1
Q
Wasting of hand muscles
A
- Pancoast tumour (compresses brachial plexus –> hand weakness)
2
Q
Bounding pulse
A
- CO2 retention (stimulated chemoreceptions = increased cardiac output)
3
Q
Features of Horner’s Syndrome
A
- Miosis
- Partial ptosis
- Anhydrosis
- Enophthalmos (opposite of exophthalmos)
4
Q
Normal inspiratory: expiratory ratio
A
- 1:2
5
Q
Causes of increased vocal resonance vs decreased
A
Increased = increased lung density
- Consolidation
- Collapse
- Tumour
Decreased = decreased lung density
- Effusion
- Pneumothorax
- Emphysema
6
Q
Causes of fine vs coarse crepitation
A
Fine
- Fibrosis
- Oedema
Coarse
- Consolidation
- Bronchiectasis
- COPD
7
Q
Cause of monophonic vs polyphonic wheeze
A
Monophonic = single large airway
- Cancer
- Foreign body
Polyphonic = different-sized airways constricting at different times
- Asthma
- COPD
- Infection
8
Q
Causes of pleural rub
A
Abnormal pleura rubbing each other causing friction
- Pleurisy
- Effusion
- Mesothelioma
9
Q
How is Diffusion Capacity calculated?
A
- Breathe in CO (crossed alveolar membrane) and helium (does not)
- Amount of CO that crosses into blood = TLCO
- Helium concentration breathed out is how much air in lungs to dilute it = total lung volume –> use to calculate KCO (gas transfer per unit volume)
10
Q
MRC scale for breathlessness
A
1: strenuous exercise
2: slight hill
3: stop for breath walking flat
4: stop after 100m
5: when dressing
11
Q
CXR sign of hyper-expansion
A
More than 6 anterior or 10 posterior ribs in the mid-clavicular line at the lung diaphragm level.
12
Q
Indications for LTOT
A
- PaO2 <7.3
OR PaO2 <8 and :
- Secondary polycythaemia
- Pulmonary HTN
- Cor pulmonale
13
Q
Eligibility for LVRS in COPD
A
- FEV1 <50%
- SOB affects quality of life
- Don’t smoke
- 6min walk test >140m
- (Ideally upper lobe emphysema)
14
Q
Treatment for COPD
A
- LAMA+LABA
- LAMA+LABA+ICS if asthma features, eos >0.3
15
Q
Eligibility for transplant in COPD
A
- FEV1 <50%
- SOB affects quality of life
- Don’t smoke
- Completed pulmonary rehabilitation
16
Q
Contraindications for NIV in COPD exacerbation
A
- Undrained pneumothorax
- Confusion
- Facial injuries
- Upper airway obstruction
- Upper GI surgery
17
Q
Respiratory causes of clubbing
A
ABCDEF
Abscess (lung) and Asbestosis
Bronchiectasis
Cystic fibrosis
Dirty tumours (bronchogenic carcinoma, mesothelioma)
Empyema
Fibrosing alveolitis (IPF)
18
Q
Causes of clubbing and creps
A
FAB you know this:
Fibrosing alveolitis (IPF)
Asbestosis
Bronchiectasis, Bronchogenic carcinoma.
19
Q
HRCT signs of bronchiectasis
A
- Cylindrical (advanced), saccular (cystic), varicose (irregular airways)
- Bronchial thickening/dilation (“tram tracks”)
- Lack of normal airway tapering–> see bronchi within 1cm of pleura
- “Signet ring sign” = bronchi > 1.5 times larger than
adjacent vessel - Mucus plugging in bronchioles
20
Q
Causes of bronchiectasis
A
- Congenital (CF, PCD, Young’s)
- Childhood infection (pertussis, TB, measles)
- Mechanical (cancer, granuloma, lymph node TB)
- Immune underactive (congenital = hypogammaglobulin, acquired = AIDS)
- Immune overactive (ABPA)
- Aspiration (localised RLL)
21
Q
CF diagnostic test
A
- Sweat chloride >60mmol/L
22
Q
Features of Young’s syndrome
A
- Like CF but no abnormal sweat/pancreatic insufficiency
- Diagnosed in middle-aged men who test for infertility
23
Q
Cause and mechanism of CF
A
- Autosomal recessive disease due to defect in CFTR gene on chromosome 7
- CFTR found in all exocrine tissues (hence sinusitis and pancreatitis)
- Stops Chloride moving out of cells–> Na follows to keep isoelectric–> water follows into cells –> thick secretions
24
Q
CF bug which can lead to increased worsening of lung function
A
- Burkholderia cepacia ‘complex’ (Gram -ve)
25
Signs of old TB
- Supraclavicular scar (phrenic nerve crush)
- Thoracotomy
- Chest deformity/missing ribs (thoracoplasty = remove 2 ribs so anterior chest wall collapses into affected side)
- Tracheal deviation to fibrosis in old TB site
- Dull percussion
26
Investigation signs of old TB
- Apical fibrosis
- Pleural scarring
- Aspergilloma in old TB cavity
- Kyphosis (Pot's Disease)
- Bronchiectasis (lymph node obstruction causing distal bronchiectasis)
27
Investigations for TB
- 3 sputum samples (including early morning): culture and auramine stain for AFB
- Nucleic acid amplification test (NAAT)
- IGRA (previous TB)
- HIV test!!!
