Interactive Cases in General Medicine 2

Question 1

In pulmonary oedema, crepitations are (unilateral/bilateral)

Answer 1

Bilateral

Question 2

If there is sudden onset breathlessness, it could be pneumothorax, PE, or pneumonia. How can you differentiate

Answer 2

Pneumonia if wheeze, breathlessness, cough, sputum, haemoptysis, weight loss

PE if signs present e.g. previous DVT, immobility, surgery, malignancy

Pneumothorax otherwise if sudden onset

Question 3

What can cause increased JVP?

Answer 3

Right heart failure secondary to pulmonary hypertension (secondary to COPD/PE)

Question 4

When dealing with breathless patients, look at the onset. Describe how breathlessness onset affects ddx

Answer 4

Seconds: Pneumothorax, PE, foreign body, (anxiety)

Minutes:
Airways inflammation/obstruction, chest infection, acute heart failure, pulmonary haemorrhage

Days/weeks:
Any of the above unresolved,
interstitial lung disease, malignancy/large pleural effusion, anaemia/thyrotoxicosis, neuromuscular

Question 5

No lung markings on a lung in a CXR is consistent with a?

Answer 5

Pneumothorax

Question 6

How do you manage someone with sudden breathlessness and suspected pneumothorax

Answer 6

CXR to exclude pneumothorax (or to confirm pneumothorax)

Start them on oxygen

IF pneumothorax present in X-ray - do CHEST DRAIN:

Primary pneumothorax:
Less than 2cm, discharge, repeat x-ray. Greater than 2cm, Aspiration/chest drain (if aspiration unsuccessful), pain relief.

Secondary pneumothorax (existing lung disease):
Less than 2cm, aspiration. Greater than 2cm, chest drain, pain relief.

Question 7

Fluffy air space shadowing on a chest x ray can be due to?

Answer 7

Pus or fluid

This could be a pulmonary oedema (only case when its unilateral after a chest drain has been inserted into one lung)

Question 8

Pleural aspiration is done under the guidance of?

Answer 8

Ultrasound

Question 9

In which type of respiratory failure is CPAP used?

Answer 9

Type 1 respiratory failure

Question 10

What is the most appropriate next step in the management of suspected PE

Answer 10

LMWH

Question 11

BiPAP is given to people with what type respiratory failure

Answer 11

Type 2

Question 12

If pt has bullies lung disease, do NOT …

Answer 12

Aspirate/chest drain

Question 13

How to differentiate between obstructive and restrictive lung disease

Answer 13

FEV1/FVC ratio <70% = obstructive

FEV1/FVC ratio >70% = restrictive

Question 14

Fibrosis is (obstructive/restrictive)

Answer 14

Restrictive

Question 15

Look at fluffy vs reticular nodular shadowing

Answer 15

DO IT

Question 16

How should a CXR be presented? (starting spiel)

Answer 16

This is a PA/AP CXR of:

1. Name and DOB
2. Taken on (date)
3. At (time)

Comment on rotation, inspiration, penetration (too white = underpenetrated)

Question 17

The left hemidiaphram MUST be visible where?

Answer 17

Behind the heart

If it isn’t visible there, something is wrong

Question 18

Describe what the following opacities could mean:

1. Interstitial/alveolar shadowing
2. Reticulo-nodular shadowing
3. Homogeneous shadowing
4. Masses/cavitations

Answer 18

1. Interstitial alveolar shadowing (fluffy) = fluid (pulmonary oedema), pus (pneumonia), blood
2. Reticulo-nodular shadowing / Homogeneous shadowing = pleural effusion

Question 19

How does the trachea deviate in a pleural effusion vs lung collapse?

Answer 19

Pleural effusion Pushes trachea AWAY from effused lung

In Collapse, the trachea Comes towards collapsed lung

Question 20

How to approach looking at CXRs?

Answer 20

1. Compare R vs L U/M/L zones: looking for alveolar/interstitial shadowing, reticulonodular shadowing, homogeneous shadowing
2. Follow the periphery:
   Is it pneumothorax? Look at pleural thickness, costophrenic angles, diaphragm, heart, mediastinum