Podcast
Questions and Answers
A 72-year-old male with a 40-pack-year smoking history presents with a chronic cough and progressive dyspnea. Physical examination reveals bibasal expiratory wheezes. Arterial blood gas shows compensated hypercapnia. Pulmonary function tests reveal an FEV1/FVC ratio of 40%. Which of the following pathophysiological mechanisms is MOST consistent with these findings?
A 72-year-old male with a 40-pack-year smoking history presents with a chronic cough and progressive dyspnea. Physical examination reveals bibasal expiratory wheezes. Arterial blood gas shows compensated hypercapnia. Pulmonary function tests reveal an FEV1/FVC ratio of 40%. Which of the following pathophysiological mechanisms is MOST consistent with these findings?
- Restrictive lung disease characterized by decreased lung compliance.
- Alveolar consolidation leading to ventilation-perfusion mismatch.
- Increased pulmonary vascular resistance secondary to thromboembolism.
- Irreversible airflow limitation due to airway inflammation and remodeling. (correct)
In the context of COPD management, the GOLD classification incorporates both symptom burden and exacerbation risk. Which of the following scenarios BEST exemplifies a patient categorized as GOLD Grade D?
In the context of COPD management, the GOLD classification incorporates both symptom burden and exacerbation risk. Which of the following scenarios BEST exemplifies a patient categorized as GOLD Grade D?
- A patient with an mMRC score of 0, CAT score of 5, and two severe exacerbations requiring hospitalization in the past year.
- A patient with an mMRC score of 3, CAT score of 22, and one moderate exacerbation requiring oral corticosteroids in the past year.
- A patient with an mMRC score of 1, CAT score of 8, and no exacerbations in the past year.
- A patient with an mMRC score of 2, CAT score of 15, and three moderate exacerbations requiring antibiotics and oral corticosteroids in the past year. (correct)
Mr. Smith, a COPD patient, is initiated on a LABA/LAMA combination inhaler. Considering the pharmacological principles of COPD management, what is the PRIMARY rationale for combining these two bronchodilator classes?
Mr. Smith, a COPD patient, is initiated on a LABA/LAMA combination inhaler. Considering the pharmacological principles of COPD management, what is the PRIMARY rationale for combining these two bronchodilator classes?
- To directly target and reverse the underlying airway remodeling in COPD.
- To reduce the risk of inhaled corticosteroid-related side effects.
- To synergistically enhance bronchodilation through complementary mechanisms of action. (correct)
- To provide rapid relief of acute exacerbation symptoms.
Two years after COPD diagnosis, Mr. Smith presents with new onset haemoptysis, weight loss, and chest pain. A chest X-ray reveals a left-sided pleural effusion and mediastinal widening. Which of the following diagnostic investigations is MOST crucial in establishing a definitive diagnosis in this scenario?
Two years after COPD diagnosis, Mr. Smith presents with new onset haemoptysis, weight loss, and chest pain. A chest X-ray reveals a left-sided pleural effusion and mediastinal widening. Which of the following diagnostic investigations is MOST crucial in establishing a definitive diagnosis in this scenario?
Light's criteria are used to classify pleural effusions as transudative or exudative. Which of the following pleural fluid analysis results would classify Mr. Smith's pleural effusion as MOST likely exudative, raising suspicion for malignancy?
Light's criteria are used to classify pleural effusions as transudative or exudative. Which of the following pleural fluid analysis results would classify Mr. Smith's pleural effusion as MOST likely exudative, raising suspicion for malignancy?
Mr. Smith's CT Thorax reveals a left upper lobe mass with mediastinal lymphadenopathy. Bronchoscopy with biopsy confirms non-small cell lung cancer. According to the TNM staging system, if the tumour is classified as T2N2M0, which of the following statements BEST describes the stage and its implications?
Mr. Smith's CT Thorax reveals a left upper lobe mass with mediastinal lymphadenopathy. Bronchoscopy with biopsy confirms non-small cell lung cancer. According to the TNM staging system, if the tumour is classified as T2N2M0, which of the following statements BEST describes the stage and its implications?
