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52 Cards in this Set
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21 year man has a productive cough, wheeze and steatorrhoea. OE he is clubbed and cyanosed, has bilateral coarse crackles |
Cystic Fibrosis |
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63 y man presents to A&E with wt loss, cough , haemoptysis and shortness of breath. OE he is anaemic clubbed and apyrexial |
Bronchogenic carcinoma |
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65 y man presents with SOB and cough productive of pink frothy sputum. OE he is cyanosed and tachycardia, has bibasal end -isnpiratory crackles. JVP is elevated |
Pulmonary oedema |
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70 y woman presents with fever rigors SOB and right sided pleuritic chest pain. OE the right side of chest shows reduced expansion, dull percussion and increased tactile vocal remits |
Pneumonia OE the right side of chest shows reduced expansion, dull percussion and increased tactile vocal remits = consilidation Consolidation means replacement of alveolar air by fluid, cells , tissue , or other materials MOST COMMON : Pneumonia |
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30 y farmer presents with repeated ep of fever , rigors dry cough and SOB with onset several hours after starting work. OE he is pyrexial with coarse end-expiratory crackles. CXR shows mid-zone mottling. |
Extrinsic allergic alviolitis Is hypersensitivity reaction to inhaled antigens. Most common in Farmers : Aspergillus Clavatus on germinating barley / Thermophilic actinomycetes in moldy hay |
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Cystic Fibrosis ( general information) |
Autosomal Recessive condition Assx with a mutation in the CFTR gene on chromosome 7. Pt are susceptible to recurrent Resp inf and the development of bronchiectasis. Acute exacerbation usually caused by Pseudomonas spp. ( PS : may be highly resistant to AB) 'Haemoptysis' may indicate = Aspergilloma. Pancreatic Insufficiency devopls => resulting=> in malabsorption & Steatorrhoea. Growth and puberty are delayed in most pt. Males usually infertile ( due to Vas deference and epididymis failure to develop ) INV: High Sweat Na and Cl concentration ( >60 mmol/l) are highly suggestive |
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Causes of Respiratory causes of Clubbing |
Carcinoma of bronchus Mesothelioma Bronchiectasis Abscess Empyema Cryptogenic fibrosing alveolitis Cystic Fibrosis PS: NOT: COPD , ASTHMA ( are not causes of clubbing) |
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Pulmonary Oedema |
Sx are presentation of Pul. Oedema 2ry to Left Ventricular Failure.Occurs due to Left sided filling pressure are elevated => causing high pulmonary capillary pressures. => transudation of fluid from plasma into alveoli => pairing gas exchange + Reducing pulmonary compliance.Sputum is pink = result of leakage of red blood cells into the alveoli which is a consequence of ruptured pulmonary capillaries |
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80 y man presents with bilateral cavitation bronchopneumonia after an influenza infection. Cause? Mx? |
Staphylococcus aureus Seen in : elderly , recovering from Influenza , IV drugs users (b/c of infected needles) usually assxStaphylooccal endocarditis of tricuspid valve. MX: Flucloxacillin (penicillin) |
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24 y student presents with severe headache, fever, dry cough , arthralgia. has recently bought several Parrots and was previously fit and well Cause of pneumonia ? Mx? |
Chlamydia Psittaci ( Psittacosis ) Rare, Suspected in any pt with Lower Resp infection & exposure to Birds. Dx inv: no acute one available. Done using a rising title of Compliment fixing Antibody ( similar to other atypical pneumonia causes i.e.: Legionella pneumophillia & Mycoplasma ) MX: Macrolide Antibiotic (Erythromycin) |
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40 y man with HIV presents with fever, dry cough , wt loss and exertion dyspnoea Cause of pneumonia ? |
Pneumocystis carinii a complication of HIV. an Opportunistic infection in other immunocompromised pt (i.e. immunosuppressive drugs & cancer chemotherapy ) |
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75 y man presents with headache, dry cough, anaemia , and a skin rash Blood tests detect cold agglutinins. Cause of pneumonia ? Mx? |
Mycoplasma infection most common atypical cause of community acquired pneumonia . Usually cases occur during an an epidemic. HINT: Autoimmune hemolytic anaemia caused by 'cold agglutinins' dx inv: rising antibody titre Mx: Erythromycin. ( macrolide antibody) Immediately on clinical suspicion . |
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25 y old A/C technician, who suffered from flu-like symptoms a week ago, has developed a dry cough. CXR: multilobar shadowing. Blood test: hypoNa and lymphopenia Urinalysis: Haematuria Cause of Pneumonia ? |
