Respiratory example questions Flashcards by Goshan Gobi

What are the respiratory causes of clubbing?

Fibrotic lung disease
Chronic suppurative lung disease (bronchiectasis, chronic lung abscesses)
Lung cancer (all except small cell)

nb. COPD does not cause clubbing, if a COPD patient has clubbing look for co-existing pathology.

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What are the common causes of wheeze?

Obstructive lung diseases, particularly COPD or asthma

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What is stridor and what does it indicate?

It is a high-pitched, monophonic breath sound, usually occuring in inspiration.
It results from turbulent air flow in the larynx or lower in the bronchial tree and implies obstruction at these (upper airway) levels.

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What are the causes of dullness to percussion on respiratory examination?

Effusion
Consolidation
Lobectomy or pneumonectomy
Raised hemidiaphragm
Pleural thickening

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How do you differentiate consolidation and pleural effusion clinically?

Both are dull on percussion (though effusion is classically ‘stony dull’).
In effusion vocal resonance is decreased or absent, in consolidation vocal resonance is increased.

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How do you differentiate a transudative from an exudative pleural effusion?

Transudate
- Protein <30g/l: in patients with normal serum protein

Exudate
- Protein >30g/l: in patients with normal serum protein

Light’s criteria
More sensitive for diagnosis of exudative effusions and helpful if fluid protein between 25-35 g/l. Positive if one of these is true:
Pleural:serum protein ratio; >0.5 = exudate
Pleural:serum LDH ratio; >0.6 = exudate
Pleural LDH >2/3 the upper limit of normal serum LDH

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What are the causes of fibrosis?

Usual interstitial pneumonia (UIP)
Occupational: asbestosis, silicosis, pneumonoconiosis, extrinsic allergic
Rheumatologival arthritis
Infection: aspergillosis, TB
Drugs: amiodarone, methotrexate, bleomycin, cyclophosphamide, nitrofurantoin
Vasculitis
Radiation fibrosis
Recurrent aspiration
Sarcoid
Histiocytosis

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A patient is brought in following a collapse. He complained of sudden onset shortness of breath and pleuritic chest pain. On examination his trachea is deviated to the left and there is hyperresonance on the right side of his chest. What is the next appropriate management step?

Large bore cannula in right second intercostal space mid-clavicular line.

This patient has a tension pneumothorax as indicated by the tracheal deviation. It is life threatening and a large cannula should be inserted in the mid clavicular line , second intercostal space. The trachea is deviated away from the side effected. Management must not be delayed for a CXR.

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Which of the following has been proven to improve survival in COPD?

a) Long term oxygen therapy
b) Salbutamol inhaler
c) Salbutamol nebulisers
d) Steroids
e) Nil

a) Long term oxygen therapy
- LTOT is the only treatment which has been proven to improve survival as well as provide symptom control. It is thought to work by improvement of pulmonary vasculature haemodynamics.

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A 52 year old gentleman presents with unwell with a cough productive of green sputum with occasional blood flecks. He is also complaining of shortness of breath and has a cold sore. On examination he is pyrexial, tachypneoic, tachycardic and there is left basal coarse crackles.
What is the most likely diagnosis?

Pneumonia due to sterptococcus pneumoniae

This patient is most likely to be suffering from pneumonia secondary to streptococcal pneumoniae. It is the most common cause of community acquired pneumonia and further clues to this being the diagnosis is the evidence of a cold sore and the blood stained sputum

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A patient who was previously a coal miner is found on chest xray to have numerous small round opacities with normal lung markings. What is the most likely diagnosis?

Simple pneumoconiosis category 2

This gentleman is most likely to be suffering from simple pneumoconiosis as he is an ex coal miner. Simple pneumoconiosis is categorised based on its CXR findings. In category 1 there is a few small round opacities. In category 2 there is numerous small round opacities but normal lung markings visible. Category 3 is characterised by very numerous opacities with normally lung markings partially or totally obscured.