Mr. Smith is deemed unfit for surgical resection of his lung cancer due to age and comorbidities and is started on chemoradiotherapy. One month into treatment, he develops fever, cough with green sputum, and hypoxia. Which of the following is the MOST likely diagnosis?
Mr. Smith is deemed unfit for surgical resection of his lung cancer due to age and comorbidities and is started on chemoradiotherapy. One month into treatment, he develops fever, cough with green sputum, and hypoxia. Which of the following is the MOST likely diagnosis?
Mr. Smith is diagnosed with community-acquired pneumonia. His CURB-65 score is calculated as 3. Based on this score, what is the MOST appropriate initial management strategy?
Mr. Smith is diagnosed with community-acquired pneumonia. His CURB-65 score is calculated as 3. Based on this score, what is the MOST appropriate initial management strategy?
Mr. Smith, with pneumonia and underlying COPD, develops acute respiratory failure requiring BiPAP. To assess his in-hospital mortality risk in the context of COPD exacerbation and pneumonia, which scoring system is MOST appropriate to utilize?
Mr. Smith, with pneumonia and underlying COPD, develops acute respiratory failure requiring BiPAP. To assess his in-hospital mortality risk in the context of COPD exacerbation and pneumonia, which scoring system is MOST appropriate to utilize?
In managing Mr. Smith's community-acquired pneumonia, which of the following clinical parameters would be the MOST reliable indicator of a beneficial response to antibiotic therapy within the first 72 hours?
In managing Mr. Smith's community-acquired pneumonia, which of the following clinical parameters would be the MOST reliable indicator of a beneficial response to antibiotic therapy within the first 72 hours?
Considering the principles of COPD management, which of the following interventions has been shown to MOST significantly impact long-term mortality and disease progression in patients with COPD, regardless of GOLD stage?
Considering the principles of COPD management, which of the following interventions has been shown to MOST significantly impact long-term mortality and disease progression in patients with COPD, regardless of GOLD stage?
Mr. Smith's initial arterial blood gas showed compensated hypercapnic respiratory failure. Which of the following BEST describes the compensatory mechanism in this scenario?
Mr. Smith's initial arterial blood gas showed compensated hypercapnic respiratory failure. Which of the following BEST describes the compensatory mechanism in this scenario?
In the context of lung cancer risk factors, which of the following factors is considered to have the HIGHEST attributable risk for the development of lung cancer worldwide?
In the context of lung cancer risk factors, which of the following factors is considered to have the HIGHEST attributable risk for the development of lung cancer worldwide?
Which of the following surgical approaches for lung cancer resection is MOST likely to be associated with the HIGHEST postoperative pain and prolonged recovery?
Which of the following surgical approaches for lung cancer resection is MOST likely to be associated with the HIGHEST postoperative pain and prolonged recovery?
A patient with suspected lung cancer undergoes staging investigations. Which of the following findings would classify the patient as having Stage IV lung cancer according to the TNM staging system?
A patient with suspected lung cancer undergoes staging investigations. Which of the following findings would classify the patient as having Stage IV lung cancer according to the TNM staging system?
In the management of COPD exacerbations, systemic corticosteroids are frequently used. What is the PRIMARY mechanism by which corticosteroids are thought to improve outcomes in COPD exacerbations?
In the management of COPD exacerbations, systemic corticosteroids are frequently used. What is the PRIMARY mechanism by which corticosteroids are thought to improve outcomes in COPD exacerbations?
Which of the following statements BEST reflects the role of prophylactic antibiotics in the routine long-term management of COPD?
Which of the following statements BEST reflects the role of prophylactic antibiotics in the routine long-term management of COPD?
In the diagnostic workup of suspected lung cancer, bronchoscopy plays a crucial role. In which of the following clinical scenarios is bronchoscopy with biopsy considered MOST essential for diagnosis and staging?
In the diagnostic workup of suspected lung cancer, bronchoscopy plays a crucial role. In which of the following clinical scenarios is bronchoscopy with biopsy considered MOST essential for diagnosis and staging?
Mr. Smith's chest X-ray for pneumonia shows a 'diffuse opacity in the right middle lobe'. Which of the following anatomical descriptions BEST characterizes the location of the right middle lobe?