Legionella Pneumophila rare atypical community pneumonia Cases occur Sporadically / oR / assx with infected Air-conditioning systems. Sx: Flu like sx -> Lower Resp infection ( Dry cough, Dyspnoea) HINTs: HypNa, Lymphopenia. Dx test: legionella antigen in the urine. Prevention: adequate chlorination of the water supply are important to prevent outbreaks |
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65 y smoker presents with SOB , gallop rythm and production of Pink frothy sputum. |
Pulmonary Oedema 2ry to L.Vent failure (hint: increased JVP , Gallop rhythm) Most likely cause : Ischameic Heart disease. high index of suspicion of underlying ishcamic event ( MI) |
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24 y man initially complaining of cough and intermittent haemptysis presents a few weeks later with hematuria. Biopsy: crescentic Glomurolunephritis. Renal Biopsy: Linear pattern Disposition on immunefluroscence Cause of hemoptysis? |
Good Pasture's syndrome Pulmonary Renal Syndrome HINT: Renal Biopsy: Linear pattern Disposition onimmunefluroscence Mx: immunosuppressive : corticosteroids. but Plasmapheresis to remove the anti-GBM antibodies is also successful |
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Pulmonary Renal Syndrome ( Previous question DDX) |
is diffuse alveolar hemorrhage plus glomerulonephritis, often occurring simultaneously. Cause is almost always an autoimmune disorder. Diagnosis is by serologic tests and sometimes lung and renal biopsy. Serology : Wegener’s granulomatosis : cANCA (cytoplasmic anti-neutrophil cytoplasmic antibody) (PR3) and GoodPasture's : anti-glomerular basementmembrane (GBM) antibodies of the IgG type Renal Biopsy: GD : a classiclinear staining on direct immunofluorescence |
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GoodPasture's disease: ( further explanation) |
condition resulting from the presence of anti-GBM antibodies. Itis believed that the binding of these antibodies to the kidney glomerularmembrane and lung alveolar membrane mediates a type II hypersensi-tivity reaction, which is responsible for the pathology in those organs. There is a strong association with HLA-DR2. The disease is said to occurmore frequently in smokers and those exposed to the fumes of hydro-carbon solvents. Sufferers should avoid smoking, which can aggravaterespiratory symptoms and increase the likelihood of lung haemorrhage. |
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34 y woman originally complaining of nasal obstruction develops cough, hemoptysis and pleuritic chest pain. CXR: multiple nodular masses |
E. Wegnener's granulomatosis small artery vasculitis (PR3 ANCA positive) characterized by lesions involving the URT, lungs, kidneys. Look out for Eye signs: scleritis, uveitis, retinitis (in up to 50 % pt) however it can affect ay organ and less common assx sx may show Mx: Immunosuppresive medications. ( high dose corticosteroids + Cyclophosphamide) |
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22y man presents with fever nightsweats, wt loss, cough productive of cupfuls of blood. Ziehl-Neelsen stain is positive for Acid fast bacilli (AFB) |
A.TB Although the lung is themost commonly affected organ in TB, infection may present in othersites, e.g. urinary tract, bone, central nervous system (CNS). Miliary TB is the term used to describe widespread TB through haematologicaldissemination. It carries a poor prognosis. |
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35 y businessman returns from a. trip abroad and collapses at the airport with Haemoptysis and pleuritic chest pain. ECG : Sinus tachycardia , and Right axis deviation |
K. Pulmonary Embolus dx inv: clinical suspicion + ventilation-perfusion scanning & Pulmonary angiography. ( now using CT ) risk factors: previous thromboembolic events, OCP, surgery ( esp pelvic) , immobility , inherited thrombophilia |
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CXR: Multiple bilateral nodules b/n 0.5 and 5 cm in a former miner with rheumatoid arthritis |
J. Caplan's Syndrome a pulmonary manifestation of RA which is characterized by presence of pulmonary nodules. Typically occurs in RA + exposure to Coal dust. Sx: cough, SOB, haemptysis |
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Other Respiratory Manifestation associated with Rheumatoid Arthritis ( extra information ) |
Fibrosing alveolitis , Pleural effusions (rare) Obliterative Brochiolitis RA can also affect the cricoarytenoid joins => leading to URT obstruction |
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CXR: Kerley B lines, Bat wing shadowing Prominent upper lobe vessels Cardiomegaly |
M . Acute left Ventricular failure That causes Pulmonary edema PS: Kerley B lines difficult to see in real life Kerley B lines : thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs Are seen in interstitial Pulmonary Edema PSS: R. vent failure may present with cardiomegaly , but pulmonary edema does not occur |
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CXR Trachea deviated to right Horizontal fissure & Right hilum displaced upwards |
