Week 3: Respiratory medicine (2) (emergencies, X-ray, infections) Flashcards

Question

unprovoked PE

Answer 1

*PE i.e. no obvious risk factor – in these cases consider underlying malignancy or thrombophilia*

Answer 2

* ABCDE * Oxygen if hypoxic * Analgesia if pain * Subcutaneous DOAC (or LMWH if contraindicated) whilst awaiting CTPA * Should be fully anticoagulated once confirmed **diagnosis on CTPA**

Answer 3

* hypotension/ imminent cardiac arrest * signs of right heart strain on CT / Echo * Consider thrombolysis with IV alteplase (risk of intracerebral bleed approx. 4%)

Answer 4

* intro * quality of film * ABCDE * review areas

Answer 5

* Name and age of patient * Date CXR taken * Type of CXR (e.g. PA or AP, erect or mobile) * **Quality of film**

Answer 6

* **Rotation** * Medial aspect of each clavicle should equidistant from spinous processes * Spinous processes should be vertically orientated against vertebral bodies * **Inspiration** – 5-6 anterior ribs * **Projection** (not AP or PA) * **Exposure**- left hemidiaphragm should be visible to the spine and vertebrae should be visible behind the heart

Answer 7

trachea central, carina, bronchi, hilar structures

Answer 8

lungs, pleura

Answer 9

heart size and border

Answer 10

costophrenic angles - flattened?

Answer 11

soft tissue, bones, tubes, valves, pacemakers, review areas

Answer 12

* the lung apices * the retrocardiac region * behind the diaphragm * the peripheral region of the lungs * the hilar regions

Answer 13

e.g. “loss of right costophrenic angle which may be in keeping with a pleural effusion” as opposed to “a right pleural effusion”)

Answer 14

* Refer to zones * Right Upper, Middle and Lower, * Left Upper, Middle and Lower * Shadowing can be * Complete (whiteout of whole lung field) * Dense / opacification (affecting one or more zones), * Diffuse * Alveolar (cotton wool like appearance)

Answer 15

(The heart diameter is the shorter white arrow; the thoracic diameter is the longer black arrow. The Heart diameter is over 1⁄2 the thoracic diameter. The Cardio-thoracic ratio is therefore increased = Cardiomegaly.)

Answer 16

atelectasis

Answer 17

pleural effusion pneumothorax

Answer 18

Cant tell the difference between lung cancer and pneumonia on X-ray

Answer 19

ACEi, ARB, B blockers, NSAIDS

Answer 20

*Lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs ( double pneumonia ) or only one ( single pneumonia ).* **Risk factors** Smoking, age\>65, immuno-suppression, exposure to chemicals, and underlying lung disease

Answer 21

s a form of pneumonia, usually caused by Legionella pneumophila. Association with infected water in showers or hot tubs – ask your patient if there is a ***history of recent travel or stay in a air conditioned hotel?*** Associated with higher CURB-65 scores.

Answer 22

Pneumonia TB (usually uopper lobe) lung cancer lobar collapse haemorrhage

Answer 23

* HIV test * Immunoglobulins * Pneumococcal IgG serotypes * Haemophilus influenzae b IgG * Follow up in clinic in 6 weeks with a repeat CXR to ensure resolution

Answer 24

* Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more serious diseases such as Severe Acute Respiratory Syndrome (SARS-CoV) * SARS-CoV-2 (severe acute respiratory syndrome-related coronavirus 2) is the name of the virus, not the disease that results from it. * Can cause a viral pneumonia

Answer 25

* hypoxia (below 92%) * lymphopaenia * bilateral, lower zone changes on CXR

Answer 26

* Unwell patients require oxygen supplementation, some going on to CPAP or invasive ventilation * Evidence Base e.g. Dexamethasone (and consider Tocilizumab +/- Remdesivir) * Antibiotics may be needed if suspected superadded bacterial infection

Answer 27

vaccination

Answer 28

given to ‘at risk’ people who have tested positive of COVID-10 Casirivimab/imdevimab, sold under the brand name **REGEN-COV** among others, is a medicine developed by the American biotechnology company Regeneron Pharmaceuticals. It is an artificial "antibody cocktail" designed to produce resistance against the SARS-CoV-2 coronavirus responsible for the COVID-19 pandemic

Answer 29

A bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person. * Mycobacterium tuberculosis. * Acid-fast bacilli