28
CXR findings of TB
- Hilar/paratracheal lymphadenopathy
- Pulmonary nodules/infiltrates
- Upper lobe cavitation
29
Management of TB
- Notify PHE and contact trace
- Before treatment: LFTs, acuity, colour blindness
- If fully sensitive: RIPE for 2 months --> RI for 4 more months
- Give pyridoxine (B6)
30
Side effects of TB meds
- Rifampicin: liver enzyme inducer (COCP, anti-epileptics)
- Isoniazid: peripheral neuropathy
- Pyrazinamide: gout
- Ethambutol: optic neuritis
They ALL cause hepatitis!
31
Squeaks on auscultation
- Hypersensitivity pneumonitis
32
Causes of upper zone fibrosis
CHARTS
- Coal worker's pneumoconiosis
- Hypersensitivity pneumonitis (fibrotic EAA)
- Ank spond/ABPA
- Radiation
- Tuberculosis
- Sarcoidosis/Silicosis
33
Causes of lower zone fibrosis
RATIO
- Rheumatoid arthritis
- Asbestosis
- Tissue disease connective (scleroderma, Sjögren’s, SLE)
- IPF
- Other - chemicals (lead, paraquat, dry-cleaning fluids) or drugs
34
Causes of asymmetrical fibrosis
- Old TB
- Cancer/radiotherapy
35
Iatrogenic causes of fibrosis
BBC is MANS Gold
- Bleomycin
- Cyclophosphamide
- Methotrexate
- Amiodarone
- Nitrofurantoin
- Sulphasalzine
- Gold (used to treat RA)
36
List different idiopathic interstitial pneumonias
- UIP: in IPF, not steroid responsive, poorer prognosis
- NSIP: more steroid responsive
- Desquamative Interstitial Pneumonia (DIP): due to smoking, steroid-responsive
- Cryptogenic Organizing Pneumonia (COP): resembles pneumonia but does not respond to abx-- give steroids for 6-12months (happens in inflammatory conditions e.g. RA)
- Acute Interstitial Pneumonia (Haman-Rich Syndrome): rapid ARDS, supportive treatment may respond to steroids
37
Antibody for limited systemic sclerosis
- Anti-centromere
38
Antibody for diffuse systemic sclerosis
- Anti-topoisomerase (anti-Scl 70)
39
Antibody for dermatomyositis
- Anti-Jo 1
40
Which ILD conditions have high lymphocytes in BAL
- Hypersensitivity pneumonitis
- Sarcoidosis
- Organizing pneumonia
- Lymphocytic interstitial pneumonia (LIP)
41
5 respiratory complications of RA
- Pleural effusion
- Nodules
- Fibrosis
- Caplan Syndrome (pneumoconiosis and RA)
- Obliterative bronchiolitis (bronchiole inflammation --> necrotizing fibrosis)
42
How much effusion do you need to get symptoms
- >500ml
- Need >1L for tracheal deviation away
- Need 300ml to see on PA CXR (25ml on lateral film)
43
Cause of transudate effusions
CHAM
- CCF
- Hypoalbumin (nephrotic syndrome)
- All failures (inc cirrhosis)
- Meig's Syndrome (ovarian fibroma)
44
Cause of exudative effusions
PINTS
- Pneumonia
- Infarction (PE)
- Neoplasm
- TB/trauma
- Sarcoid/scleroderma
45
Differential for dull bases
- Collapse
- Consolidation
- Fibrosis
- Raised diaphragm (phrenic nerve palsy, hepatomegaly)
- Pleural thickening
46
Why take blood test at same time as pleural aspirate
- So serum LDH and albumin can be taken for Light's criteria
47
Definition of transudate vs exudate
Protein concentration
- Exudate >35g/L
- Transudate <25g/L
48
Light's criteria for pleural effusion
Exudate:
- Pleural albumin: serum albumin > 0.5
- Pleural LDH: serum LDH > 0.6
- Pleural LDH > 2/3rds upper normal limit of serum LDH
25 % of patients with transudates are mistakenly identified as having exudates by Light’s criteria
49
Definition of empyema
- pH <7.2 (and glucose <2)
50
What is normal glucose level in effusion
- >2mmol/L
51
Causes of low glucose effusions
MEAT:
- Malignancy
- Empyema
- Arthritis (rheumatoid)
- TB
52
Diagnostic criteria for haemothorax