C. Right upper lobe Collapse Horizontal fissure: position is a goodclue to the presence of volume loss. On the right , it should rn from middle of the right hilum and can be traced to the level of the sixth rib in the axillary line. In R. Upper lobe collapse =Elevated |
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CXR of Left Upper lobe collapse ( further information ) |
There is no left middle lobe and hence no horizontal fissure Theupper lobe is anterior to a greater proportion of the lower lobe. Hence, it can give rise to a hazy white appearance over alarge part of the left lung field. NOT to be confused with Pleural Effusion; in collapse Tracheal deviation is to the side of the lesson + elevation of hilum + preservation of costophrenic angle |
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CXR: Numerous calcified nodules sized less than 5 mm located predomanintly in the lower zones of lungs |
F. Varicella pneumonitis HINT : Multiple , small , calcified nodules Other causes of calcified nodules: TB, histoplasmosis , Chronic renal failure |
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CXR: Double shadow right heart border Prominent left atrial appendage Left main bronchus elevation. |
A. Advanced mitral stenosis (caused by left atrial enlargement ) |
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A 28 y old African -Caribbean man presents with dry cough, progressive SOB CXR: bilateral hilar lymphadenopathy |
K. Sarcoidosis Other causes of bilateral hilariously lymphadenopathy : TB, malignancy , organic dust diseases, extrinsic allergic alviolitis |
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CXR of a 13 year old boy with Cystic fibrosis has Tramline & Ring shadows |
C.Bronchiectasis (common early complication of CF) Other causes of bronchiectasis : Kartagner's Syndrome ( immotile ciliary syndrome) Pertussis Bronchial obstruction |
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Cystic Fibrosis Sx & On examinaiton (further. information |
Sx: cough productive of large amounts of purulent sputum and there can be hemoptysis OE: pt may be clubbed with coarse inspiratory crackles that can be heard over infected areas of lung . |
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40 y woman presents with gross clubbing and progressive SOB. Ex: fine end-inspiratory crackles. CXR: ground - glass appearance of the lung: |
F.Cryptogenic Fibrosing alveolitis when it progresses it may develop a 'Honeycomb' CXR. Fibrosing alveolitis : ( not Cryptogenic ) : assx with RA , systemic sclerosis, ulcerative colitis |
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65 y smoker presents with SOB . CXR: eight ribs cane seen anteriorly , above the diaphragm on each Side of the chest in the mid-clavicular line. |
G. COPD more than six ribs visible suggests hyperexpansion. which may occur in COPD |
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a 7 y girl with slight wheeze and SOB despite inhaled salbutamol mx? ?????????????CHECK??????????????/ |
M. Oral Sodium Cromoglycate OR: Salbutamol with SPACER ????????? spacer improves delivery in children and pt with poor inhaler technique. Ps it is imp to optimize bronchodilator therapy in younger pt as early initiation of corticosteroids may lead to Growth s=retardation. |
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22y student with mild asthma that needs treatment for occasional early morning wheeze |
K. Inhaled salbutamol this is step 1 of (BTS) British Tohoracic Society 2003 guidlines |
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A 17 y student complains that he has to use his salbutamol inhaler regularly to control wheezing |
C. Inhaled beclomethasone (Corticosteroids) part 2 of BTS |
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32 y pt taking max dose-inhaled therapy and slow-release theophylline shows persistently inadequate control of Sx mx? |
B. Oral Prednisolone ( Glucocorticosteroids ) (even though it should be avoided, all other options had been exhausted BTS step 5 a pt with such poorly controlled asthma should be under a specialist |
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25 y woman requires add-on therapy b/c inhaled beclomethasone and salbutamol do not adequately combat her sx |
H. Inhaled Salmeterol Under BTS step 3 : two options : either: long acting B inhaler OR : dose of inhaled steroids can be increased PS: beclomethasone (a.k.a Qvar a steroid) |
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65 y man with long standing COPD presents with severe SOB. He has been treated with oxygen and nebulizer bronchodilators. An hr later : PaO2 6.0 kPa ( on max O2) PaCO2 16.0 kPa, pH 7.2 MX? |
D. Nasal intermittent positive pressure ventilation EMERGENCY ; severe exacerbation of COPD and consequent type II respiratory failure that has responded poorly to medical therapy. Conventional mx would involve formal intubaiton ventilation , and transfer to ICU . NIPPV ( non invasive intermittent positive pressure ventilation ) . For a successful NIPPV needs a conscious and cooperative pt. |