Mr. Smith's chest X-ray for pneumonia shows a 'diffuse opacity in the right middle lobe'. Which of the following anatomical descriptions BEST characterizes the location of the right middle lobe?
In the context of pneumonia management, BiPAP (Bilevel Positive Airway Pressure) is initiated for Mr. Smith due to respiratory acidosis. What is the PRIMARY physiological goal of BiPAP in this setting?
In the context of pneumonia management, BiPAP (Bilevel Positive Airway Pressure) is initiated for Mr. Smith due to respiratory acidosis. What is the PRIMARY physiological goal of BiPAP in this setting?
Considering the pharmacotherapy for community-acquired pneumonia, the choice of antibiotics is often guided by local guidelines and patient-specific factors. In Mr. Smith's case, IV Co-amoxiclav and oral Clarithromycin were chosen. What is the MOST likely rationale for using this combination therapy?
Considering the pharmacotherapy for community-acquired pneumonia, the choice of antibiotics is often guided by local guidelines and patient-specific factors. In Mr. Smith's case, IV Co-amoxiclav and oral Clarithromycin were chosen. What is the MOST likely rationale for using this combination therapy?
In the context of COPD exacerbations, the DECAF score includes 'eosinopenia' as a prognostic factor. What is the MOST likely pathophysiological explanation for why eosinopenia is associated with increased mortality risk in COPD exacerbations?
In the context of COPD exacerbations, the DECAF score includes 'eosinopenia' as a prognostic factor. What is the MOST likely pathophysiological explanation for why eosinopenia is associated with increased mortality risk in COPD exacerbations?
Which of the following statements accurately describes the typical clinical presentation of lung cancer-related pleural effusion?
Which of the following statements accurately describes the typical clinical presentation of lung cancer-related pleural effusion?
In managing a patient with lung cancer and malignant pleural effusion, what is the PRIMARY goal of chest tube drainage and pleurodesis?
In managing a patient with lung cancer and malignant pleural effusion, what is the PRIMARY goal of chest tube drainage and pleurodesis?
Which of the following is the MOST appropriate initial investigation to assess for underlying lung malignancy in a patient presenting with a new, unexplained pleural effusion?
Which of the following is the MOST appropriate initial investigation to assess for underlying lung malignancy in a patient presenting with a new, unexplained pleural effusion?
In the context of lung cancer screening, low-dose computed tomography (LDCT) is recommended for high-risk individuals. Which of the following BEST defines the 'high-risk' criteria for LDCT lung cancer screening based on current guidelines?
In the context of lung cancer screening, low-dose computed tomography (LDCT) is recommended for high-risk individuals. Which of the following BEST defines the 'high-risk' criteria for LDCT lung cancer screening based on current guidelines?
Which of the following pathological subtypes of lung cancer is MOST strongly associated with cigarette smoking and tends to be centrally located in the bronchi?
Which of the following pathological subtypes of lung cancer is MOST strongly associated with cigarette smoking and tends to be centrally located in the bronchi?
In the management of COPD, pulmonary rehabilitation is a cornerstone of non-pharmacological therapy. Which of the following BEST describes the PRIMARY benefits of pulmonary rehabilitation for patients with COPD?
In the management of COPD, pulmonary rehabilitation is a cornerstone of non-pharmacological therapy. Which of the following BEST describes the PRIMARY benefits of pulmonary rehabilitation for patients with COPD?
Which of the following statements BEST describes the expected FEV1/FVC ratio and total lung capacity (TLC) in a patient with severe COPD characterized by significant emphysema?
Which of the following statements BEST describes the expected FEV1/FVC ratio and total lung capacity (TLC) in a patient with severe COPD characterized by significant emphysema?
In the management of acute exacerbations of COPD, non-invasive ventilation (NIV) such as BiPAP is often considered. Which of the following clinical scenarios is generally considered a RELATIVE CONTRAINDICATION to the use of NIV in COPD exacerbation?
In the management of acute exacerbations of COPD, non-invasive ventilation (NIV) such as BiPAP is often considered. Which of the following clinical scenarios is generally considered a RELATIVE CONTRAINDICATION to the use of NIV in COPD exacerbation?
