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Respiratory 13/Dr Chantae Reid-Agboolaado,Agenda 10 MCQ style questions Taken from MLA content map - Conditions and presentations Poll Explanation + ConsiderationsHowto approach an MLAMCQ:Question 1: Hb 120 (M)130 - 170 67M care-home resident presents to the Acute Medicine Unit with a g/L 2 weeks history of malaise, cough and fevers. During the (F)120 - 150 g/L consultation he tells you he is at home, and that he wants to go upstairs to his bedroom. On examination he is febrile, and confused; Airway patent; RR 33, WCC 14.5x10^9/L 3.0 - 10.0 Sats 93%, coarse crackles on the left lower zone; HR 110; BP 85/65; CRT <2; BM 7; T 38C. Bloods are as follows: CRP 250mg/L <5 Based on this presentation what is the best treatment option? Na2+ 140 mmol/L 135 - 145 a) PO Amoxicillin K+ 4.0 mmol/L 3.5 - 5.3 b) PO Doxycycline c) IV Piperacillin-Tazobactam CL- 100 mmol/L 95 - 106 d) IV Co-Amoxiclav e) PO Trimethoprim Urea 7.2 mmol/L 2.5 - 7.8Question 1: Hb 120 (M)130 - 170 67M care-home resident presents to the Acute Medicine Unit with a g/L 2 weeks history of malaise, cough and fevers. During the (F)120 - 150 g/L consultation he tells you he is at home, and that he wants to go upstairs to his bedroom. On examination he is febrile, and confused; Airway patent; RR 33, WCC 14.5x10^9/L 3.0 - 10.0 Sats 93%, coarse crackles on the left lower zone; HR 110; BP 85/65; CRT <2; BM 7; T 38C. Bloods are as follows: CRP 250mg/L <5 Based on this presentation what is the best treatment option? Na2+ 140 mmol/L 135 - 145 a) PO Amoxicillin K+ 4.0 mmol/L 3.5 - 5.3 b) PO Doxycycline c) IV Piperacillin-Tazobactam CL- 100 mmol/L 95 - 106 d) IV Co-Amoxiclav e) PO Trimethoprim Urea 7.2 mmol/L 2.5 - 7.8Pneumonia Clinical suspicion of diagnosis, calculate: NICE guidelines [NG138] CURB 65 Each scores 1 point: ● Confusion ● Urea >7 mmol/L ● Respiratory rate >30 ● Blood pressure <90mmHg Systolic or <60mmHg Diastolic ● Age >65Figure/statement slideFigure/statement slideQuestion 2: A 55F is being treated in AMU for an infective exacerbation of COPD. This is her third admission for an exacerbation in the past 6 months, receiving a full course of treatment before discharge. During the ward round she tell you she has noticed her clothes not fitting her right, feeling fatigued towards the end of the day, and finding it harder to move from the bed to her chair. On examination you also notice bruising along her arms, as well as prominent stretch marks along her abdomen. Which of the medications is most likely to have caused her symptoms? a) Prednisolone b) Salbutamol c) Ipratropium d) Carbocisteine e) salmeterolQuestion 2: A 55F is being treated in AMU for an infective exacerbation of COPD. This is her third admission for an exacerbation in the past 6 months, receiving a full course of treatment before discharge. During the ward round she tell you she has noticed her clothes not fitting her right, feeling fatigued towards the end of the day, and finding it harder to move from the bed to her chair. On examination you also notice bruising along her arms, as well as prominent stretch marks along her abdomen. Which of the medications is most likely to have caused her symptoms? a) Prednisolone b) Salbutamol c) Ipratropium d) Carbocisteine e) salmeterolCOPD Fundamentals of therapy: Complications GOLD 2024 report groups patients into 3 groups: A B and E depending on their mMRC (Modified Medical Research Salbutamol: Tachycardia, palpitations Council) Dyspnea Scale, COPD Assessment Test against the number of COPD exacerbations. LABA: headache, muscle cramps, fine tremor Medications prescribed: LAMA: Tachycardia, nausea, vomiting, SABA (typically salbutamol) diarrhoea, dry mouth LABA + LAMA +/- ICS Corticosteroids: risk of Cushing’s syndrome During acute exacerbation: Cushing’s syndrome: proximal myopathy; Oral Steroids easy bruising; central obesity; abdominal +/- Antibiotics if infective