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Which of the following is not a feature of ARDS (acute respiratory distress syndrome)?

a) Protein rich fluid in alveolar space
b) Refractory hypoxia
c) Bilateral diffuse infiltrates on chesy X-ray
d) No evidence of cardiac failure
e) Protein low fluid in alveolar space

e) Protein low fluid in alveolar space
- ARDS can be caused by numerous conditions including sepsis, pneumonia, smoke inhalation, trauma, acute pancreatitis, eclampsia and fat embolism. It leads to a non cardiogenic pulmonary oedema where there is leakage of protein rich fluid into the alveoli which leads to respiratory failure. There is an acute onset and there is bilateral diffuse infiltrates on chest xray. There should be no evidence of cardiac failure. The hypoxia is normally refractory and high levels of oxygen are required.

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A 25 year old female presents with dry cough, fever and shortness of breath. She has also been suffering from night sweats and malaise. She has also noticed bruise like lesions on her shins. She is found to have an elevated ESR and a CXR reveals bilateral hilar lymphadenopathy, a pleural effusion and evidence of reticulo nodular shadowing in the upper lobes.
What is the most likely diagnosis?

Sarcoidosis

The finding of respiratory symptoms, erythema nodosum and bilateral hilar lymphadenopathy is very suggestive of sarcoidosis. As well as bilateral hilar lymphadeonpathy, sarcoidosis can lead to interstitial lung disease which often leads to fibrosis and reticulo nodular shadowing in the upper lobes.

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A 22 year old female who has previously suffered from panic attacks presents with acute shortness of breath, palpitations, perioral tingling and paraesthesia in hands and chest tightness. Given the most likely diagnosis, what would you expect to observe on blood gas?

Low CO2

This patient is most likely suffering from hyperventilation. The clue to the diagnosis is the previous panic attacks. The ABGs are likely to show low CO2 which would account for the perioral tingling and paraesthesia.

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What percentage increase in FEV1 post bronchodilator, is required for the diagnosis of asthma?

> 12%

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A 42 year old with Rheumatoid arthritis presents with increasing dyspnoea and a non productive cough. A CXR reveals diffuse reticular opacities and pulmonary functions tests reveal a restrictive pattern. What is the most likely diagnosis?

Interstitial lung disease

Rheumatoid arthritis can effect the lungs. It can lead to pulmonary fibrosis with interstitial lung damage. It is thought to occur in 2 to 5%. Pulmonary fibrosis can also occur secondary to DMARDs such as methotrexate. Caplans syndrome is the association of rheumatoid nodules with pneumoconiosis. BOOP does not present in this fashion. COPD and asthma lead to obstructive pattern on pulmonary function tests.

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A 66 year old male is brought in with severe pneumonia. He is in type 1 respiratory failure with an O2 level of 6.9 kPa. He is normally fit and well and is only on antihypertensives. He states he does not want to be on a “life support machine”. He requires intubation. What should be done next?

Intubate

In this case this patient has a very good premorbid state. He is only on antihypertensives. Although the wish not to be put on a “life support machine” may be a previous decision made by the patient it is difficult to assess this in this situation. He is hypoxic and is likely confused and agitated. He may have misconceptions about ventilation and these may have never been formally discussed and thus this patient is not making an informed decision. Therefore the doctor responsible for care must make the decision. In this patient he is likely to respond very well to ventilation and survive. Although it is appropriate to discuss the decision with the family, it is unfair for this to be their decision.

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Which of the following is not a poor prognostic factor for pneumonia?

a) Respiratory rate of 28
b) Confusion
c) Age 72
d) Systolic BP 88mmHg
e) Urea of 7.2mmol/L

a) Respiratory rate of 28
- According to CURB 65 a RR of 30 or more is associated with poor prognosis. The other options all indicate a poor prognosis and the CURB 65 score is used to guide treatment because of this.

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A 52 year old presents with normally well controlled asthma presents with, shortness of breath, wheeze and nocturnal cough. He has noticed coughing up blood on several occasions. He also complains of feeling generally unwell with a headache and fever. Bloods reveal an elevated eosinophil count and IgE. A CXR reveals new infiltrates. Which of the following will confirm the diagnosis?

a) Lung biopsy
b) High resolution CT
c) Serology for aspergillus precipitins
d) Autoantibodies
e) Pulmonary function tests

c) Serology for aspergillus precipitins
- This patient presents with features of deteriorating asthma with haemoptysis, general malaise and headache. This is inkeeping with allergic bronchopulmonary aspergillosis. There is evidence of eosinophilia, increased IgE and infiltrates CXR therefore either skin test for aspergillus or serology showing elevated precipitins to aspergillus will be useful in confirming the diagnosis.

