1
Q
What are the causes of an acute dry and productive cough?
A
Acute dry cough:
- URTI - such as laryngitis, pharyngitis
- drugs - ACE inhibitors
Acute productive cough:
- pneumonia (LRTI)
- tuberculosis (TB)
2
Q
What are the causes of chronic dry and productive cough?
A
Chronic dry cough:
- lung cancer
- GORD
- mesothelioma
Chronic productive cough:
- lung cancer
- bronchiectasis
- cystic fibrosis
3
Q
What are the causes of mixed dry and productive cough?
A
Mixed dry cough:
- heart failure
- asthma
Mixed productive cough:
- heart failure
- COPD
4
Q
What type of cough is usually present in heart failure?
A
- it is usually a dry cough
- it often produces rust-coloured sputum that signifies haemoptysis
- sometimes the cough may be productive
5
Q
What type of cough is usually present in asthma?
A
- it is usually a dry cough
- it may be productive and produce sputum if there is an underlying infection
6
Q
What is the definition of pneumonia?
What are the 3 different types?
A
an infection of the alveoli in the lungs
it is a lower respiratory tract infection
- community-acquired pneumonia
- atypical pneumonia
- hospital-acquired pneumonia
7
Q
What are the 3 most common causes of community-acquired pneumonia?
A
- streptococcus pneumoniae
- haemophilus influenzae B
- moraxella catarrhalis
8
Q
What are the common causes of atypical pneumonia?
A
- Mycoplasma pneumonia
- Legionella pneumophila
- this is associated with faulty air conditioning systems
- Chlamydia psittaci
- this is associated with keeping pet birds
- Chlamydia pneumoniae
9
Q
What are the 3 most common causes of hospital-acquired pneumonia?
How is this defined?
A
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Klebsiella
- this is more common in alcoholics
HAP is defined as acquiring pneumonia after being in hospital for at least 48 hours
10
Q
What is aspiration pneumonia and what causes it?
A
- caused by anaerobes from gut flora
- it occurs when food enters the lungs, often in stroke patients
11
Q
What are the general risk factors for pneumonia?
A
- smoking
- travel
- being immunocompromised
12
Q
What are the associated features of Staph aureus and Klebsiella causing hospital-acquired pneumonia?
A
they are both associated with cavitating lesions
it is a gas-filled area of the lung in the centre of a nodule or area of consolidation
this looks like an abscess with an air-fluid level inside
13
Q
What specific feature is pneumonia caused by Mycoplasma pneumonia associated with?
A
it is associated with transverse myelitis
this is inflammation of both sides of one section of the spinal cord
14
Q
What specific features is pneumonia caused by Legionella pneumophilia associated with?
A
- hyponatraemia and abnormal LFTs
15
Q
What are the normal symptoms associated with typical pneumonia?
A
- fever
- shortness of breath (dyspnoea)
- cough that is productive and produces green sputum
- pleuritic chest pain
- this is chest pain that is worse on inspiration
- confusion
16
Q
What are the symptoms associated with atypical pneumonia?
A
- dry cough
- headache
- diarrhoea
- myalgia
- hepatitis
17
Q
What clinical signs would you expect to be present on inspection of someone with pneumonia?
A
- signs of respiratory distress
- intercostal recession - seeing the ribs going in and out
- obviously tachypnoeic
- peripheral / central cyanosis
- e.g. blue lips or nails
- observations will show raised HR and RR and reduced O2 sats
- patient will have a drop in BP if it is severe and they are heading towards sepsis
18
Q
What would you expect to see on palpation, percussion and auscultation in someone with pneumonia?
A
Palpation:
- reduced chest expansion
Percussion:
- dull to percussion over areas of consolidation
Auscultation:
- coarse basal crepitations
- bronchial breathing
- increased vocal resonance
- when patient says “99”, it will sound louder over areas of consolidation
19
Q
What key feature can make someone more susceptible to atypical organisms that cause pneumonia?
A
being immunocompromised
this can include someone who takes regular steroid medications
20
Q
What investigations would be done in pneumonia?