exacerbation striae; osteoporosis; glucose intolerance; facial changes; ‘Buffalo’ hump; skin thinning. +/- Anti-mucolytics (Carbocisteine)COPD Complications Salbutamol: Tachycardia, palpitations LABA: headache, muscle cramps, fine tremor LAMA: Tachycardia, nausea, vomiting, diarrhoea, dry mouth Corticosteroids: risk of Cushing’s syndrome Cushing’s syndrome: proximal myopathy; easy bruising; central obesity; abdominal striae; osteoporosis; glucose intolerance; facial changes; ‘Buffalo’ hump; skin thinning. Figure/statement slide GOLD report, 2024Question 3: You are clerking in a patient admitted for an elective pH 7.35 7.35-7. laparoscopic cholecystectomy the following day. As part of the 45 assessment an ABG is performed: paCO2 8.0 4.6 – 6.4mm What does the ABG show? Hg a) Acute respiratory acidosis pO2 9.0 11.0 – b) Respiratory acidosis with full metabolic compensation 14.4m mHg c) Acute metabolic acidosis d) Respiratory alkalosis with partial metabolic HCO3 35 22 – 26 mEq/L compensation e) Respiratory acidosis with partial metabolic compensation Base 4+ -2 to +2 Excess mmol/LQuestion 3: You are clerking in a patient admitted for an elective laparoscopic cholecystectomy the following day. As part of the assessment an ABG is performed: pH 7.35 7.35-7.45 What does the ABG show? paCO2 8.0 4.6 – a) Acute respiratory acidosis 6.4mmHg b) Respiratory acidosis with full metabolic pO2 9.0 11.0 – compensation 14.4mmH c) Acute metabolic acidosis g d) Respiratory alkalosis with partial metabolic HCO3 35 22 – 26 compensation mEq/L Base 4+ -2 to +2 e) Respiratory acidosis with partial metabolic compensation Excess mmol/LT1RFvsT2RF Interpretation basics: ● T1RF - Failure of oxygenation 1) pH - Acidosis vs Alkalosis Low O2 normal CO2 2) pCO2 - respiratory vs metabolic 3) HCO3- Metabolic compensation (Acute vs chronic) Treat with CPAP ● T2RF - failure of ventilation; Two things Other uses for ABGs/VBGs wrong! Rapid electrolyte results Low O2 *and* High CO2 Lactate Treat with BiPAP (Always confirm with formal/test tube bloods)T1RFvsT2RF Interpretation basics: ● T1RF - Failure of oxygenation 1) pH - Acidosis vs Alkalosis Low O2 normal CO2 2) pCO2 - respiratory vs metabolic Treat with CPAP 3) HCO3- Metabolic compensation (Acute vs chronic) pH 7.35 7.35-7.45 ● T2RF - failure of ventilation; Two things wrong! paCO2 8.0 4.6 – 6.4mmHg Low O2 *and* High CO2 pO2 9.0 11.0 – 14.4mmH Treat with BiPAP g HCO3 35 22 – 26 mEq/L Base 4+ -2 to +2 Excess mmol/LQuestion 4: Airway Patent with wheeze An 18M presents to A&E after feeling breathless while competing at a sports event. He is a known asthmatic and was Breathing RR 8, Sats 90%, recently switched to PRN Anti-inflammatory Reliever (AIR) Little/no breath therapy alongside Maintenance and reliever therapy (MART). He sounds on is acutely short of breath and is distressed. Paramedics have auscultation; PEFR trialled salbutamol which has had little effect. poor- 30% predicted Examination findings are as follows: Circulation HR 135; BP 75/64; How severe is his asthma attack? CRT 3s a) Moderate b) Mild Disability/Exposure BM 5; T 37.8; GCS c) Severe 14 (Confused) d) Life-threatening Slight blue tinge to e) Normal mouth and fingersQuestion 4: Airway Patent with wheeze An 18M presents to A&E after feeling breathless while competing at a sports event. He is a known asthmatic and was Breathing RR 8, Sats 90%, recently switched to PRN Anti-inflammatory Reliever (AIR) Little/no breath therapy alongside Maintenance and reliever therapy (MART). He sounds on is acutely short of breath and is distressed. Paramedics have auscultation; PEFR trialled salbutamol which has had little effect. poor- 30% predicted Examination findings are as follows: Circulation HR 135; BP 75/64; How severe is his asthma attack? CRT 3s a) Moderate b) Mild Disability/Exposure BM 5; T 37.8; GCS c) Severe 14 (Confused) d) Life-threatening Slight blue tinge to e) Normal mouth and fingersStratifying