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In regards to cryptogenic fibrosis alveolitis, which of the following is not true?

a) Reduced elastic recoil
b) Reduced FEV1
c) Reduced FVC
d) Normal to high FEV1/FVC
e) Poor lung compliance

a) Reduced elastic recoil
- CFA leads to a fibrotic ppicture on pulmonary functions tests and thus there is poor lung compliance as the lungs are stiff and increased elastic recoil. The other features are in keeping with a fibrotic picture.

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A 55 year old gentleman presents to his GP with haemoptysis. He had a previous history of tuberculosis. He has a cough and feels fevered at times. A chest xray reveals a cavitating lesion in the left upper lobe. Bloods reveal an elevated aspergillus precipitins.
What is the most likely diagnosis?

Aspergilloma

The most likely diagnosis is aspergilloma. It often presents with haemoptysis and a cavitating lesion occurs where there has been previous cavitating lung disease such as tuberculosis and therefore most commonly found in upper lobes. Fever and cough are less common. Chronic necrotising aspergillosis is rare, the patient is normally immunocompromised and it presents like an indolent pneumonia and haemoptysis is less common.

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A 48 year old gentleman presents with extreme tiredness and difficulty concentrating. His wife states he is irritable and he is a very loud snorer and occasionally chokes during the night. His libido is low, he is suffering from headaches and he has been falling asleep during the day as he feels very unrefreshed after his sleep. His BMI is 35. Given the most likely diagnosis, which of the following is not a risk factor?

a) Sedative drugs
b) Smoking
c) Diabetes
d) Obesity
e) Male

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c) Diabetes
- The diagnosis is obstructive sleep apnoea and these symptoms are classically of this. Risk factors for its development including male sex, middle aged, smoking, obesity, sedative drugs and excess alcohol consumption. Although it is associated with diabetes it is not a specific risk factor for its development. It is diagnosed via polysomnography whereby physiological recordings are made during sleep and the number of apnoea/hypopnoea episodes are measured. It is associated with hypertension, IHD, stroke, metabolic syndrome and diabetes. OSA can lead to RTAs sue to daytime sleepiness and it can lead to pulmonary hypertension and corpulmonale. Lifestyle advice such as weight loss, smoking cessation and reduced alcohol advice should be given. Other management options include intra oral devices to anterior displace the mandible and surgical techniques have been utilised. OSA can lead to significant hypoxia over night and night time CPAP may be required.

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Polysomnography

Which of the following is not an absolute contraindications to CPAP (continuous positive airway pressure)?

a) Pneumothorax
b) Facial burns
c) Epistaxis
d) Basal skull fracture
e) COPD

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e) COPD
- COPD is not as absolute contraindication but CPAP should be utilised cautiously. The rest of the options are contraindications.

In which of the following is CPAP contraindicated? a) Hypotension b) Hypovolaemia c) Basilar skull fracture d) Asthma e) Active tuberculosis

c) Basilar skull fracture - Basilar skull fracture is a contraindication. The other options are situations where CPAP should be used cautiously but they are not an absolute contraindication.

When a patient is diagnosed with COPD what is the most important step in management? a) Smoking cessation b) Salbutamol c) LTOT d) Tiotropium e) CXR

a) Smoking cessation

What is the most appropriate management of a DVT during pregnancy? a) Aspirin b) Dalteparin c) Warfarin d) IVC filter e) Monitoring

b) Dalteparin - LMWH are safe in pregnancy and are therefore the first line management. Warfarin is teratogenic and must be avoided, the other options have no role to play.

What is a teratogenic drug?

A teratogen is an agent that can disturb the development of the embryo or fetus. - Teratogens halt the pregnancy or produce a congenital malformation (a birth defect). Classes of teratogens include radiation, maternal infections, chemicals, and drugs.

Which of the following leads to an elevated alveolar arterial O2 gradient? a) Kyphoscoliosis b) COPD c) Pulmonary Embolism d) Bronchial Embolism e) Asthma

c) Pulmonary embolism - The alveolar arterial O2 gradient is the difference between the alveolar concentration of oxygen and arterial concentration of oxygen. - It is increased when hypoxia is secondary to diffusion defect, V/Q mismatch or shunting thus pulmonary embolus leads to an increase Aa gradient.