Mr. Smith, despite smoking cessation, continues to experience frequent COPD exacerbations. Which of the following pharmacological agents, added to his LABA/LAMA inhaler, is MOST likely to be effective in reducing exacerbation frequency, particularly if he has evidence of chronic bronchitis phenotype?
Mr. Smith, despite smoking cessation, continues to experience frequent COPD exacerbations. Which of the following pharmacological agents, added to his LABA/LAMA inhaler, is MOST likely to be effective in reducing exacerbation frequency, particularly if he has evidence of chronic bronchitis phenotype?
In the management of lung cancer, targeted therapies are increasingly used, particularly in adenocarcinoma. Which of the following molecular targets is MOST commonly associated with targeted therapy in lung adenocarcinoma?
In the management of lung cancer, targeted therapies are increasingly used, particularly in adenocarcinoma. Which of the following molecular targets is MOST commonly associated with targeted therapy in lung adenocarcinoma?
Which of the following chest X-ray findings is MOST suggestive of a pleural effusion?
Which of the following chest X-ray findings is MOST suggestive of a pleural effusion?
In the interpretation of pulmonary function tests, what is the BEST indicator for differentiating between obstructive and restrictive lung disease patterns?
In the interpretation of pulmonary function tests, what is the BEST indicator for differentiating between obstructive and restrictive lung disease patterns?
Which of the following is a known complication of COPD that can lead to right-sided heart failure?
Which of the following is a known complication of COPD that can lead to right-sided heart failure?
Mr. Smith's case highlights the progression from COPD to lung cancer and subsequent pneumonia. Which of the following statements BEST describes the interrelationship between these conditions?
Mr. Smith's case highlights the progression from COPD to lung cancer and subsequent pneumonia. Which of the following statements BEST describes the interrelationship between these conditions?
In the context of communication skills for managing COPD patients, which of the following approaches is MOST effective in promoting smoking cessation?
In the context of communication skills for managing COPD patients, which of the following approaches is MOST effective in promoting smoking cessation?
Considering the ethical principles of patient care, particularly in the context of advanced lung cancer, which of the following approaches is MOST aligned with patient autonomy and shared decision-making?
Considering the ethical principles of patient care, particularly in the context of advanced lung cancer, which of the following approaches is MOST aligned with patient autonomy and shared decision-making?
Mr. Smith, a 72-year-old with COPD (GOLD D), is prescribed a LABA/LAMA inhaler. Three months later, he returns for a follow-up. Which clinical indicator would MOST strongly suggest that his current dual bronchodilator therapy is optimally managing his COPD symptoms, according to GOLD guidelines?
Mr. Smith, a 72-year-old with COPD (GOLD D), is prescribed a LABA/LAMA inhaler. Three months later, he returns for a follow-up. Which clinical indicator would MOST strongly suggest that his current dual bronchodilator therapy is optimally managing his COPD symptoms, according to GOLD guidelines?
Two years post-COPD diagnosis and LABA/LAMA initiation, Mr. Smith presents with haemoptysis, weight loss and new chest pain. A chest X-ray reveals a pleural effusion. Pleural fluid analysis is MOST critical to differentiate between which pair of aetiologies in this clinical context?
Two years post-COPD diagnosis and LABA/LAMA initiation, Mr. Smith presents with haemoptysis, weight loss and new chest pain. A chest X-ray reveals a pleural effusion. Pleural fluid analysis is MOST critical to differentiate between which pair of aetiologies in this clinical context?
Mr. Smith's lung mass is staged as T2N2M0 non-small cell lung cancer. Considering the TNM staging system and its prognostic implications, which statement BEST reflects the clinical significance of the 'N2' designation in his staging?
Mr. Smith's lung mass is staged as T2N2M0 non-small cell lung cancer. Considering the TNM staging system and its prognostic implications, which statement BEST reflects the clinical significance of the 'N2' designation in his staging?
Mr. Smith, with COPD and lung cancer (T2N2M0), develops community-acquired pneumonia and is treated with IV Co-amoxiclav and oral Clarithromycin. Despite antibiotic therapy, 72 hours later, he remains febrile and dyspneic. Which of the following clinical findings would be the MOST concerning and warrant immediate escalation of care beyond current management?