A
Bedside tests:
- sputum MCS
Blood tests:
- FBC
- CRP
- ABG
- blood cultures
Imaging:
- chest X-ray
- also a pleural fluid sample can be taken via thoracentesis for MCS if a pleural effusion is present
21
Q
What would the blood test results look like in someone with pneumonia?
A
- FBC shows high WCC
- CRP will be raised as it is a marker of infection
- ABG will show type 1 respiratory failure, which is a low O2
22
Q
If atypical pneumonia is suspected, what additional tests are performed to identify the causative organism?
A
- serology should be performed
- urinary antigens and LFTs if legionella is suspected
- for mycoplasma, a blood film will show cold agglutins
23
Q
What are the 2 different types of pneumonia on a chest X-ray?
A
Lobar pneumonia:
- this affects one or more sections (lobes) of the lungs
Bronchopneumonia:
- this affects patches throughout both lungs
24
Q
What type of pneumonia is shown in this image?
A
this image shows lobar pneumonia
25
What type of pneumonia is shown here?
this image shows **_bronchopneumonia_**
this is shown by **patchy / heterogenous consolidation**
26
What are air bronchograms?
they are **_black translucent lines overlying consolidation_**
the **alveoli are full of pus** so air builds up in terminal bronchioles behind the alveoli
air is black on x-ray
27
What scoring system is used to determine the severity of pneumonia?
**_CURB-65 score_**
* C - Confusion = 8
* U - Urea \> 7 mmol/L
* R - Respiratory rate \> 30
* B - Blood pressure \< 90/60 mmHg
* Age \> 65
Score of 1 = GP
Score of 2 = A&E (+ short stay)
Score of 3+ = admission (+/- consider ICU)
28
What is involved in the acute management of pneumonia?
* give **_oxygen_** and make sure the patient is **sitting upright**
* **_IV fluids_** to **restore BP**
* **_IV painkillers_** (for pleuritic chest pain)
* **_IV antibiotics_**
* **CPAP** if required
29
What antibiotics are used to treat community-acquired pneumonia and atypical pneumonia?
***_Community-acquired:_***
* typically **_amoxicillin_** is given and **co-amoxiclav** in severe cases
***_Atypical:_***
* a macrolide such as **_clarithromycin_** is given
* commonly **_amoxicillin + clarithromycin_** are given as you are often not sure what exactly is causing the pneumonia
30
What antibiotics are typically given to treat hospital-acquired pneumonia?
How is this treatment different to that of CAP / atypical?
you need to know what is causing the infection before prescribing the antibiotic for HAP
* **_flucloxacillin_** is given if it is ***Staphylococcus aureus***
* **_vancomycin_** is given if it is **MRSA**
* **_tazocin + gentamicin_** is given if it is ***Pseudomonas aeruginosa***
31
What antibiotic is given to treat aspiration pneumonia?
**_metronidazole_**
this is used against anaerobic bacteria and protozoa
32
What are the potential complications of pneumonia?
* **pleural effusion**
* **lung abscess** - often in *Staph aureus* infections
* **empyema**
* ****this is pus in the pleural cavity
* **sepsis**
33
What is a lung abscess and what are the 3 main symptoms of a lung abscess that has occurred as a complication of pneumonia?
* it involves **_necrosis of the pulmonary tissue_** and formation of **_cavities_** containing **necrotic debris or fluid** caused by **microbial infection**
* swinging fevers
* persistent pneumonia
* foul-smelling sputum
34
What is the definition of tuberculosis infection?
Who are you most likely to catch TB from and why?
infection by ***_Mycobacterium tuberculosis_**,* which causes **_multi-systemic disease_**
you are more likely to catch TB from **relatives** than strangers as it requires **prolonged exposure**
35
What are the 3 / 4 stages of TB infection?
***_Primary:_***
* this is the initial infection
* it is often **asymptomatic**, but there can be **pulmonary symptoms**
***_Latent:_***
* **asymptomatic** infection
***_Post-primary:_***
* **reactivation** of infection when the individual becomes **_immunocompromised_**
* this can be due to steroid use, increasing age, etc.
* this leads to **_severe symptoms_**
***_Miliary:_***
* lymphohaematogenous dissemination of TB
* it spreads across the body and causes disease everywhere
36
What are the risk factors for TB?