- Hct effusion/Hct serum > 0.5
53
Cause of chylothorax
Lymph seeps into pleural space
- Post-pneumonectomy
- Lymphoma/cancer
- Trauma
54
Diagnostic criteria for chylothorax
- Triglycerides >1.3mmol/L
55
Other calculation for exudate effusion
Serum albumin - pleural albumin = <1.2g/dL
56
Simple vs complicated parapneumonic effusion
Complicated
- Empyema (pH <7.2)
- Culture positive fluid
57
Definition of apnoea
- No breathing for 10 seconds
58
Definition of hyponoea
- Breathing <50% below baseline AND desaturation or sleep arousal
59
Components of a sleep study (i.e. diagnostic tests)
- EEG
- EMG
- Electro-oculogram (EOG)- determines sleep stage/REM
(Do 2nd study with CPAP pressure titration if diagnosis confirmed)
- Need 5 episodes/hour to diagnose OSA
60
How is OSA severity calculated (and what is severe)
Apnoea-hypopnea index (number of event per hour of sleep)
- >30 is severe
61
Causes of OSA
Upper airway obstruction
- Obesity
- Macroglossia (Down's/hypothyroid)
- Mandibular deficiency (micrognathia or retrognathia)
Reduced upper airway tone
- Neurological issue
62
Causes of central sleep apnoea
- Cheynes-Stokes apnoea: stroke, heart failure
- Brainstem lesion
- Opioid use
63
Hoarse voice- relevance to respiratory?
- Left laryngeal nerve palsy (passes along trachea)
64
Hand features of Horner's Syndrome
- Weakness/atrophy of intrinsic muscles (T1)
- Pain/paraesthesia at 4th/5th digits (C8) and medial forearm (T1)
65
Clubbing and pain at wrist/ankles
- Hypertrophic pulmonary osteoarthropathy: subperiosteal bone formation (periosteum is layer above bone)
- Any lung cancer type, esp squamous and adenocarcinoma
66
Features of Lambert-Eaton Syndrome
- Proximal muscle weakness- improves with exercise
- Reduced tendon reflexes- improves with exercise (check reflexes before and after testing power)
- Cranial nerve involvement (ptosis, diplopia)
67
Lambert-Eaton Syndrome in which lung cancer
- Small cell lung cancer
68
Pathophysiology of Lambert-Eaton Syndrome
- Antibodies against voltage-gated calcium channels--> reduced acetylcholine release from presynaptic nerve terminals (so adjacent muscle does not depolarise)
69
Difference between Myasthenia Gravis and Lambert-Eaton Syndrome
- Myasthenia: antibodies against acetylcholine-receptor
- Lambert-Eaton: antibodies against voltage-gate calcium channel
70
Paraneoplastic syndromes in lung cancer
Neurological:
- Lambert-Eaton (small cell)
- Peripheral neuropathy
Musculoskeletal
- Hypertrophic pulmonary osteoarthropathy (SCC, adenocarcinoma)
Endocrine
- Hypercalcaemia (PTH-related peptide) (SCC)
- SIADH (small cell)
- Ectopic ACTH (small cell)
Skin
- Acanthosis nigricans
- Thrombophlebitis migrans
71
Presenting features of SIADH
- Confusion
- Hyponatraemia-- with raised urine osmolarity/low serum osmolarity, raised urine sodium
72
Treatment of SIADH
- Fluid restrict if euvolaemic
- Tolvaptan (vasopressin receptor antagonist)
- Demeclocycline (tetracycline which reduces responsiveness of collecting tubule to ADH)
- Slow sodium chloride tablets
73
Staging classification for small cell cancer
- Limited = same hemithorax (15-20months)
- Extensive = outside of hemithorax (8-13months)
74
WHO performance status
- 0: asymptomatic
- 1: light work
- 2: bed <50% of day, can self-care but not work
- 3: bed >50% of day, limited self-care
- 4: bedridden
- 5: dead
75
Eligibility criteria for lung cancer surgery
- FEV1 >2L for pneumonectomy and >1.5L for lobectomy
- Ideally DLCO >80% and pre-op VO2 max >15ml/min/kg
76