Mr. Smith, with COPD and lung cancer (T2N2M0), develops community-acquired pneumonia and is treated with IV Co-amoxiclav and oral Clarithromycin. Despite antibiotic therapy, 72 hours later, he remains febrile and dyspneic. Which of the following clinical findings would be the MOST concerning and warrant immediate escalation of care beyond current management?
In the context of Mr. Smith's COPD management, long-term oxygen therapy (LTOT) is being considered. Which of the following arterial blood gas (ABG) results would be the PRIMARY criterion for initiating LTOT according to established guidelines for COPD patients?
In the context of Mr. Smith's COPD management, long-term oxygen therapy (LTOT) is being considered. Which of the following arterial blood gas (ABG) results would be the PRIMARY criterion for initiating LTOT according to established guidelines for COPD patients?
Flashcards
What is COPD?
What is COPD?
Progressive airflow limitation that is not fully reversible.
First Step To Explain COPD
First Step To Explain COPD
Review ALO's for the topic from Year 1.
Second Step To Explain COPD
Second Step To Explain COPD
Explain the principles of diagnosis in patients with a suspected diagnosis of COPD/ Lung Cancer/Pneumonia.
Fourth Step To Explain COPD
Fourth Step To Explain COPD
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First Step To Explain Lung Cancer
First Step To Explain Lung Cancer
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Second Step To Explain Lung Cancer
Second Step To Explain Lung Cancer
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Fourth Step To Explain Lung Cancer
Fourth Step To Explain Lung Cancer
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First Step To Explain Pneumonia
First Step To Explain Pneumonia
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Second Step To Explain Pneumonia
Second Step To Explain Pneumonia
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Fourth Step To Explain Pneumonia
Fourth Step To Explain Pneumonia
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History of Presenting Complaint
History of Presenting Complaint
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Respiratory Symptoms
Respiratory Symptoms
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Hypertension
Hypertension
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Hyperlipidaemia
Hyperlipidaemia
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Gout
Gout
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Cataracts
Cataracts
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Medications
Medications
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Previous Admission
Previous Admission
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Social History
Social History
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Travel and Vaccination History
Travel and Vaccination History
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Differential Diagnosis
Differential Diagnosis
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General inspection
General inspection
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Closer inspection
Closer inspection
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ABG Meaning
ABG Meaning
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Obstructive
Obstructive
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COPD Management Principles
COPD Management Principles
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COPD
COPD
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Complications of COPD
Complications of COPD
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Communication Skills
Communication Skills
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Lung Cancer Risk Factors
Lung Cancer Risk Factors
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Lung Cancer Risk Factors
Lung Cancer Risk Factors
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Lung Cancer Risk Factors
Lung Cancer Risk Factors
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What is the purpose of US insertion?
What is the purpose of US insertion?
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Light's Criteria
Light's Criteria
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Exudative Causes
Exudative Causes
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Transudative Causes
Transudative Causes
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Surgical Resection
Surgical Resection
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Cancer Treatments
Cancer Treatments
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Small-cell Lung Cancer Staging
Small-cell Lung Cancer Staging
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Surgery
Surgery
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What is an altenative treatment to patient instead commence on?
What is an altenative treatment to patient instead commence on?
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CURB 65 Score
CURB 65 Score
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Mr. Smith is managed by
Mr. Smith is managed by
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Mr. Smith is managed by
Mr. Smith is managed by
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Mr. Smith's treatment for Pneumonia
Mr. Smith's treatment for Pneumonia
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Study Notes
- This lecture covers COPD, lung cancer, and pneumonia for Year 3 THEPII students.
Learning Outcomes
- Review ALOs from Year 1
- Explain COPD/Lung Cancer/Pneumonia management principles
- Explain diagnosis principles for patients with suspected COPD/Lung Cancer/Pneumonia
- Outline management steps, including pharmacological agents
- Choose appropriate investigations for COPD/Lung Cancer/Pneumonia diagnosis
Patient Medical History
- Mr. Smith, 72, was referred to a respiratory outpatient clinic.
- He had a 6-month history of worsening shortness of breath and productive cough.
- He reported increasing breathlessness in the last 8 weeks, limiting activity.