asthma severity Severe Life-threatening Inability to complete sentences in one breath; SHOCK mnemonic Silent chest on auscultation Oxygen saturation on air less than 92%; Hypotension Respiratory rate more than 25 breaths per minute; (PEFR) less than One-third predicted Pulse more than 110 beats per minute; Cyanosis PEF 33–50% best or predicted. (K)onfusion/ drowsyStratifying asthma severity Why care: Severity of exacerbation guides management and where to treat Guides management along hospital guidelines. ● Moderate: initial treatment in primary care + urgent transfer to hospital if symptoms do not respond; ○ PRN Salbutamol and oral steroid. ● Severe: Treat with nebulisers and emergency transfer to hospital if initial therapy ineffective; ○ Nebulised salbutamol +/- nebulised ipratropium if not responding ● Life threatening: give emergency treatment while arranging emergency transfer to hospital; ○ nebulised salbutamol + Nebulised ipratropium +/- theophylline -> ITU review in case of deteriorationQuestion 5: Airway Patent A 18M presents to the emergency department following an altercation. On examination he has a stab wound to his right upper chest, as well as bruising to his abdomen, abrasions to Breathing RR 25, Sats 92%, both arms and bleeding from his nose. On examination he Breath sounds appears breathless and is panicked. heard over left lung fields, none heard over right; What is the best initial intervention? tracheal deviation to the left a) Urgent Chest x-ray b) Needle decompression left 2nd intercostal space MCL Circulation HR 110; BP 80/64; c) Needle decompression right 2nd intercostal space MCL CRT 2s d) Urgent CT scan Disability/Exposure BM 5; T 37.8; GCS e) Chest drain insertion to left lateral pleural space 15Question 5: Airway Patent A 18M presents to the emergency department following an altercation. On examination he has a stab wound to his right upper chest, as well as bruising to his abdomen, abrasions to Breathing RR 25, Sats 92%, both arms and bleeding from his nose. On examination he Breath sounds appears breathless and is panicked. heard over left lung fields, none heard over right; What is the best initial intervention? tracheal deviation to the left a) Urgent Chest x-ray b) Needle decompression left 2nd intercostal space MCL Circulation HR 130; BP 80/64; c) Needle decompression right 2nd intercostal space MCL CRT 2s d) Urgent CT scan Disability/Exposure BM 5; T 37.8; GCS e) Chest drain insertion to left lateral pleural space 15Figure/statement slideFigure/statement slidePneumothorax Primary vs Secondary vs Tension Management Primary: air in pleural space with no Clinical diagnosis, if suspected + pre-existing lung disease/pathology haemodynamic compromise: Secondary: air in pleural space with Needle decompression Or finger pre-existing lung disease/pathology thoracostomy to one of two sites: Tension: air in pleural space with haemodynamic compromise Haemodynamic compromise features: BTS Guidelines: low/dropping blood pressure, raised heart >2 cm in size - Chest drain rate, low/dropping saturations, rising respiratory rate.Pneumothorax Primary vs Secondary vs Tension Management Primary: air in pleural space with no Clinical diagnosis, if suspected + pre-existing lung disease/pathology haemodynamic compromise: Secondary: air in pleural space with Needle decompression Or finger pre-existing lung disease/pathology thoracostomy to one of two sites Tension: air in pleural space with haemodynamic compromise Haemodynamic compromise features: BTS Guidelines: low/dropping blood pressure, raised heart >2Cm - Chest drain rate, low/dropping saturations, rising respiratory rate.Pneumothorax Primary vs Secondary vs Tension Management Clinical diagnosis, if suspected + haemodynamic Primary: air in pleural space with no compromise: pre-existing lung disease/pathology Needle decompression Or finger thoracostomy to one of two sites: Secondary: air in pleural space