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Name 5 diseases that would cause a restrictive picture on spirometry.
restrictive = reduced FEV1 and very reduced FVC giving a normal or raised ratio (>0.75)
- pulmonary fibrosis
- neuromuscular disease e.g. GBS, MG,
It is decided that a patient is at high risk of asthma, with a FEV1/FVC ratio <0.7. What is the next investigation?
trial of treatment in high risk patients.
intermediate risk - spirometry to assess for reversible obstruction (increase in FEV1 of >400ml with salbutamol)
- low risk - investigate for other causes of symptoms.
- PEFR diary is now considered less accurate, but it still used in children. diurnal variation is (highest PEFR-lowest/highest)/100. greater than 20% is significant.
When should theophylline dose be reduced in a COPD patient?
when on a macrolide or fluoroquinolone e.g. gent or ciprofloxacin.
When is a COPD patient suitable to go on LTOT?
- 2 readings of O2 SATS <7.3KPA
- 2 readings 7.3-8.0 with polycythaemia, nocturnal hypoxaemia, peripheral oedema, pulmonary HTN.
What are the features of yellow nail syndrome?
hypoplastic lymph system leads to lymphoedema, yellow nails and pleural effusions. 40% have bronchiectasis.
respiratory causes of clubbing?
- lung cancer
- Pulmonary fibrosis
cardiac causes of clubbing?
- infective endocarditis
- atrial myxoma
What is the mechanism of damage in A1ATD?
- alpha-1-antitrypsin protects against neutrophil elastase. When it is deficient damage occurs to lung alveoli and liver (more rarely). occurs age 20-50.
- presents as emphysema onset before 45, fibrosis predominantly effects lower lobes.
- idiopathic hepatitis.
- Managed with weekly A1AT injection (pooled human plasma) if non-smoker, COPD patient or v. low levels.
- COPD management.
What are the ECG changes typical of hypokalaemia?
- flattened T wave
- prominent U wave
- ST depression
Causes of hypocalcaemia?
- Renal failure
- vit D def
- hypoalbuminaemia (binds calcium)
ECG changes in hypercalcaemia?
- short QT
- Tall U wave
features of pulmonary oedema?
- interstitial oedema
- bat's wing appearance
- upper lobe diversion
- kerly b lines
- pleural effusion
How does whooping cough present?
Caused by bordetella pertussis. normally vaccinated against. children <1 have incomplete immunity.
Catarrhal Stage (1-2 weeks) Low grade feverMalaiseMild ConjunctivitisRhinitisSneezingLacrimationParoxysmal
- Cough Stage (2-4 weeks with peak at 2 weeks)
- Decreased oral intake
- Older infants, children and adults: Gradually progressive cough in spasms Inspiratory whoop (not heard in adults)Vomiting may occur with severe cough Cyanosis following coughing spasms Fine rales on lung exam CoughSyncope
Convalescent Stage (1-2 weeks) Coughing spasms resolve over 1-3 months ("80 day cough")
How is it investigated?
PCR or nasal swab/NP aspirate.
Main SE of 4 TB drugs:
RIFAMPICIN: orange secretions, acute renal failure, pruritis, flu-like syndrome with infrequent dosing, thrombocytopenia, haemolytic anaemia. enzyme inducer therefore increases elimination of warfarin, phenytoin, pill, antiretrovirals, ketoconazole, chloramphenicol, methodone.
ISONIAZID: hepatotoxic (reduce dose for liver failure. signs of hepatoxicity include nausea, vomiting, abdo pain, fever, rash) peripheral neuropathy (give B6 ie. pyridoxine if DM, pregnant, alcoholic etc) increases blood level and toxicity of phenytoin.
ETHAMBUTOL: dec visual acuity, optic neuritis.
PYRAZINAMIDE: hepatotoxicity, arthralgia, GI upset, rash, hyperuricaemia.
How many mmHg is 100% oxygen saturation and 90% sats (thus being able to predict anything in between)?
- 100% = 90mmHg
- 90% = 60mmHg
- therefore you can calculate that 95% is 75mmHg.
- For each % add 3mmHg.
- What is 98%?
What 4 factors shift the oxygen saturation curve to the right?
- This means for a given as pp increases oxygen sats stays the same at a given point therefore oxygen is given up more easily to tissues.
- Why might tissues need more oxygen availability?
- hyperthermia (inc. metabolic rate)
- decreased pH (acidic)
- increased 2,3-DPG
- increased CO2
- n/b not affected by hypoxia!
Aside from bronchial obstruction and recurrent infection give 5 causes of bronchiectasis.
- recurrent infections examples are TB, aspergillosis, abscess, measles, pertussis (whooping cough) RSV bronchiolitis.
- Other causes:
- dyskinetic cilia syndrome
- Kartageners syndrome
How does Kartageners syndrome differ from primary ciliary dyskinesia?
- Kartageners is an autosomal recessive syndrome with a triad of:
- - situs inversus
- - sinus abnormalities (leading to sinusitis and bronchiectasis)
- - primary ciliary dyskinesia (as a component)
50% of PCD patients have the full Kartageners triad. PCD is due to abnormal cilia morphology and/or abnormal propulsion of mucus.
- This causes:
- - recurrent otitis media
- - neonatal resp distress.
- - chronic rhinorrhoea, rhinitis, sinusitis
- - COPD, chronic bronchitis, pneumonias
- male infertility due to reduced motility of sperm may also occur.