* **travel**
* South Asians / India / Bangladesh
* **immunocompromised** individuals e.g HIV infection
37
What are the general signs and symptoms of TB?
* FLAWS
* fever, lethargy, appetite loss, weight loss, night sweats
* shortness of breath
* **productive cough** that produces **green sputum**
* **_haemoptysis_**
* lymphadenopathy
38
What are complications of TB that affect the lungs and brain?
***_Lungs:_***
* TB pneumonia (LRTI)
* pleural effusion
***_Brain:_***
* meningitis
39
What are the complications of TB affecting the abdomen and skin?
***_Skin:_***
* erythema nodosum
* clubbing
***_Abdomen:_***
* peritonitis
* ascites
40
What are the potential complications of TB affecting the heart and spinal cord?
***_Heart:_***
* pericardial effusion
* constrictive pericarditis
* normocytic anaemia
***_Spinal cord / bones:_***
* Pott's disease
* spinal cord compression
* osteomyelitis
41
What are the complications of TB affecting the reproductive organs and kidneys?
***_Reproductive organs:_***
* epididymo-orchitis
* infertility
***_Kidneys:_***
* renal failure
* Addison's disease (adrenal insufficiency)
42
What bedside tests are performed to identify TB infection?
How long does this take?
* **_sputum MCS_** is performed - **3 samples** are needed
* microscopy with **_Ziehl-Neelsen stain_**
* culture takes **_6 - 8 weeks_**
* because culture takes so long, **treatment needs to be started blind** as you won't know what agents the TB is susceptible to
43
What blood tests would be taken in suspected TB infection?
What results are expected?
* FBC
* CRP
* ABG
* blood cultures
* **_HIV_**
* would expect **raised WCC and CRP** as infection markers
* ABG should show **type 1 respiratory failure** (low O2)
44
What other tests are done in the investigation of TB?
* lymph node biopsy which will show **caseating granuloma**
* mantoux / tuberculin skin test (TST)
45
How is TB identified on a chest X-ray?
* **patchy / heterogenous consolidation**
* **bi-hilar lymphadenopathy**
* **upper lobe scarring** tends to suggest a past infection
* there may be evidence of **cavitating lesions** and/or **pleural effusions** but these are less characteristic
46
How is miliary TB identified on chest X-ray?
widespread **_nodular shadowing_**
this represents severe TB with very poor prognosis
47
In this scenario, what type of oxygen would you prescribe the patient?
**_15L of oxygen_** via a **_non-rebreather mask_**
* target sats are between **94 - 98%**
* **_2L_** of oxygen via a **_nasal cannula_** would be given when the patient's sats were around **94-95%**
* when sats are extremely low, you want to give ***high flow oxygen via a non-rebreather mask***
48
What is the definition of bronchiectasis?
it is a chronic condition that causes **_permanent dilation_ of the airways**
* there is dilation of both the **bronchi** and the **bronchioles**
* this takes time to develop as **recurrent infection and inflammation** are required to break down the airways and make them dilate
* the **_cell walls are damaged_** and there is **_increased mucus production_**
49
What are the congenital causes of bronchiectasis?
* **cystic fibrosis**
* **primary ciliary dyskinesia** (Kartagener's syndrome)
* **Young's syndrome**
50
What triads characterise the symptoms of primary ciliary dyskinesia and Young's syndrome?
***_Primary ciliary dyskinesia:_***
* bronchiectasis
* sinusitis
* situs inversus
* this is where all of the organs are located on the wrong side of the body
***_Young's syndrome:_***
* bronchiectasis
* sinusitis
* infertility
51
What are the acquired causes of bronchiectasis?
* **_infection_**
* pneumonia
* tuberculosis
* measles
* pertussis
* someone having a lot of infections is more likely to get bronchiectasis as **_recurrent inflammation_ breaks down the airway walls**
* can also be caused by **_lung cancer_**
52
What are the symptoms associated with bronchiectasis?
* symptoms are similar to TB / pneumonia except there is a **_LOT of sputum_** production
* **_chronic cough_** and production of **_copious green sputum_**
* **haemoptysis**
* weight loss
* shortness of breath
* fever
53
What signs are present on inspection and auscultation in bronchiectasis?