A patient is found to have chronic type 2 respiratory failure. Which one of the following is the most likely cause? a) Pulmonary hypertension b) Kyphoscoliosis c) Pneumonia d) Asthma e) Recurrent pulmonary embolus

b) Kyphoscoliosis - Neuromuscular disorders lead to type II respiratory failure. - Kyphoscoliosis similarly can lead to a type 2 respiratory failure. The other options can lead to a type 1 respiratory failure.

Asthma leads to an increase in which of the following? a) None of these options b) FEV1 c) FVC d) Gas transfer e) Residual volume

e) Residual volume | - In asthma there is an increase in residual volume beta reduction of FEV1, FVC and gas transfer

A 28 year old female presents to her GP as she has been suffering from epistaxis for numerous years and has been becoming increasingly short of breath. She is a non smoker and is otherwise well. On examination there is evidence of facial telangiectasia and clubbing. A CXR reveals a round mass which has a uniform density and is sharply defined, located in the left lower lobe. Gases reveal a type 1 respiratory failure. What is the most likely diagnosis? a) Asthma b) Pulmonary AV malformation c) Bronchial Carcinoma d) Carcinoid tumour e) Tuberculosis

b) Pulmonary AV malformation - The history of epistaxis and telangiectasia make the most likely diagnosis a pulmonary AV malformations. Due to right to left shunts there is hypoxia. Asthma would not lead to these features or the CXR findings which are highly suggestive of AV malformation. TB typically effects the upper lobe and carcinoma would be unusual in a young patient who does not smoke.

A 52 year old male who keeps pigeons presents to his GP. He states for some months he has had a productive cough, shortness of breath on exertion, fatigue, anorexia and has lost 2 stones in weight. On examination there is bibasal inspiratory crackles. A CXR reveals reticulonodular shadowing. Which of the following can aid in the diagnosis? a) Antigen specific IgG antibodies b) Full blood count c) Eosinophil d) Sputum culture e) Aspergillus precipitins

a) Antigen specific IgG antibodies - The most likely diagnosis is extrinsic allergic alveolitis. This is a diffuse granulomatous inflammation in lung parenchyma and airways following repeated exposure to organic antigens. This patient presents in the sub acute form although there is an acute and chronic form. In the acute form there is a flu like illness with fever, chest tightness, cough and dyspnoea 4 to 6 hours after exposure. In the chronic form there is typically fatigue, upper lobe fibrosis and dyspnoea on exertion. Causes include farmers lung due to mouldy hay exposure, bird fanciers lung and numerous others. A CXR may reveal reticulonodular shadowing in sub acute form and upper lobe fibrosis is typical of the chronic form. Hugh resolution CT and antigen specific IgG antibodies are useful for the diagnosis. The key to management is avoidance of the allergen and corticosteroids.

A 52 year old male who keeps pigeons presents to his GP. He states for some months he has had a productive cough, shortness of breath on exertion, fatigue, anorexia and has lost 2 stones in weight. On examination there is bibasal inspiratory crackles. A CXR reveals reticulonodular shadowing. What is the most likely diagnosis? a) Extrinsic allergic alveolitis b) Cardiac failure c) Cryptogenic allergic alveolitis d) ABPA e) Sarcoidosis

a) Extrinsic allergic alveolitis

Which of the following is not true regarding alpha 1 antitrypsin deficiency? a) Pizz genotype produces sever disease b) Liver is commonly involved c) Most commonly recessively inherited d) Alpha 1 antitrypsin is a glycoprotein e) Protects from neutrophil elastase

c) Most commonly recessively inherited | - Alpha 1 antitrypsin is usually inherited as an autosomal dominant or co dominant and only as recessively rarely.

Which of the following is not a cause for transudative pleural effsusion? a) Cirrhosis b) Pulmonary embolism c) Hypothyroidism d) Cardiac failure e) Pneumonia

e) Pneumonia | - Pneumonia leads to an exudative pleural effusion whilst the others lead to a transudate.