Answer 30

* Often fever and nocturnal sweats (typically drenching) * Weight loss (weeks – months) * Malaise * **Respiratory TB:** cough ± purulent sputum/ haemoptysis, may also present with pleural effusion * **Non-Respiratory TB:** Skin (erythema nodosum); Lymphadenopathy; Bone/joint; Abdominal; CNS (meningitis); Genitourinary; Miliary (disseminated); Cardiac (pericardial effusion)

Answer 31

*Admit to a side room& start infection control measures (e.g. masks & negative pressure room)* * If productive cough: x3 sputum samples for AAFB (acid-alcohol fast bacilli – acid-fast stain also called Ziehl-Neelsen stain) &TB culture (If no productive cough & pulmonary TB suspected consider bronchoscopy) * Routine bloods (especially LFTs) & include HIV test and vitamin D levels * Consider CT chest if pulmonary TB suspected but clinical features/ CXR not typical

Answer 32

start antibiotics for pneumonia (as per CURB-65) whilst investigating possibility of TB.

Answer 33

then start anti-TB therapy AFTER sputum samples sent.

Answer 34

* TB culture can take 6-8 weeks. So, treatment is often started before a culture confirmed diagnosis can be made. A novel PCR test (Gene Xpert) is available in some centres which can give immediate information regarding drug sensitivities or resistance

Answer 35

* **Ripe (rifampicin, isoniazid, pyrazinamide, ethambutol for 2 moths follow by R and I for 4 months** * Minimum of 6 moths total * Patients weight important – dose dependent * Check baseline LFTs and monitor * Check visual acuity before giving ethambutol * Compliance is crucial and directly observed therapy sometimes used for patients * Pyridoxine also given (while on isoniazid) as prophylaxis against peripheral neuropathy

Answer 36

hepatitis, orange/red secretions, many drug interactions inc warfarin

Answer 37

hepatitis peripheral neuropathy

Answer 38

hepatitis, vomiting

Answer 39

optic neuritis (must do a baseline visual acuity test and LFTs must be monitored closely)

Answer 40

* Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection * **Gold standard diagnostic test = High Resolution CT** * Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection * Gold standard diagnostic test = High Resolution CT

Answer 41

* Post infective – whooping cough, TB * Immune deficiency – Hypogammaglobulinaemia * Genetic / Mucociliary clearance defects – Cystic fibrosis, primary ciliary dyskinesia, Young’s syndrome (triad of bronchiectasis, sinusitis, and reduced fertility), Kartagener syndrome (triad of bronchiectasis, sinusitits, and situs inversus) * Obstruction – foreign body, tumour, extrinsic lymph node * Toxic insult – gastric aspiration (particularly post lung transplant), inhalation of toxic chemicals/gases * Allergic bronchopulmonary aspergillosis * Secondary immune deficiency – HIV, malignancy * Rheumatoid arthritis * Associations – inflammatory bowel disease; yellow nail syndrome

Answer 42

* Immunoglobulin levels * Cystic Fibrosis Genotype * Aspergillus IgE / IgG and Total IgE * HIV test * Rheumatoid Factor * Auto Antibodies * Alpha-1-antitrypsin level

Answer 43

* Haemophilus influenzae * Pseudomonas aeruginosa * Moraxella catarrhalis * Stenotrophomonas maltophilia * Fungi – aspergillus, candida * Non-tuberculous mycobacteria * Less common - Staphylococcus aureus (think about CF)

Answer 44

1. Treat underlying cause 2. Physiotherapy – mucus / airways clearance 3. Sputum for routine culture as well as nontuberculous mycobacteria 4. 10-14 days antibiotics according to sputum cultures / sensitivities for acute exacerbations (infections): Common 1st line Oral Antibiotics: 5. IV antibiotics for severe infections

Answer 45

achilles tendonitis

Answer 46

* Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations * Supportive – flu / covid vaccines, bronchodilators if required * Pulmonary Rehab – MRC Dyspnoea Score \>3 * Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations * Supportive – flu / covid vaccines, bronchodilators if required * Pulmonary Rehab – MRC Dyspnoea Score \>3 * Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations * Supportive – flu / covid vaccines, bronchodilators if required * Pulmonary Rehab – MRC Dyspnoea Score \>3

Answer 47

* Sometimes patients and clinicians find it difficult to distinguish an acute infection (exacerbation) in patients with bronchiectasis versus their baseline chronic symptoms. Here is a useful definition: * A person with bronchiectasis with a deterioration in 3 or more key symptoms for at least 48 hours: * Cough * Sputum volume and / or consistency * Sputum purulence * Breathlessness and / or exercise tolerance * Fatigue * Haemoptysis

Answer 48

Signet ring sign ## Footnote with the dilated bronchus representing the “ring” and the adjacent smaller artery representing the “jewel” on the ring.