History of Presenting Complaint
- Shortness of breath for 6 months
- Gradual onset
- Progressively worsening
- Brought on by exertion
- Takes ~5 minutes to recover breath after exertion
- Cough for the last year
- Productive of white sputum
- Present every day
- Worse in the morning
- Wheezing is present
Respiratory History
- No coughing up blood
- No recurrent chest infections
- Symptoms not worse at any particular time
Cardiac History
- No leg/ankle swelling
- No nocturnal breathlessness when lying flat
- Uses one pillow while sleeping
- No chest pain
Constitutional History
- No fevers
- Stable weight
- No night sweats
Past Medical History
- Hypertension diagnosed 15 years ago.
- Hyperlipidaemia diagnosed 8 years ago.
- Gout diagnosed 3 years ago.
- Cataracts diagnosed 2 years ago.
Medications
- Amlodipine 10mg PO OD (once daily)
- Rosuvastatin 20mg PO OD
- Allopurinol 100mg PO OD
Past Surgical History
- Cholecystectomy (gallstone removal) 4 years prior
Previous Admissions
- Elective admission for cholecystectomy
Family History
- Father died of throat cancer at 68
- Mother died of stroke at 81
- Younger sister in good health
Social History
- Lives with wife
- Two-story house
- Retired barman
- Current smoker with a 40-pack-year history
- Drinks 20 units of alcohol per week
Differential Diagnosis Considerations
- COPD
- Congestive heart failure
- Bronchiectasis
- Lung cancer
- Alpha 1 antitrypsin deficiency
- Asthma
Physical Examination Details
-
Exposure: Entire chest must be exposed
-
Position: 45° supine
-
Observe for: Alertness, accessory respiratory muscle use, distress, colour, and devices.
-
Vitals: Blood pressure, heart rate, oxygen saturation, temperature, weight, and BMI.
-
Closer Inspection should involve:
- Palmar erythema
- Clubbing
- Peripheral cyanosis
- Tar staining
- First web space wasting
-
Wrist Exam: Assess asterixis, radial artery rate & rhythm and respiratory rate
-
Arms Exam: Check blood pressure and Pemberton's sign
-
Eyes Exam: Check conjunctival pallor and Horner's syndrome
-
Mouth Exam: Assess peripheral and central cyanosis and oral candidiasis
-
Neck Exam: Palpate cervical lymph nodes, assess JVP, check for tracheal deviation and tug
-
Chest Exam:
- Inspection: Scars, chest wall deformities, and symmetrical wall movement.
- Palpation: Chest expansion and tactile fremitus.
- Percussion
- Auscultation: Crepitations (inspiratory vs. expiratory) and wheezing
Physical Examination Findings For Mr. Smith
- BP 126/82, HR 74 bpm, RR 24, SpO2 88% on room air, Temp. 36.2
- Alert but dyspneic, using accessory respiratory muscles
- No pallor or ptosis
- No lymphadenopathy, raised JVP, or tracheal deviation
- Reduced symmetrical chest expansion
- Normal tactile fremitus
- No change in percussion
- Reduced air entry bilaterally
- Bibasal expiratory wheeze, no crepitations
- Normal vocal resonance
- No lower limb oedema
Full Blood Count Results
- Haemoglobin: 15.2 g/dL (Male range: 13.5-18.0 g/dL, Female range: 11.5-16.0 g/dL)
- Mean cell volume: 91 fL (82-100 fL)
- Platelets: 220 * 10^9/L (150-400 * 10^9/L)
- White blood cells: 6.2 * 10^9/L (4.0-11.0 * 10^9/L)
- Neutrophils: 4.9 * 10^9/L (2.0-7.0 * 10^9/L)
- Lymphocytes: 1.3 * 10^9/L (1.0-3.0 * 10^9/L)
LFT Results