* **_clubbing_** is present on inspection
* **_basal crepitations_** are heard on auscultation
54
What are the 4 different causes of basal crepitations?
* heart failure
* pneumonia
* bronchiectasis
* idiopathic pulmonary fibrosis
55
What type of infections are people with bronchiectasis more susceptible to?
they are more susceptible to **_superimposed "extra" infections_** as their airways are not working as well
these superimposed infections can be caused by:
* *Pseudomonas aeruginosa*
* *Streptococcus pneumoniae*
* *Haemophilus influenzae*
56
What bedside tests, blood tests and imaging would be done in investigations for bronchiectasis?
***_Bedside tests:_***
* **sputum MCS**
* **sweat test** to diagnose cystic fibrosis
* **genetic testing** for PCD / Young's syndrome
***_Bloods:_***
* FBC
* CRP
* ABG
* blood culture
***_Imaging:_***
* CXR may be used but the best way to diagnose bronchiectasis is with a **_high resolution CT_** (HR-CT)
57
What will the blood test and ABG results show in bronchiectasis?
* FBC will show **high WCC**
* CRP will be elevated
* ABG may show **type 1 respiratory failure** with low O2
or **type 2 respiratory failure** with low O2 + high CO2
58
What is the classical feature seen on HR-CT in bronchiectasis?
the classic feature is the **_Signet ring sign_**
59
What are the possible complications of bronchiectasis?
* **_recurrent infections_**
* large, dilated airways are more susceptible to infections
* **cor pulmonale** (RHF)
* **respiratory failure**
60
What is involved in the conservative management for bronchiectasis?
it is an **_irreversible_** condition so the aim of supportive management is to **prevent complications**
* exercise and good diet
* annual influenza vaccination
* **airway clearance of mucus**
* chest physiotherapy
* high frequency oscillation devices
* nebulised hypertonic saline
61
What is the pharmacological treatment for bronchiectasis and when may this be given?
* if there is an **acute infection**, **_IV antibiotics_** are given
* **_prophylactic oral antibiotics_** are given to **prevent infecton**
this is usually **_azithromycin_**
62
What is the definition of lung cancer and what are the 2 different types?
it is a **_malignant neoplasm_** of the lung
* **primary** originates from the **lung**
* **secondary** metastasises from **another organ**
* most commonly the breast / colorectal cancer
63
What are the 4 different types of primary lung cancer?
* **small cell** lung cancer
* **non-small cell** lung cancer
* adenocarcinoma
* squamous cell carcinoma
* large cell carcinoma
64
What type of cells does each type of lung cancer originate from?
* **small cell lung cancer** originates from **_endocrine cells_**
* **adenocarcinoma** originates from **_goblet cells_**
* **squamous cell carcinoma** originates from **_squamous epithelial cells_**
* **large cell carcinoma** originates from **_epithelial cells_**
65
What are the hormonal / location associations of SCLC, adenocarcinoma and SqCC?
***_Small cell LC:_***
* associated with **_SIADH_**, which causes **_hyponatraemia_** as the body retains too much water
* associated with **_ectopic ACTH_** that causes **_Cushing's syndrome_**
***_Adenocarcinoma:_***
* usually affects the **_peripheral lung_**
* is **less associated with smoking** than the other types
***_Squamous cell carcinoma:_***
* associated with **_PTH-related peptide_** (PTHrp), which **increases calcium** and **decreases phosphate**
66
67
What are the risk factors for primary lung cancer?
* **smoking**
* **asbestos exposure**
* particularly squamous cell carcinoma
68
What are the symptoms of lung cancer?
***_Primary tumour:_***
* **cough** - can be **dry** or **productive**
* **_haemoptysis_**
* **shortness of breath**
***_Systemic signs:_***
* weight loss
* loss of appetite
* night sweats
69
What symptoms can be caused by local invasion of lung cancer?
* a **pancoast tumour** in the apex of the lung can cause **_horner's syndrome_** by compressing the sympathetic trunk
compression of the **left recurrent laryngeal nerve** produces a **_bovine cough_**
* potential **_superior vena cava obstruction_**
* this is an emergency as blood is not returning to the heart
70
What are the most common sites for lung cancer to metastasise to and how might these present?
