tyrosine Kinase inhibitors e.g. **erlotinib**
28
What is the cell type change in Barrett's Oesophagus?
Lower 3rd of the oesophagus exhibits metaplasia, **squamous epithelial cells** in the lining of the oesophagus change to **simple columnar epithelium** with goblet cells.
Associated with adenocarcinoma, and as such is a pre-malignant condition.
29
What is the initial part of the nasal cavity called? What cell type lines it? And what does it change into as you progress down the resp tract?
Vestibule
Keratinised stratified **squamous** epithelium
Keratin is lost and eventually the cells change into pseudostratified ciliated **columnar** epithelium cells with goblet cells - **respiratory epithelium**
30
What is under the respiratory epithelium, and what does it contain?
Lamina propria
seromucous glands and a rich venous plexus
31
What is this? Where is it found? What cell type covers it?
Vocal folds
In the larynx
Stratified squamous epithelium
32
How many C shaped cartilages are present in the trachea?
15-20
33
At what point in the respiratory tree is cartilage lost? What happens to the columnar epithelium as the resp. tree gets smaller?
Bronchi are the last parts of the respiratory tree to contain cartilage.
Bronchioles lack cartilage but may still contain some goblet cells. Columnar epithelium gets shorter in height until they become cuboidal in the smallest bronchioles.
34
What are Clara cells? What is their role?
Non-ciliated "club cells" found on the surface of terminal broncioles
Several functions, including...
* stem cells
* detoxification
* immune modification
* surfactant production
35
At what point in the respiratory tree does the conducting portion become the respiratory portion?
At the respiratory bronchioles, found on the end of the terminal bronchioles
36
Other than Type I and Type II pneumocytes, what other cell type is present in alveoli?
Alveolar macrophages
37
What are the 5 stages of a cough, and what nerve(s) are involved at each stage?
1. **Deep inspiration** using diaphragm (phrenic nerve), intercostal muscles (intercostal nerves) and accessory muscles of inspiration
2. **Adduction of the vocal cords** to close the rima glottidis (vagus nerve)
3. **Contraction of anterolateral abdominal wall muscles** (intercostal nerves) to increase intra-abdominal pressure -\> acts on adducted vocal cords
4. **Sudden abduction of vocal cords** to open the rima glottidis (vagus nerve)
5. **Soft palate tenses** (trigeminal nerve) and **elevates** (vagus nerve) to close off nasopharynx (if it didn't, this would be a sneeze!)
38
Sensory receptors in which nerves trigger sneezing?
Sensory receptors in which nerves trigger coughing?
Sneezing - CN V or CN IX
Coughing - CN IX or CN X
39
What structures are contained in the carotid sheath?
* vagus nerve
* internal carotid artery
* common carotid artery
* internal jugular vein
40
The intercostal nerves are the anterior rami of the spinal nerves. What vertebral levels do these arise from?
T1-T11
41
What important clinical sign is suggestive of dyspnoea (difficulty breathing)?
Recruitment of accessory muscles i.e. through "fixing" the upper limbs in place so the muscles can pull the ribs upwards and outwards
42
What are the accessory muscles of deep (forced) inspiration
Pec major
Pec minor
Scalenus
sternocleomastoid
43
What muscle type are the intrinsic muscles of the larynx? What nerve supplies them?
These muscles abduct/adduct the vocal cords during the cough reflex
Skeletal (voluntary) muscle
Supplied by somatic (motor) branches of the **Vagus nerve**
Adduct
44
Describe the path of the vagus nerve down through the body
Connects with CNS at the medulla
Passes through the jugular foramen and travels in the carotid sheath
Sensory supply to the mucosa lining the larynx
Motor supply to the intrinsic muscles of the larynx
Descend **posteriorly to the lung root,** supplying parasympathetic axons to the chest organs (**including the lungs** via the pulmonary plexus)
Pass through the diaphragm **on the oesophagus**
On the surface of the stomach, divides into symp and parasymp branches to supply the foregut and midgut.
45
What are the muscles of the anterolateral abdominal wall? (4)
* rectus abdominis
* external oblique (superficial)
* internal oblique (middle)
* transverse abdominis (deep)
46
Describe the external oblique:
- where does it attach superiorly?
- where does it attach inferiorly?
- how does it attach in the middle of the abdomen?
- superiorly attaches to **superficial aspects of the lower ribs**
- inferiorly attaches to the **anterior part of the iliac crest** and **the pubic tubercle**
- at the **linea semilunaris**, the muscle ends and the aponeurosis (flattened tendon) begins. These meet in the middle at the **linea alba** (white line), over the umbilicus.
47
Describe the internal oblique:
- where does it attach superiorly?
- where does it attach inferiorly?
- how does it attach in the middle of the abdomen?
- superiorly attaches to the **inferior border of the lower ribs**
- attaches inferiorly to the **iliac crest** and the **thoracolumbar fascia** of the lower back
- aponeuroses meet at the **linea alba**
48
Describe the transverse abdominis:
- where does it attach superiorly?