- Bilirubin: 11 umol/L (3-17 umol/L)
- Alanine transferase (ALT): 24 iu/L (3-40 iu/L)
- Aspartate transaminase (AST): 29 iu/L (3-30 iu/L)
- Alkaline phosphatase (ALP): 67 umol/L (30-100 umol/L)
- Gamma glutamyl transferase (yGT): 10 u/L (8-60 u/L)
- Albumin: 39 g/L (32-40 g/L)
Urea and Electrolytes Results
- Sodium: 138 mmol/L (135-145 mmol/L)
- Potassium: 4.1 mmol/L (3.5-5.0 mmol/L)
- Urea: 5.7 mmol/L (2.0-7 mmol/L)
- Creatinine: 78 umol/L (55-120 umol/L)
Other Lab Results
- BNP: Normal
- Alpha 1 Antitrypsin Levels: Normal
- Immunoglobulins: Normal
Arterial Blood Gas
- pH: 7.36 (7.35-7.45)
- PCO2: 6.8 kPA (4.6-6 kPA)
- PO2: 9.1 kPA (10.6-14.6 kPA)
- HCO3: 34 mmol/L (23-31 mmol/L)
- Oxygen Saturation: 0.89 (0.95-1)
- Likely Compensated hypercapnic (or Type 2) respiratory failure
Diagnostics
- Chest X-Ray
- Pulmonary Function Testing
- FEV1: 1.26L (42% of predicted)
- FVC: 3.14L (80% of predicted)
- FEV1/FVC: 40
- DLCO: 20.25 (53% of predicted)
- Diagnosis of COPD is made
PFT Spirometry basics
- Obstructive:
- FEV1/FVC ratio<0.7
- TLC - normal / increased
- RV - normal / increased
- DLCO – reduced (emphysema) / normal (asthma, bronchitis)
- FVC - normal / increased
- FEV1 - reduced
- Restrictive
- FEV1/FVC >0.7
- TLC - reduced
- RV - reduced
- DLCO – reduced (parenchymal) / normal (chest wall deform, neuromuscular)
- FVC - reduced
- FEV1 - variable
- Mixed
- Variable TLC, RV, FVC, FEV1, FEV1/FVC, DLCO
COPD Classifications
- COPD is classified using the GOLD (Global Initiative for Chronic Obstructive Lung Disease) system, considering airflow limitation, symptoms, and exacerbation risk.
- GOLD 1: Mild
- GOLD 2: Moderate
- GOLD 3: Severe
- GOLD 4: Very Severe
mMRC Grading System and COPD assessment tool
- The mMRC (modified Medical Research Council) grading system assesses breathlessness severity.
- The CAT (COPD Assessment Test) is used to quantify the impact of COPD on a patient's life.
- Recognition of exacerbations is deemed important in clinical course, independent of symptoms.
- The clinical impact of exacerbations are categorized as C & D->E.
COPD Management Principles
- Pharmacological interventions (inhalers, oral medications)
- Pulmonary rehabilitation
- Smoking cessation
- Vaccinations
- Prophylactic antibiotics (if frequent infections)
- Long-term oxygen therapy (if criteria met)
Management Strategies for Mr. Smith
- COPD is classified as GOLD D per the GOLD classification (GOLD E).
- Commence long-acting beta agonist and long-acting muscarinic antagonist combination inhaler (LABA/LAMA- 1st line therapy if eosinophils <300cells/µl).
- Referral to smoking cessation nurse, with his consent.
- Referral to pulmonary rehab and physiotherapy.
- Schedule appropriate vaccinations (pneumococcal, influenza,, and Covid-19 booster).
Complications of COPD
- Non-Infective Exacerbations
- Infective Exacerbations
- Acute and/or Chronic Respiratory Failure
- Secondary Polycythemia
- Pulmonary Hypertension
- Cor Pulmonale
Communication and patient care skills
- Discuss the importance of quitting smoking and nicotine replacement therapy options to give patients support to quit smoking.
Subsequent Presentation of Mr. Smith(2 years later)
- Re-presents with one episode of frank haemoptysis.