Features of Superior Vena Cava Obstruction
- Pemberton's sign: lifting arms above head worsens signs (thyroid compressed against thoracic inlet, which contains the SVC)
- Facial plethora
- Facial/upper body oedema
- SOB
- Hoarse voice
- Fixed elevated JVP
- Stridor if severe
77
Causes of Superior Vena Cava Obstruction
Disease of right lung/lymph nodes/mediastinum
- Small cell lung cancer
- Non-Hodgkin's Lymphoma
- Thymoma
78
Treatment of Superior Vena Cava Obstruction
- Dexamethasone 8mg BD with PPI cover
- Stenting
- If not stentable: emergency radiotherapy
79
Symptoms of metastatic spinal cord compression
- New back pain/worse than usual back pain
- Limb weakness--> difficulty walking
- Incontinence/retention
80
Management of metastatic spinal cord compression
- 16mg dexamethasone STAT --> 8mg BD (0800 and 1200)—with PPI cover
- STRICT bed rest until neurosurgeons confirm if spine stable
- Surgery + post-op radiotherapy (or only radiotherapy in non-surgical candidates)
81
Treatment of hypercalcaemia of malignancy
- STOP calcium supplements!
- 2-6L over 24hrs initially
- STAT zolendronic acid --> consider another dose at day 5 (adjust dose if Cr clearance <60)
- Denosumab if zolendronic doesn’t work
82
Trachea deviation in lobectomy?
- Only in upper lobectomy = towards lobectomy (may be central in other lobectomies)
83
Breath sounds in pneumoectomy
- Usually decreased (thoracic cavity fills with gelatinous stuff)
- May have bronchial breathing in upper zones due to deviation of trachea towards the pneumonectomy
84
Types of pneumonectomy
- Simple: lung
- Extrapleural (mesothelioma): lung, diaphragm, parietal pleura and pericardium (these linings replaced with Gore-Tex surgical patches)
85
Operative mortality for pneumonectomy and lobectomy
- Lobectomy: 2-4%
- Left pneumonectomy: 3%
- Right pneumonectomy: 10% (complications are higher)
86
Complications of pneumonectomy
- Post-pneumonectomy syndrome (right pneumonectomy): hyperinflation of other lung--> compresses distal trachea and mainstem bronchus--> symptoms a few months after surgery --> needs re-do surgery
- Bronchopleural fistula
- Pulmonary oedema
87
Signs of pulmonary HTN
- Left parasternal heave (RV hypertrophy)
- Loud P2 and palpable
- Wide splitting of S2
- Tricuspid regurg (RV dilation)--> pansystolic murmur left sternal edge loudest on inspiration
88
Definition of cardiomegaly on CXR
- Cardiac silhouette: thoracic cavity >0.5
89
CXR signs of pulmonary HTN
- Cardiomegaly (cardiac silhouette: thoracic cavity >0.5)
- Enlarged pulmonary trunk, with prominent peripheral vessels
90
ECG signs of pulmonary HTN
- Prominent p waves (p pulmonale) due to RA enlarged
- Right axis deviation
- RBBB
91
Diagnostic definition of pulmonary HTN
- Mean pulmonary artery pressure > 25mmHg with a pulmonary capillary wedge pressure/left atrial pressure <15mmHg
92
List the 5 classes of pulmonary HTN
- 1: Pulmonary arterial hypertension
- 2: Left-sided cardiac disease
- 3: Lung disease (hypoxaemia)
- 4: CTEPH
- 5: Others (sarcoid, Langerhans cell histiocytosis)
93
How to palpate for parasternal heave
- Heel of hand vertical along left sternal edge
- Heave = hand lifted off the chest with each systole
94
BAL feature of fibrosis which suggests steroid-responsiveness
- Lymphocytes > neutrophils
95
CT features of UIP
- Bibasal subpleural honey-combing
- Traction bronchiectasis
- Heterogenous distribution
96
CT features of NSIP
- Ground-glass shadowing
- Reticular opacities
97
One lung normal breath sounds, other lung has fine creps-- diagnosis?