with pre-existing lung disease/pathology 2nd intercostal space, midclavicular line Tension: air in pleural space with Or haemodynamic compromise 3rd, 4th, 5th intercostal space midaxillary line Haemodynamic compromise features: low/dropping blood pressure, raised heart BTS Guidelines: rate, low/dropping saturations, rising Chest x-ray of lung showing pneumothorax >2cm -> Chest respiratory rate. drainQuestion 6: A 65 year old man presents with his wife to GP clinic complaining of Airway Patent non-refreshing sleep. This has progressively worsened over the past year and is now disrupting his work as an office manager. He is now finding it difficult to concentrate and now has episodes where he feels he is falling asleep during Breathing RR 10, Sats 96%, the day. He is a smoker, and drinks a bottle of wine a night with his dinner. His Breath sounds heard over all lung wife tells you he is a loud snorer, often turning frequently in his sleep. Sometimes he wakes up sounding like he is choking before returning to sleep. fields She is concerned about his sleep and whether he is safe to drive. Circulation HR 110; BP What is the next best step? 125/84; CRT 2s a) Trial salbutamol PRN Disability/Exposure BM 5; T 37.8; GCS b) Trial BiPAP + Lifestyle advice 15; BMI 33 c) Lifestyle advice Large body d) Trial CPAP + Lifestyle advice habitus, mobilising around e) Long term oxygen therapy clinic comfortablyQuestion 6: A 65 year old man presents with his wife to GP clinic complaining of Airway Patent non-refreshing sleep. This has progressively worsened over the past year and is now disrupting his work as an office manager. He is now finding it difficult to concentrate and now has episodes where he feels he is falling asleep during Breathing RR 10, Sats 96%, the day. He is a smoker, and drinks a bottle of wine a night with his dinner. His Breath sounds heard over all lung wife tells you he is a loud snorer, often turning frequently in his sleep. Sometimes he wakes up sounding like he is choking before returning to sleep. fields She is concerned about his sleep and whether he is safe to drive. Circulation HR 110; BP What is the next best step? 125/84; CRT 2s a) Trial salbutamol PRN Disability/Exposure BM 5; T 37.8; GCS b) Trial BiPAP + Lifestyle advice 15; BMI 33 c) Lifestyle advice Large body d) Trial CPAP + Lifestyle advice habitus, mobilising around e) Long term oxygen therapy clinic comfortablyObstructive sleep apnoea OSA/ OHS NICE Guidelines Loss of muscle tone in the upper airway muscles during sleep causing transient airway obstruction. Risk factors from this stem: obesity, large neck circumferences, decreased muscle tone due to alcohol or drugs. Investigations/ Treatment: Sleep studies, polysomnography Trial of Continuous positive airway pressure (CPAP), referral to specialists for surgical/ orthodontics splinting if still symptomaticFigure/statement slideFigure/statement slideQuestion 7: Airway Patent A 65F post-op total hip replacement patient presents to A&E with new chest pain. During the consultation she coughs up phlegm with streaks of Breathing RR 24, Sats 92%, Breath sounds heard over all blood. She also tells you if hurts on her right side lung fields, tracheal when she takes a breath in. central Examination findings are summarised as follows: Circulation HR 135, BP 115/74; CRT 2s What is the most important diagnosis to exclude? JVP 2 cm above sternal notch a) Pneumonia b) Pleural effusion Disability/Exposure BM 5; T 38.8; GCS 15; BMI 35 c) Pulmonary embolism d) Heart failure Large body habitus, mobilising around e) Lung cancer examination room independentlyQuestion 7: Airway Patent A 65F post-op total hip replacement patient presents to A&E with new chest pain. During the consultation she coughs up phlegm with streaks of Breathing RR 24, Sats 92%, Breath sounds heard over all blood. She also tells you if hurts on her right side lung fields, tracheal when she takes a breath