Which of the following is not a cause of an exudative pleural effusion? a) Malignancy b) Hypothyroidism c) Pancreatitis d) Tuberculosis e) Pneumonia

b) Hyperthyroidism | - Hypothyroidism leads to a transudate whilst the other options lead to an exudate.

What is an appropriate treatment regime for someone diagnosed with pulmonary tuberculosis?

- Initially rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months then isoniazid and rifampicin for further 4 months - An appropriate regime is treatment with 4 drugs for 2 months followed by isoniazid and rifampicin for a further 4 months. - In TB meningitis there should be 2 drugs for 2 months and then 10 months of treatment with isoniazid and rifampicin.

A 72 year old gentleman who was a retired insulator fitter. He is suffering from increasing shortness of breath and a dry cough. On examination there is evidence of bilateral inspiratory crackles and clubbing. CXR reveals pleural plaques and reticular shadowing at both bases. What is the most likely diagnosis?

COPD - Pulmonary asbestosis is a pneumoconiosis secondary to asbestos inhalation. It is associated with certain occupations such as boilermakers, inhalation workers etc. The fibres are fibrogenic and lead to inflammation in the lung. Pleural plaques alone are not associated with these features however in this gentlemans case there is evidence of fibrotic changes in the lung as well as pleural plaques. In a mesothelioma you would expect to find pleural thickening or a pleural effusion. Sarcoidosis typically causes upper lobe fibrosis. Clubbing can be observed in asbestosis.

A 14 year old boy who has previously had a staphylcoccal pneumonia presents with a chronic very purlent cough with occasional haemoptysis and chest pain. On examination there is bibasal coarse crackles. What is the most likely diagnosis? a) Pulmonary embolus b) Asthma c) Pneumonia d) COPD e) Bronchiectasis

e) Bronchiectasis - Asthma does not lead to these symptoms and the patient is young to have devleoped COPD. Haemotpysis is not a predominant feature of asthma or COPD and purulent cough is not a feature of Pulmonary embolism. Bronchiectasis is a persistent or progressive condition which is characterised by dilated thick wall bronchi. - A purulent cough is the main feature however dyspnoea, chest pain and haemoptysis can occur. HRCT is the gold standard for diagnosis and reveals bronchial wall dilatation. Serum immunoglobulins should be performed to exclude antibody deficiency as an underlying cause. Aspergillus precipitins should be measured to ensure this is not an underlying cause. Other tests include measurement of sweat chloride and CFTR to exclude cystic fibrosis as the underlying cause and ciliary function tests. PFTS, sputum microbiology and bronchoscopy may all be indicated.

Which of the following is not an acute complication of pneumonia? a) Pleural effusion b) Acute renal failure c) Bronchiectasis d) Sepsis e) Empyema

c) Bronchiectasis | - Bronchiectasis is a chronic complication whilst the others are acute.

A patient who has been previously diagnosed with coal workers pneumoconiosis develops worsening shortness of breath and cough productive of black sputum. On CXR there is large nodular fibrotic masses in the upper lobes. What is the most likely diagnosis? a) Tuberculosis b) Progressive massive fibrosis c) Worsening pneumoconiosis d) Caplans syndrome e) Klebsiella pneumonia

b) Progressive massive fibrosis - Simple pneumoconiosis is a nodular interstitial lung disease which is asymptomatic. Unfortunately there is risk of development of progressive massive fibrosis and the clinical features and symptoms described here are characteristic of it with the black sputum being pathognomonic. It produces a mixed obstructive and restrictive picture with reduced lung volumes and gas transfer.

A patient has an abnormal CXR which is suggestive of lung cancer. What investigation should be performed next? a) Pulmonary function tests b) Routine bloods c) Further CXR in 6 months d) Bronchoscopy e) CT chest, abdomen and pelvis

e) CT chest, abdomen and pelvis - A CT CAP should be performed next to confirm the diagnosis and stage of the disease, and look for any evidence of metastases. - A bronchoscopy or a CT guided biopsy would probably be the next most appropriate step.

A patient presents with a history suggestive of asthma. Which investigation would you organise next? a) Chest X-ray b) Nil required c) Pulmonary function tests d) Peak flow e) Routine bloods

c) Pulmonary function tests - If a patient presents with a history likely of asthma then pulmonary function tests should be performed and will confirm if there is evidence of airflow obstruction. - Peak flow is useful for the monitoring for asthma but not the diagnosis.