- Increased dyspnoea ongoing for 6 weeks
- Reports unintentional weight loss of 8kg in the last 3 months
- Drenching night sweats
- Left sided chest pain
Physical Examination
- On general inspection patient appears cachectic
- BP 129/78 mmHg, HR 87 beats/min and regular, RR 24 breaths/min, oxygen saturation 91% on room air
- No elevation in JVP
- Chest expansion decreased, same as previous
- Dullness to percussion in the middle and lower zones of the left chest
Common risk factors for lung cancer
- Occupation (miners, heavy metal workers)
- Smoking/tobacco
- Second-hand smoke
- Family history
- Dietary factors
- Radon gas
- Ageing
- Other illnesses
- Pollution
- Exposure to radiation
Light's Criteria for Pleural Effusion
- This criteria helps to classify pleural fluid as either transudative or exudative
- Transudative:
- Protein (Pleural/Serum) ≤0.5
- LDH (Pleural/Serum) ≤0.6 OR Pleural LDH two-thirds upper limit of normal serum LDH
- Exudative:
- Protein (Pleural/Serum) >0.5
- LDH (Pleural/Serum) >0.6 OR Pleural LDH > two thirds upper limit of normal serum LDH
- Additional Tests on Pleural Fluid: Cell Count & Differential, Gram Stain & Culture, Cytology, Glucose, Amylase, pH
Transudative Causes
- Congestive Heart Failure (CCF)
- Nephrotic Syndrome
- Cirrhosis
Exudative Causes
- Malignancy
- Pneumonia
- Pulmonary Embolism (PE)
Lung Cancer Management Principles
- Discussion at Lung Cancer MDM:
- Respiratory Physician
- Thoracic Surgeon
- Medical Oncologist
- Radiation Oncologist
- Pathologist
- Radiologist
- Lung Cancer Clinical Nurse Specialist
- Surgical Resection
- Wedge resection, lobectomy, pneumonectomy
- Chemotherapy AND/OR
- Immunotherapy AND/OR
- Radiotherapy AND/OR
Lung Cancer Patient Management
-
Diagnosed with Non-Small Cell Lung Cancer
- A PET CT scan shows that the cancer has not spread beyond the thoracic cavity, however it is present in his mediastinal lymph nodes
- T2N2M0 staging, which equates to Stage III disease
-
His case is discussed at the lung cancer MDM
-
Due to his age and comorbidities he is not a candidate for surgery to excise the tumor
He is instead commenced on a chemoradiotherapy regime
Community Acquired Pneumonia
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A month into his treatment for lung cancer, Mr Smith is brought in by ambulance to the emergency department with a fever, cough productive of green sputum, and hypoxia
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On examination, he appears to be confused, does not know person, place, or time
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BP 102/70, HR 98bpm, RR 32, SpO2 82% on RA, Temp. 38.2
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Right middle zone coarse crepitations on auscultation
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Raised white cell count with neutrophilia, raised CRP, and an acute kidney injury with a urea of 12mmol/L in Bloods
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A chest x-ray shows a diffuse opacity in the right middle lobe
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A diagnosis of community acquired pneumonia is made
CURB-65 Pneumonia Severity Score
- Estimates mortality to guide antibiotic therapy.
- Confusion
- No = 0 , Yes = +1
- BUN >19 mg/dL (>7 mmol/L urea)
- No = 0, Yes = +1
- Respiratory Rate ≥30
- No = 0, Yes = +1
- Systolic BP 90 mmHg or Diastolic BP ≤60 mmHg
- No = 0, Yes = +1
- Age ≥65
- No = 0, Yes = +1
CURB-65 Scores
- 0 or 1: 1.5% mortality, outpatient care
- 2: 9.2% mortality, inpatient vs. observation admission
- 3: 22% mortality, inpatient admission vs consideration for ICU admission with score of 4 or 5
Mr. Smith is managed by...
Giving supplemental oxygen, nebulized salbutamol/ipratropium An IV cannula, and he is started on 1L 0.9% NaCl Prescribing IV hydrocortisone 100mg Starting antibiotics per hospital guidelines (IV Coamoxiclav, oral Clarithromycin) Commencing BiPAP to correct respiratory acidosis
DECAF Score For Acute COPD Exacerbation
- Used to Estimate mortality, in-hospital, in acute COPD exacerbation
- Low-risk DECAF Scores (0-1) associated with lower mortality; these may be candidates for early discharge
- High-risk (3-6) can be associated with high risk of death, early escalation, and higher level of monitoring vs palliative care should be considered
Choose most appropriate option to monitor for beneficial effects of Mr Smith's antibiotics in the first 3 days of treatment Respiratory rate, heart rate, temperature and review of sputum.
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