- - staph and h. influenzae are the most common infective organisms.
What is Samter's triad?
- aspirin sensitivity
- nasal polyps
Associations with nasal polyps?
can be classified as eosinophil rich (most common type in uk) infective or secondary to other causes.
- chronic rhinosinusitis
- chronic vasculitis
- aspirin sensitivity (Samters triad + asthma)
- CF (test children with polyps)
- churg-strauss syndrome
- NASAL POLYPS ARE NOT ASSOCIATED WITH ALLERGY
- infection of trachea, bronchi and bronchioles.
- acute bronchitis is often viral. chronic recurrent is bacterial.
How are polyps managed?
- all polyps should be referred to ENT.
- unilateral polyp is v. suspicious and could be malignant. more often they are bilateral.
- all children with polyps should be tested for CF.
- nasal steroid drops are first line.
Define Churg-Strauss syndrome
A rare idiopathic vasculitis disease effecting coronary circulation, lungs, abdominal viscera and skin. it effects small and medium sized vessels and is associated with asthma.
Give 3 ways that Churg-Strauss syndrome manifests
- 1. asthma and allergic rhinitis
- 2. eosinophilic infiltrative disease e.g. eosinophilic pneumonia and eosinophilic gastroenteritis. (can have haemoptysis)
- 3. systemic medium and small vessel vasculitis with granuloma formation.
others: GN with renal failure, mononeuritis multiplex, GI vasculitis and bleeding, heart failure, myocarditis and MI, skin stuff: purpura, urticaria, digital ischaemia.
How do you define chronic bronchitis?
- chronic productive cough most days
- for at least 3 months
- over a period of 2 years.
occurs in cigarette smokers 10-12 years after starting (10-15%).
Describe the pathophysiology of chronic bronchitis
- SPUTUM SWELLING AND SPASM
- chronic sputum production leads to hypertrophy of mucus secreting glands.
- smooth muscle hyperplasia
- bronchial hyperresponsiveness
- H. influenzae colonizes lungs of smokers
Causes of decreased DLCO?
DLCO is measurement of how much carbon monoxide can cross the membrane in a given amount of time.
- decreased by:
- increased membrane thickness e.g. pulmonary fibrosis, asbestosis, sarcoidosis,
- decreased membrane area e.g. pneumonectomy.
- things causing a combination of factors e.g. emphysema, bronchiolitis obliterans with organising pneumonia.
Can be falsy reduced in anaemia!
- Also called laryngeotracheobronchitis it is an infection common in autumn-winter at a peak age of 12-24 months. most cases due to parainfluenza virus.
- there is a low grade fever coryza proceeding barking cough by several days. cough worst at night.
How is croup managed?
- Paracetamol for fever (usually low grade)
- oxygen to maintain sats above 93% if necessary.
- if stridor at rest or resp distress give 0.5ml/kg (upto 5ml) 1:1000 nebulised adrenaline.
- dexamethasone in all but mildest of cases.
- discharge if no stridor, vital signs normal and 4h at least since adrenaline was given.
What is Beck's triad?
- cardiac tamponade (trauma):
- raised JVP
- low BP
- muffled heart sounds.
Signs of lung cancer?
- Horners syndrome
- thenar eminence (median) and hypothenar (ulnar) wasting
- Dermatomyositis (gottrons flat topped violaceous papules on joints of hands, knees and elbows. facial photosensitivity and dusky erthema of face. shawl sign - erythematous poikiloderma on neck and shoulders, calcinosis cutis - calcium deposition in buttocks, elbows, knees, areas of local trauma.)
- hypertrophic pulmonary osteoarthropathy (causing wrist pain)
- axillary or s.clav lyphdphy.
- cerebellar syndrome (mets)
- hoarse voice (recurrent laryngeal nerve palsy)
- SVC obstruction (red swollen face)
- Addisons (adrenal mets which are common)
- paraneoplastic syndromes:
- SIADH (asc with SCLC, dilutional hyponatraemia),
- PTH - hypercalcaemia (squamous 55% but all types)
- Cushings (most common ass. with SCLC)
Routine investigations in lung cancer?
- FNA for peripheral tumours
- bronchoscopy for histology and operability??
- CT for staging
- radionucleotide bone scan for mets when known to be present on CT
- lung function tests.
What are the '4 review areas' when looking at a CXR?
- BEHIND THE HEART (left lower lobe - collapse can give the heart an abnormally straight border)
- DIAPHRAGMS (raised - collapse, flat - hyperinflation, calcified - plaques, loss of angle)
- through stomach - if theres a large gastric bubble use it to view posterior aspect of lung.
What is the difference between centriacinar and panacinar emphysema?
- centriacinar effects the bronchioles and alveolar ducts predominantely.
- Panacinar affects the alveoli. The type can often distinguish cause.
Extra pulmonary features of sarcoid?
- lupus pernio (papular red-brown lesions, may coalesce to form plaques. Found periorbital, nasolabial folds, mucous membranes, fingers, toes).
- weight loss
- eryhtema nodosum
What 2 things are seen on CXR in sarcoid?
- bilateral hilar adenopathy
- parenchymal infiltrates.
What is the name of the skin condition in sarcoidosis that resembles frost bite?
Define interstitial lung disease? what pneumonic is used for examples?
- chronic, non malignant disease affecting lung parenchyma or alveoli.
- Idiopathic pulmonary fibrosis
- Collagen vascular disease
- Occupational exposure.