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17 y female presents with wheeze and marked peri-oral swelling. Pao2. 7.0 kPa ( on 28 % O2) PaCo2 4.1 kPa mx? |
K.100% O2, IM adrenaline, nebulizer salbutamol classic presentation of Acute Anaphylaxis . type I igE. Initial treatment . 0.5 epinephrine (adrenaline ) 1:1000 solution ( 50ug) delivered IM can be repeated in absence of clinical improvement or if deterioration occurs. IV epinerphrine is dangerous and should be given slowly only in a dilution of at least 1:1000 in an immediately life-threatening situation e.g. Frank Cardiac Arrest |
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14 y old with asthma with acute severe asthma attack Pa)2 10.0kpa (28% ) PaCo2 8 kpa |
L.IV Hyrdocortisone Intubation and ICU if t not responding to drug therapy pt is both hypoxic and retaining Co2 ( norm: 4.5-6) |
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28 y man involved in a road traffic accident presents with severe respiratory distress E: reveals decreased expansion on R. side of chest with mediastinal shift to left |
H. Right -sided decompression Tension Pneumothorax a medical EMERGENCY a Cannula must be inserted into the 2nd intercostal space in the mid-clavicular line of the affected side until a functioning intercostal tube can be positioned |
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young man presents with an acute onset SOB E: reveals decreased expansion on the right: SaO2 95 % |
C. Chest Radiograph CXR is Indicated to confirm dx of Pneumothorax and assess degree of collapse in healthy no further mx needed. should be observed for 6 hours and if there is no increase in size of pneumothorax may be discharged with early follow-up and repeated CXR Spontaneous pneumothorax is common in young ( tall, thin) men. In pt with large pneumothoraces simple aspiration is recommended as first line-treatment , if unsuccessful , a chest drain will be required. |
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A Previously healthy 65 y smoker with early COPD complains of SOB on exertion SOB= ( shortness of breath) Mx? |
A. Inhaled Sablbutamol Stop smoking, encourage excercise and reducing obesity Use of inhaled bronchodilators is First line therapy for early COPD |
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65 y woman with longstanding COPD presents with SOB and cough productive of colored sputum mx |
F. 28% O2, Nebulized Salbutamol + Ipratropium, Oral Prednisolone, Oral Amoxicilline this is presentation of infective exacerbation of COPD |
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a 70 y man admitted with Acute severe exacerbation of COPD does not respond to oxygen and nebulizer bronchodilators |
L. NIPPV Early use of NIPPV may improve outcome and avoid intubaiton |
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a 65 y pt with advanced COPD treated with Brochodilators and steroids still feels breathless. His baseline PaO2: 6.5 kpa (norm >10.5 kpa) |
D. Long term O2 therapy |
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a 55 y pt with COPD requires regular add-on therapy after bronchodilators do not control symptoms |
H. Oral Aminophylline ( bronchodilator ) taken before going to bed may be helpful in sx in the early hours of mourning . It should be used with cautious b/c it has a narrow therapeutic index Sx of toxicity ?: Nausea, vomiting , cardiac arrhythmias |
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Standard therapy for community acquired pneumococcal pneumonia not requiring hospital admission |
H. Oral Amoxicillin Oral erythromycin can be prescribed as an alternative if the pt is allergic to penicillin or in combo with amoxicillin if an atypical if an atpical organism is suspected |
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a 35 y pt on the ward admitted to hospital 10 days ago presents wth severe pneumonia mx |
E. IV Ceftazidime Hospital Aquired ; i.e. Pseudomonas spp ( multiple antibiotic resistant. Third generation Cephalosporin : i.e. Ceftazidime |
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a 40 y builder presents with severe Community -Aq Pneumonia . Atypical pathogens are suspected mx |
M. IV CEfuroxime + Erythromycin this is standard therapy for severe comm-aq pneumonia. Rifampicin can be added empirically f there is a high clinical suspicion of Legionella infection |
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22 y HIV +ve on anti-retroviral presents with Pneumocystis Carinii pneumonia mx |
K.IV Co-Trimoxazole
mx of choice : high -dose co-trimoxazole (Antibiotic) delivered IV for 2-3 weeks . IV Pentamidine if co-Trimaxazole is C/I ore not tolerated. Corticosteroids are often used as an adjunct if there is HYPOXEMIA |
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a19 boy contracts pneumonia with sx of headache fever and dry cough.
serology : Chlamydia infection Mx? |
C.Oral tetracycline It often presents with biphasic illness: URT sx precede the pneumonia. Dx is made retrospectively . Tetracycline is mx of choice |