***_Bone:_***
* presents with **bone pain** and **fractures**
***_Brain:_***
* presents with **headaches** and **blurred vision** as a result of raised ICP
***_Liver:_***
* presents with **hepatomegaly**
***_Lymphadenopathy_***
71
How will lung cancer present on inspection, percussion and auscultation?
***_Inspection:_***
* **clubbing**
* lymphadenopathy
***_Percussion:_***
* **dull** percussion over the tumour
***_Auscultation:_***
* **crepitations** may be present
* increased vocal resonance
* when the patient says "99", it will sound louder over the tumour
72
What are the 4 causes of respiratory clubbing?
* bronchiectasis
* idiopathic pulmonary fibrosis
* lung cancer
* tuberculosis
73
What bedside tests and blood tests are performed to investigate lung cancer?
What results might be seen?
***_Bedside tests:_***
* sputum MCS
***_Bloods:_***
* FBC
* **calcium** (bone mets or PTHrp)
* **ALP** (bone mets)
* **LFTs** (liver mets)
74
What imaging / biopsy investigations are performed in lung cancer?
***_Imaging:_***
* chest X-ray
* **CT CAP** or **PET scan** is used for **_staging_** the cancer
***_BIopsy:_***
* needed to confirm the diagnosis
* performed via **bronchoscopy**
* or via **transthoracic needle** if the cancer is in the periphery of the lung
75
How is lung cancer staged?
***_Stage 1:_***
* cancer is found within the **_lung only_**
***_Stage 2:_***
* cancer is found within the lung and **_nearby_ lymph nodes**
***_Stage 3:_***
* cancer is in the lung and the **lymph nodes in the _centre of the chest_**
***_Stage 4:_***
* cancer has spread to **both lungs**, into the area around the lungs or to **distant organs**
76
How is primary lung cancer identified on chest X-ray?
* there is **_consolidation_** that is usually **heterogenous**
* (bi-hilar lymphadenopathy)
* (pleural effusion)
* (cavitating lesions - usually present in SqCC)
77
What does secondary lung cancer look like on chest X-ray?
* there are many **_coin-shaped lesions_** that are referred to as **cannonball mets**
78
What is atelectasis and why can it occur in lung cancer?
* atelectasis is the **_collapse or closure of the lung_** leading to reduced or absent gas exchange
* it can affect **_part_ or _all of_ one lung**
* if the cancer starts **obstructing the bronchioles**, air cannot get to the alveoli to inflate them so the lung begins to collapse
79
How can atelectasis (lower lobe collapse) be identfied on chest X-ray?
* a **triangular opacity behind the heart** is visible
* this is the **_"sail sign"_** where the dense edge of the collapsed left lower lobe has been squashed into a sail shape
* a **double left heart border** is also present
(x-ray shows left lower lobe collapse)
80
How can atelectasis (total lung collapse) be identified on chest x-ray?
* there is **tracheal deviation** **_towards_** the direction of the collapse
* there is **mediastinal shift** **_towards_** the direction of the collapse
* the spine can be seen very clearly as the heart has deviated
* this x-ray shows total left lung collapse and the arrows show the edge of the lung
81
What is mesothelioma?
a malignant neoplasm of **_mesothelial cells_** of the **_pleura_**
it is a rare condition
82
What are the risk factors for mesothelioma?
asbestos exposure
83
What are the symptoms associated with mesothelioma?
* a **cough** that is **_dry_**
* **shortness of breath**
* weight loss
* loss of appetite
* night sweats
84
What sign is present on auscultation in mesothelioma?
**pleural friction rub**
this sounds like walking on fresh snow
85
What bedside tests, blood tests and imaging would be done in the investigation for mesothelioma?
***_Bedside tests:_***
* **sputum** cytology
* **pleural fluid** cytology via thoracocentesis
***_Bloods:_***
* FBC
* calcium (bone mets or PTHrp)
* ALP (bone mets)
* LFTs (liver mets)
***_Imaging:_***
* CXR
* CT PAP or PET scan for staging
***_Biopsy_***
86
How can mesothelioma be identified on CXR?
* there is **_pleural thicking_**
* **_pleural plaques_** may be visible due to asbestos
* sometimes **pleural effusions** may occur
Core Conditions - Other
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