- where does it attach inferiorly?
- how does it attach in the middle of the abdomen?
- superiorly attaches to the **deep aspects of the lower ribs**
- inferiorly attaches to **iliac crest** and the **thoracolumbar fascia** of the lower back
- also meets in the middle at the **linea alba**
49
The rectus abdominis sits in between the aponeurosis of the transverse abominis/internal oblique/external oblique.
What separates the recuts abdominis into a 6-pack?
Internal oblique
Tendinous intersections separate the 2 long flat muscles of the rectus abdominis into smaller sections.
50
Describe the path of the thoracoabdominal nerves
7th - 11th intercostal nerves travel anteriorly, then their terminal branches leave the intercostal spaces in the plane between the internal oblique and the transverse abdominis to become the **thoracoabdominal nerves.**
51
In terms of size, what is the difference between a small and large pneumothorax?
Small - 2 cm or less between lung and parietal pleura
Large - more than 2cm between lung and parietal pleura
52
How is a pneumothorax diagnosed?
- hyperresonance on percussion
- reduced ipsilateral chest expansion
- reduced ipsilateral breath sounds
- CXR shows a visible lung edge
53
A tension pneumothorax may cause a mediastinal shift, in which the trachea would be deviated away from/towards the side of the pneumothorax.
What else may occur?
Away from - build-up of pressure due to pneumothorax pushes mediastinal structures away
Compression of the SVC, reducing venous return to the heart and resulting in **hypotension**
54
What vertebral level is the sternal angle found at? What anatomical landmark does this correspond with?
T4, also the level at which the superior mediastinum becomes the inferior mediastinum.
55
In a large pneumothorax, needle aspiration (thoracentesis)/chest drain placement is required. Where should this be placed?
4th or 5th intercostal space in the midaxillary line
56
In a tension pneumothorax, an emergency large-gauge cannula is needed. Where is this placed?
2nd or 3rd intercostal space, mid-clavicular line on the same side as the tension pneumothorax
57
Where do diaphragmatic herniae most commonly occur?
As an oesophageal hiatus (T10)
58
Where do the inguinal ligaments attach? What do their medial halves form?
Attach at the anterior superior iliac spine (ASIS) and the pubic tubercle.
Medial halves form the floors of the inguinal canal
59
The superficial ring is the entrance/exit to the inguinal canal
The deep ring is the entrance/exit to the inguinal canal
Superficial ring is the exit
Deep ring is the entrance
60
Inguinal hernaie form in the medial/lateral half of the inguinal region
medial
61
What does the inguinal in the adult contain, in both males and females?
Males - spermatic cord
Females - round ligament of the uterus
62
What are the 2 contributing factors to development of an inguinal hernia?
* weakness in the abdominal wall (inguinal canal)
* increased intra-abdominal pressure
* chronic cough
* chronic constipation
* occupational lifting of heavy weights
* athletic effort
63
In embryological development, what is the name of the cord that the gonads follow through the deep and superficial rings of the inguinal canal?
The gubernaculum
64
What are the three layers of "coverings" that, along with the testes and associated structures, make up the spermatic cord?
Outer - external spermatic fascia
Middle - cremasteric fascia
Inner - internal spermatic fascia
65
What 3 structures does the spermatic cord contain?
Vas deferens (transports sperm)
Testicular artery (branch of the abdominal aorta)
Pampiniform venous plexus
66
What happens in the Embryonic stage of lung maturation? What time period does this cover?
Formation of respiratory diverticulum
Inital branching to give lungs, lung lobes and segments
Time period: 26 days - 6 weeks
67
What happens in the Pseudoglandular stage of lung maturation? What time period does this cover?
14 more generations of branching, giving rise to the terminal bronchioles
Time period: 6 - 16 weeks
68
What happens in the Canalicular stage of lung maturation? What time period does this cover?
The terminal bronchioles develop 2 or more respiratory bronchioles, which develop 3-6 alveolar ducts
Time period: 16 - 28 weeks
69
What happens in the Saccular stage of lung maturation? What time period does this cover?
Terminal sacs form, capillaries establish close contact
Time period: 28-36 weeks
70
What happens in the Alveolar stage of lung maturation? What time period does this cover?
Alveoli mature
Time period: 36 weeks - early childhood
71
What is the median survival for lung cancer in Scotland, following diagnosis?
5.8 months.
72
What are the differences in treatment for Small-cell vs Non-Small cell lung cancer?
Small cell (12% of cases) - rarely suitable for surgery, shows good initial response to cytotoxic chemotherapy, followed up with radiotherapy
Non-small cell - curative options are surgery or radical radiotherapy. Chemotherapy is less effective
73
What is median survival of surgical resection vs no surgical resection in lung cancer?