Answer 49

* Caused by aspergillus fumigatus exposure * Aspergillus is a common fungus found indoors and outdoors * ABPA is a combination of types 1 and 3 hypersensitivity reactions following inhalation of fungal spores i.e. it is not a fungal infection * Repeated damage from these immunological reactions leads to bronchiectasis (often upper lobe) * ABPA is seen more in patients with Asthma, Bronchiectasis and Cystic Fibrosis * Diagnosis is made by a combination of symptoms (often dry cough and wheeze) along with positive blood tests (raised Aspergillus IgE level as well as a high Total IgE – these are often accompanied by a high eosinophil level too) * Treatment (steroids) may be required if ongoing symptoms and high Total IgE level

Answer 50

CF is an autosomal recessive disease leading to mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). This can lead to a multisystem disease (most commonly affecting the respiratory and gastrointestinal systems but can affect any part of the body with CFTR) characterised by thickened secretions.

Answer 51

One or more of the characteristic phenotypic features - * Or a history of CF in a sibling * Or a positive newborn screening test result And * An increased sweat chloride concentration (\> 60 mmol/l) – SWEAT TEST * Or identification of two CF mutations – genotyping * Or demonstration of abnormal nasal epithelial ion transport (nasal potential difference)

Answer 52

* Meconium ileus * In 15-20% of newborn CF infants the bowel is blocked by the sticky secretions. There are signs of intestinal obstruction soon after birth with bilious vomiting, abdominal distension and delay in passing meconium. * Intestinal malabsorption * Over 90% of CF individuals have intestinal malabsorption. In most this is evident in infancy. The main cause is a severe deficiency of pancreatic enzymes. * Recurrent Chest infections * Newborn screening

Answer 53

* **Respiratory Infections** * Needs aggressive therapy with physio and antibiotics * Antibiotic prophylaxis

Answer 54

* **Low Body Weight** * needs careful monitoring * may be consequence of pancreatic insufficiency (lack of pancreatic enzymes), therefore in those patients give pancreatic enzyme replacement therapy * high calorie intake and often extra supplements - may need NG or PEG feeding

Answer 55

* **Distal Intestinal Obstruction Syndrome (DIOS)** * DIOS vs. constipation – faecal obstruction in ileocaecum versus whole bowel * Due to intestinal contents in the distal ileum and proximal colon (thick, dehydrated faeces) * Due to insuffiencet prescription of pancreatic enzymes or non compliance, also salt deficiency/ hot weather * Palable right iliac fossa mass (faecal) * **Diagnosis**:right palabale mass in iliac fossa, AXR demonstratingfaecal loading at junction of small and large bowel * **Treatment**: PO Gastrografin–this works by drawing water across the bowel wall by osmosis into the bowel lumen, aiming to rehydrate the dehydrated faecal mass and allow it to pass

Answer 56

diabetes **the thick, sticky mucus causes scarring of the pancreas**. This scarring prevents the pancreas from producing normal amounts of insulin. So, like people with type 1 diabetes, they become insulin deficient.

Answer 57

* No smoking * Avoid other CF patients * Avoid friends / relatives with colds / infections * Avoid jacuzzis (pseudomonas) * Clean and dry nebulisers thoroughly * Avoid stables, compost or rotting vegetation – risk of aspergillus fumigatus inhalation * Annual influenza immunisation * Sodium chloride tablets in hot weather / vigorous exercise

Answer 58

* As per bronchiectasis – physio for airways clearance * Exercise * Mucolytic treatment options also include nebulised DNase (pulmozyme) * Pancreatic Enzyme Replacement Therapy (e.g. Creon) for patients who are Pancreatic Insufficient * Nutritional supplementation if under weight * Fat soluble vitamin (A,D,E,K) replacement * Long-term antibiotics (sometimes inhaled or nebulised) * Optimisation of CF related diabetes – this occurs in approximately 1 in 3 adults with CF and if present requires insulin therapy * Novel CFTR modulators / potentiators (e.g. Kaftrio) – these have shown excellent efficacy with improvements in FEV1, weight, quality of life and a reduction in frequency of infective exacerbations * Long-term monitoring for CF related diabetes, CF related liver disease and osteoporosis

Week 3: Respiratory medicine (2) (emergencies, X-ray, infections) Flashcards

(90 cards)