- Unilateral lung transplant in fibrosis
98
Counselling needed after starting TB meds
- Get sclera everyday-- if yellow, stop TB meds and call TB nurse
- If red colour less bright, ring TB nurse
- COCP may not work
- Don't wear contact lenses as may turn orange
99
Signs of upper vs lower lobectomy
- Upper: hyper-resonant upper with dull base (raised diaphragm)-- or could be normal examination!
- Lower: dull percussion and absent breath sounds at bases
100
CXR signs of lobectomy
- Could be normal!
- Raised hemidiaphragm (note right should normally be above left)
101
Indication for bullectomy in COPD
- Bullus >1L and compresses surround lung
102
Wheeze in a rheumatoid arthritis patient
- Obliterative bronchiolitis (also occurs after lung transplant)
103
Causes of empyema
- Staph and strep
- Anaerobes
- Psuedomonas (fusobacterium)
104
Treatment for pancreatic CF disease
- Creon (lipase, protease, amylase)
- Fat-soluble vitamins (ADEK) - because CF can't absorb fat so don't absorb the vitamins normally dissolved in fat
105
Causes of false positive sweat test for CF
- Hypothyroidism
- Addison's
106
Urine tests in pneumonia
- Legionella antigen
- Pneumococcal antigen
- Haemaglobin: mycoplasma causes cold agglutins (IgMs against RBCs--> haemolysis)
107
Bug which commonly causes bacterial IECOPD
- Haemophilus influenzae (Gram -ve)
108
What additional antibiotic would you add if severe pneumonia
- Metronidazole to cover anaerobics
109
Adjunct to antibiotics/chest drain for empyema
- Intrapleural fibrinolytics (dornase alfa/alteplase for 3 days)- because bacteria cause fibrin net in Fibrinopurulant stage of empyema
110
Which pneumonia covers right heart border
- RML
111
Why are CF men infertile
- Congenital Bilateral Absence of Vas Deferens (carries sperm out of testes)
112
Definition of PEFR variability in asthma
- Varies by 20% for 3 days a week for 2 weeks
113
Stages of sarcoidosis
- 1: bilateral hilar lymphadenopathy
- 2: bilateral hilar lymphadenopathy + infiltrates
- 3: infiltrates only
- 4: fibrosis (mid-zone)
114
Skin manifestations of sarcoidosis
- Lupus pernio
- Erythema nodosum
- Maculopapular lesions/plaques
- Subcutaneous nodules
115
Other conditions which cause raised serum ACE
- Pulmonary TB
- Lymphoma
- Asbestosis
So use serum ACE to check response to treatment in sarcoidosis
116
When do d-dimer if suspect PE
- If Well's score <4 but you still suspect PE
- (If Well's score >4, you are not meant to check d-dimer!)
117
Thrombolysis criteria in PE
- Cardiac arrest
- SBP <90 with end-organ hypoperfusion (or needing vasopressors to maintain SBP 90)
- SBP drop >40 for 15mins, not caused by something else
118
Alteplase doses for PE thrombolysis
- Cardiac arrest: 50mg
- Others: 10mg bolus --> 90mg over 2hrs --> heparin infusion until stable enough for LMWH
119
How to use salbutamol in asthma attack and when to call 999
- 1 puff every 30 seconds up to max of 10 puffs
- Then call 999 if not feeling better
- Can take another 10 puffs after 10mins if ambulance not there yet
120
Chest expansion
- Where to measure
- What is normal
- What is pathologically low
- 4th ICS
- 5cm
- <2.5cm
121
Pattern of arthritis caused by sarcoidosis
- Symmetrical oligoarthritis
122
2 ways in which sarcoidosis affects kidneys
- Glomerulonephritis
- Stones (high calcium)
123
Primary Ciliary Dyskinesia triad
- Bronchiectasis
- Sinusitis
- Situs inversus
124
Breathless patient- what 2 important things need to ask in history
- PND and orthopnoea!
125
Mode of inheritance cystic fibrosis and gene/chromosome involved
- Autosomal recessive
- CFTR gene on chromosome 7
126
Tests in returning traveller
- Malaria blood film x3 and rapid diagnostic test
- Stool MC&S with ova, cysts and parasites
- AFB x3
- Extended respiratory viral screen
- Blood-bourne viruses with HIV
- Serology tests (Dengue, leptospirosis, chikungunya)
My Brainscape
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