A patient is suspected of having radiation pneumonitis. Which of the following is most useful in the management? a) Steroids b) Oxygen therapy c) Aspirin d) Antibiotics e) Nebulisers

a) Steroids - Corticosteroids are most useful in symptomatic radiation pneumonitis and can sometimes produce massive improvement in symptomology. - Antibiotics are only used if there is a suspected infection also. - Oxygen therapy may be required if there is evidence of hypoxia.

Systemic sclerosis is predominantly associated with which one of the following? a) Aspiration pneumonia b) Pulmonary nodules c) Cryptogenic fibrosing alveolitis d) Pulmonary fibrosis

d) Pulmonary fibrosis | - Systemic sclerosis can lead to pulmonary fibrosis leading to a restrictive lung disease.

A 37 year old presents with fatigue, weight loss and nausea. He describes episodes of haemoptysis and has noticed his urine being very dark. On examination he has bibasal crepitations. His bloods reveal an iron deficiency anaemia and renal impairment and urinalysis reveals proteinuria and microscopic haematuria. Which investigation will give the definitive diagnosis? a) Vascular biopsy b) Rheumatoid factor c) Inflammatory markers d) Renal biopsy e) Sputum culture

d) Renal biopsy - This patient presents with Goodpastures disease which is the combination of glomerulonephritis and pulmonary alveolar haemorrhage. It is an autoimmune disease and there is antibodies to anti glomerular basement membrane which are involved in the pathogenesis of this disease. People present as above and there can be significant hypoxia and also massive pulmonary haemorrhage complicating the disease. ANCA is also raised.

A 52 year old male presents with fatigue, shortness of breath on exertion and syncope on several occasions whilst exercising. On examination there is peripheral oedema and an elevated JVP. Chest is clear. He has a previous history of recurrent pulmonary embolus. What is the most likely diagnosis? a) Secondary pulmonary hypertension b) Primary pulmonary hypertension c) Pulmonary embolus d) Congestive cardiac failure e) COPD

a) Secondary pulmonary hypertension - This patient presents with a history indicative of pulmonary hypertension. Secondary pulmonary hypertension is likely due to recurrent pulmonary emboli. - There is features or right ventricular failure.

A 22 year old female presents with her mother to A+E with an acute exacerbation of her asthma. She is wheezy with a RR of 24 and a HR of 90 and oxygen saturations of 99%. Her PEFR is 250 (normal 300). She is commenced on a salbutamol nebuliser and clinically improves with her wheeze sounding better and her RR 18 and sats 100%. What is the next course of action? a) Commence ipratropium bromide nebulisers b) Admit for 4 hourly nebulisers and observation for 24 hours c) Discharge with 5 day course of prednisolone d) IV Hydrocortisone e) Discharge with home nebuliser

c) Discharge with 5 day course of predisolone - This patient is having a moderate exacerbation of asthma with no signs of severe or life threatening asthma. She has improved with one nebuliser and is accompanied and therefore it would be reasonable to discharge with prednisolone and return if there is any worsening of her symptoms. Advice may be given regarding multi dosing if required.

What would suggest metabolic alkalosis in a patient with a bicarbonate of 36 mmol/l?

Raised CO2 - Metabolic alkalosis is found with high pH, high bicarbonate and high CO2.

a) Sarcoidosis - The finding of respiratory symptoms, erythema nodosum and bilateral hilar lymphadenopathy is very suggestive of sarcoidosis. As well as bilateral hilar lymphadeonpathy, sarcoidosis can lead to interstitial lung disease which often leads to fibrosis and reticulo nodular shadowing in the upper lobes.

b) Low CO2 - This patient is most likely suffering from hyperventilation. The clue to the diagnosis is the previous panic attacks. The ABGs are likely to show low CO2 which would account for the perioral tingling and paraesthesia.

What percentage increase in FEV1 post bronchodilator, is required for the diagnosis of asthma? a) >25% b) >20% c) >10% d) >5% e) >12%

e) >12%

Respiratory example questions Flashcards

(53 cards)