in. central Examination findings are summarised as follows: Circulation HR 135, BP 115/74; CRT 2s What is the most important diagnosis to exclude? JVP 2 cm above sternal notch a) Pneumonia b) Pleural effusion Disability/Exposure BM 5; T 38.8; GCS 15; BMI 35 c) Pulmonary embolism d) Heart failure Large body habitus, mobilising around e) Lung cancer examination room independentlyPE Heuristic: chest pain with new oxygen Treatment options requirement +/- dyspnea- exclude pulmonary Use two level Well score to estimate probability of embolus first PE/DVT. Resulting from a clot in the pulmonary Well’s score >4 (highly likely) - CTPA + vasculature. Causing haemodynamic Treatment if confirmed compromise Well’s score <4 (not likely) - D-dimer +/- CTPA Confirmed PE: Anticoagulation - DOAC, Treatment dose LMWH. Provoked vs unprovoked PE -> treatment durationPE Heuristic: chest pain with new oxygen Treatment options requirement +/- dyspnea- exclude pulmonary Use two level Well score to estimate probability of embolus first PE/DVT. Resulting from a clot in the pulmonary Well’s score >4 (highly likely) - CTPA + vasculature. Causing haemodynamic Treatment if confirmed compromise Well’s score <4 (not likely) - D-dimer +/- CTPA Confirmed PE: Anticoagulation - DOAC, Treatment dose LMWH. Provoked vs unprovoked PE -> treatment durationQuestion 8: Appearance Straw Clear 37F presenting with increasing shortness of breath, progressing over the past month. She also has left sided chest pain when breathing in. On examination pH 7.65 7.60-7.64 you find reduced breath sounds below the 5th intercostal space, and a stony dull percussion note over this same area. A CXR is conducted which reveals a Protein 20 < 2% (10-20 pleural effusion, and a sample is taken. The cystoscopy and microscopy results g/L) are as follows: WCC 500 < 1000/mm³ Serum glucose 80 mg/dL; Serum LDH 150U/L; Serum protein 6g/dL Which of these values is most indicative of a transudative effusion? Glucose 83 Equal to plasma (mg/dL) a) pH 7.65 LDH 90 <50% plasma b) Protein 20g/L concentration c) Pleural Amylase 50 d) Pleural WCC 500 Amylase 50 30-110 U/L e) Straw appearance Triglycerides 1.1 <2 mmol/l Cholesterol 4.0 3.5–6.5 mmol/lQuestion 8: Appearance Straw Clear 37F presenting with increasing shortness of breath, progressing over the past month. She also has left sided chest pain when breathing in. On examination pH 7.65 7.60-7.64 you find reduced breath sounds below the 5th intercostal space, and a stony dull percussion note over this same area. A CXR is conducted which reveals a Protein 20 < 2% (10-20 pleural effusion, and a sample is taken. The cystoscopy and microscopy results g/L) are as follows: WCC 500 < 1000/mm³ Serum glucose 80 mg/dL; Serum LDH 150U/L; Serum protein 6g/dL Which of these values is most indicative of a transudative effusion? Glucose 83 Equal to plasma (mg/dL) a) pH 7.65 LDH 90 <50% plasma b) Protein 20g/L concentration c) Pleural Amylase 50 d) Pleural WCC 500 Amylase 50 30-110 U/L e) Straw appearance Triglycerides 1.1 <2 mmol/l Cholesterol 4.0 3.5–6.5 mmol/lPleural effusion Fluid accumulation in the pleural cavity. Clinical signs and symptoms - diagnosed with What if the protein is between 25 and 35 g/L? a chest x-ray. Light’s criteria: Symptomatic +/- diagnostic tap for pleural A pleural effusion if exudative in nature if: fluid - Cytology and microscopy ● The ratio of pleural fluid to serum protein is greater than 0.5 Transudative vs Exudative ● The ratio of pleural fluid to serum LDH is greater than 0.6 Transudative - commonly secondary to heart ● The pleural fluid LDH value is greater than failure or cirrhosis, nephrotic syndrome and two-thirds of the upper limit of the normal serum value typically have low protein levels in the pleural fluid. Protein <25 g/L Hence pleural fluid and matched serum samples are required Exudative - most commonly due to malignancy or infection, and have higher protein levels in