With surgery - 42.7 months
Without surgery - 4.8 months
74
Pleural effusion seen on CXR, what investigations to perform next?
History and examination
Pleural aspirate (if not obviously due to left sided heart failure)
Biochemistry (transudate or exudate?)
Cytology
Culture
75
What can we tell from fluid appearance when aspirating a Pleural Effusion?
Straw-coloured?
Bloody?
Milky?
Foul-smelling?
Food present?
Straw-coloured - cardiac failure, hypoalbuminaemia
Bloody - trauma, malignancy, infection, infarction
Milky - empyema, chylothorax (lymph leakage)
Foul smelling - anaerobic empyema
Food particles - oesophageal rupture
76
What is the difference between transudates and exudates? What could cause these?
Transudates - protein content \< 30g/L
Causes - Heart failure, liver cirrhosis etc.
Exudates - protein content \> 30g/L
Causes - malignancy, infection, pulmonary infarct, asbestos
77
What does the presence of the following cell types in lung fluid suggest?
- Lymphocytes
- Neutrophils
Lymphocytes suggest malignancy/TB (although any long-standing effusion will become lymphocytic)
Neutrophils suggests an acute process
78
What are some clinical features of someone with a mesothelioma?
Takes a long time to develop following exposure to asbestos.
Can present with...
* breathlessness
* chest pain
* weight loss
* fever
* sweating
* cough
79
Signs and symptoms of pneumothorax?
Symptoms
* acute onset chest pain
* SOB, hypoxia
Signs
* tachycardia
* hyperresonant percussion
* reduced expansion
* quiet breath sounds
80
Name some common upper respiratory tract infections
Coryza (common cold)
Pharyngitis - sore throat
Sinusitis
Epiglottitis
81
Name some lower respiratory tract infections
Acute bronchitis
COPD - acute exacerbation
Pneumonia
Influenza
82
Acute exacerbation of COPD - clinical features
Usually preceeded by URTI
Increasing wheeze and breathlessness. Decreased exercise capacity
On examination
* respiratory distress
* SOB
* chest tightness
* wheeze and cough +/- sputum
* coarse crackles
* may be cyanosed
83
Acute exacerbation of COPD - management
Bronchodilatory inhalers, nebulised high dose - SABA/SAMA
O2 24-28% if respiratory failure
Oral prednisolone and IV hydrocortisone
Antibiotic - amoxycillin or doxycycline if evidence of infection
84
Pneumonia - signs and symptoms
Signs
* fever
* rigors
* herpes labialis
* tachypnoea
* **crackles**
* **rub**
* cyanosis
* hypotension
Symptoms
* Malaise
* Anorexia
* Sweats
* **Confusion**
* Haemoptysis
* Diarrhoea
* Headache
* Cough
* Pleurisy
85
Pneumonia is defined as signs and symptoms of LRTI, with a new infiltrate on X ray.
What investigations would you do?
Blood culture
FBC
Serology
AGBs
Urea
LFTs
CXR
86
What are the criteria of the CURB65 score? How does % mortality change in patients with pre-existing COPD?
C - new onset Confusion
U - Urea \>7
R - Resp rate \>30/min
B - BP systolic \<90 or diastolic \<61
65 - age 65 or older
If the patient already has COPD, mortality at all scores increases by 10%
87
Treatment for CAP
Mild/Moderate (0-2) - amoxicillin, or if penicillin-allergic doxycyline on day 1 followed by IV clarithromycin
Severe (3-5) - IV co-amoxiclav and oral doxycycline, IV levofloxacin if penicillin allergic
ICU - IV co-amoxiclav and IV clarithromycin
88
Complications of pneumonia?
Pleural effusion
Empyema
Respiratory failure
Death
89
Name some types of Atypical pneumonia, and their corresponding antibiotic treatment
HAP
* Amoxicillin - Staph and Strep
* Metronidazole - anaerobes
* Gentamicin - coliforms
Aspiration pneumonia
* Metronidazole
Legionella
* Fluoroquinolones - levofloxacin, ciprofloxacin
* Macrolides - clindamycin, azithromycin
* Penicillins - amoxicillin
90
What are some of the complications of influenza? What antivirals are available?
Primary influenza pneumonia
Secondary bacterial pneumonia
Bronchitis
Antivirals - oseltamivir, zanamivir
91
Name three bacterial causes of atypical CAP. What Antibiotics are used to treat these?
Mycoplasma pneumoniae
Coxiella burnetii
Chlamydophila psittaci
Antibiotics - tetracylines (doxycycline), macrolides (clarithromycin)
92
What is the clinical presentation of Bronchiolitis? What is the main cause?
1st or 2nd year of life
Fever
Coryza
Cough
Wheeze
Severe - grunting, sternal recession
Main cause - up to 80% due to Respiratory Syncitial Virus (RSV)
93
What pathogen was first identified in 2001 in childern with acute respiratory tract infections?
Metapneumovirus
94