the fluid. Protein >35 g/LQuestion 9: A 18M presents to the acute medical unit with fever, cough with streaks of blood, and new neck lumps on the front of his neck. On further questioning he has recently moved to the UK for military training, and is complaining of being unable to sleep at night- often waking up drenched in sweat. He is struggling to complete his basic training, and says he cannot gain weight despite increasing his food intake. He is commenced on the appropriate treatment, but comes back to AMU now reporting difficulty distinguishing between colours, particularly red safety flags on range days. Which of the medications is most likely to have caused the side effects? a) Isoniazid b) Rifampin c) Pyrazinamide d) Ethambutol e) ParacetamolQuestion 9: A 18M presents to the acute medical unit with fever, cough with streaks of blood, and new neck lumps on the front of his neck. On further questioning he has recently moved to the UK for military training, and is complaining of being unable to sleep at night- often waking up drenched in sweat. He is struggling to complete his basic training, and says he cannot gain weight despite increasing his food intake. He is commenced on the appropriate treatment, but comes back to AMU now reporting difficulty distinguishing between colours, particularly red safety flags on range days. Which of the medications is most likely to have caused the side effects? a) Isoniazid b) Rifampin c) Pyrazinamide d) Ethambutol e) ParacetamolTB Highly infectious disease caused by the Note respiratory and systemic symptoms bacterium Mycobacterium tuberculosis. night sweats, fever, weight loss, and a chronic cough. Cervical and supraclavicular Note reportable disease with Public Health lymphadenopathy most common *large, England non-tender* RIPE therapy for acute (Active) TB Therapy side effects Rifampin - reddish discoloration in tears, sweat, saliva, urine, Rifampin Isoniazid - peripheral neuropathy (induces B6 deficiency), drug Isoniazid induced lupus; CYP450 inhibitor Pyrazinamide Pyrazinamide- Hepatotoxicity, hyperuricaemia -> gout like Ethambutol symptoms Ethambutol - reversible optic neuritis (baseline + follow up vision tests)Question 10: A 36M presents to his GP with recurrent chest infections. He is febrile and has a productive cough. In his past medical history you note he has diabetes, and has been seen by general Airway Patent surgery for gallstones. On examination he is slim in build, shorter than average,with noticeable finger clubbing. Breathing RR 12, Sats 96%, No added sounds on auscultation; What is the most likely causative organism for his symptoms? Circulation HR 105; BP a) Streptococcus pneumoniae 120/78; CRT 2s b) Pseudomonas aeruginosa Disability/ExposurBM 5; T 38; GCS 15 c) Staphylococcus aureus (Confused) d) Legionella pneumophila e) Moraxella catarrhalis BMI 17Question 10: A 36M presents to his GP with recurrent chest infections. He is febrile and has a productive cough. In his past medical history you note he has diabetes, and has been seen by general Airway Patent surgery for gallstones. On examination he is slim in build, shorter than average,with noticeable finger clubbing. Breathing RR 12, Sats 96%, No added sounds on auscultation; What is the most likely causative organism for his symptoms? Circulation HR 105; BP a) Streptococcus pneumoniae 120/78; CRT 2s b) Pseudomonas aeruginosa Disability/ExposurBM 5; T 38; GCS 15 c) Staphylococcus aureus (Confused) d) Legionella pneumophila e) Moraxella catarrhalis BMI 17Cysticfibrosis Error in the CFTR gene Autosomal recessive inheritance Causing failure in transportation of CL- across channels -> thickened secretions that are hard to clear. Pseudomonas aeruginosa is the most common causative organism in patients with cystic fibrosis patients. Causing the greatest burden in morbidity and mortalityThankyou Any questions? SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching