1. History and Examination Flashcards
What resp disease can cause persitent fever with night sweats and weight loss
Chronic TB and ca eg. lymphoma
Causes of instantaneous breathlessness
pneumothorax, PE, pulm oedema+ paroxysmal noctural dyspnoea, ?AMI
Causes of breathlessness, seconds to mins
Asthma, aspiration, anaphylaxis and psychogenic
Causes of breathlessness, minutes to hours
Acute bleeding, met acidosis
Causes of breathlessness, hours to days
Pneumonia, COPD exacerbation, LVF
Causes of breathlessness, days to weeks
Pleural effusion, bronchiectasis, CCF
Causes of breathlessness, weeks to months
PF, lung ca, TB, CCF
Causes of breathlessness, months to years
Diffuse parenchymal lung disease, COPD, CCF
Risk factors for PE include
Prolonged immobilsation, hormonal treatment, recent hospitalisatioon
COPD examination findings
Hyper-inflated chest ( due to loss of lung elasticitydue to loss of alveolar walls)
Reduced CS distance
Reduced cardiac and hepatic dullness, increased resonance
Quiet breath sounds, prolonged expiratory phase and polyphonic wheeze
Pneumonia examination findings
Decreased expansion on side of pneumonia
Dull on percussion
Increased breath sounds, bronchial, increased vocal resonance, whispering pectroriloquy
Lobe collapse examination finding
Reduced expansion on side of collapse
Trachea displaced to side of collapse
Dull on percussion
Absent or reduced breath sounds
Pneumothorax examination findings
Reduced expansion on side of pneumoT
Trachea pushed away to other side ( not tension)
Tracheal deviation to sign of pneumothroax and mediastinal shift ( tension)
Resonant
Absent/ reduced breath sounds
Pleural effusion examination findings
Reduced expansion on side of pleural effusion
Trachea pushed away
STONY dull
Reduced vocal resonance and breath sounds
ILD examination findings
Expansion normal
Vesicular breath sounds with fine late inspiratory crackles
Dull percussion in left midzone with bronchial breath sounds, enhanced vocal resonance and whispering pectiloquy, with possible rub
Large volume of sputum may suggest?
Bronchiectasis
What does mucopurulent sputum suggest
Bacterial infection
What does mucoid sputum suggest
Chronic bronchitis or asthma
What does cough commonly suggest
Asthma, chronic bronchitis, bronchial carcinoma, bronchiectasis,
Is asthmatic cough dry or productive?
Usually dry, and at night or early morning
Define cough in chronic bronchitis
Productive cough for most days during at least 3 consecutive months for at least 2 successive years
Usually in winter - repeated chest infections
Usually sleep undisturbed
Define cough in bronchiectasis
Loose cough productive of large volumes of sputum, may be precipitated by changes in posture, repeated chest infections
Define cough in bronchial carcinoma
Usually persistent and may be blood stained, may have hoarse voice + bovine cough
Causes of haemoptysis
- May be first Px of malignancy, presents during infection and can be intermittent or persistent
- Infarction - often assoc with pleuritic chest pain, bright at first then becomes dark
- Infection - especially in TB, may be seen in bronchiectasis
Cuase of polyphonoic vs monophonic wheeze
Asthma and bronchitis vs fixed lesion like carcinoma
What is one sign of CO2 retention in COPD pts
Morning headaches
What does loss of contour on CXR mean
Increased density in structure in contact with heart, diaphragm etc.
What can elevated hemidiaphragm suggest
Volume loss of the lung ( tumour, collapse or atelectasis), or pressure from below ( bowel dilatation, mass, abscess)
What is common sign in pleural effusion
Meniscus sign
Sign of penumothorax
Loss of lung markings
What does enlargerd hilum mean
Lung ca /sarcoidosis (hilar LN)/ pulm hypertension (Pulm art)
COPD CXR
Large lung fields with hyperlucency, flattened diaphragms and narrow mediastinum
Emphysema - May have reduced lung markings, esp in upper zones
What is the characteristic feature of bronchiectasis CT
Signet ring apperance
CXR of ILD
Generally increased interstitial marking, reduced lung volumes
Key feature of IPF is honeycomb lungs
May also have groundglass appearance
CXR of pneumonia
Airspace shadowing ( due to pus), air bronchogram, may have blunted CPA and loss of heart border
USUALLY only on one side
May have small meniscus suggesting effusion
Lobar pneumonia CXR
Will have discrepancy between consolidated and non consolidated lung
Main sign in pneumothorax CXR
Absence of lung markings
What may cause a pneumothorax and how are these seen on CT
May seen apical bleb that has burst
Test for lung cancer
EBUS
How should peak flow be carried out.
Make 3 attempts and write the highest value
How does airflow obstruction affect spirometry
Lower FEV1 and VC, takes longer to reach VC also - air comes out more slowly
Disprop reduction in FEV1 compared to VC
Flow volume loop shows very low maxiumum flows in mid and late ex due to small airways collapse ( well preserved early flow but airways eventually become narrower)
But inspiration doesn’t take that much effort
How does emphysema affect airflow
Destruction of alveolar walls leaves airway supported and collapsible
Lung volume 50 or 100% higher than pts without airflow obstruction
How does PF affect lung volume
Collagen scarring of lung parenchyma causes stiffening and shrinkage of the lungs, with loss of lung volume
Tissue at lung bases replaced by fibrous tissue and progressively moves up to midzone. Stiffening occures as fibrous tissue is layered down, restricting lung expansion
How to measure lung volume
Helium dilution- measure degree of dilution at equilibrium after 10 mins rebreathing
Plethysmography- breath air from box with mouthpiece closed off, increased in lung volume increases pressure in box, so smaller lung volume will result in lower increase in box pressure
Obstructive disease:
Lung Volume
IC
VC
RV
Increased volume, reduced IC and VC, high RV
How to measure pulmonary gas exchange, what is measured
Gas transfer test, measures Tco and Kco ( corrected per lung volume)
What reduces Kco
Emphysema, anaemia, severe fibrosis ( V/Q mismatch)
How does CO2 affect oxygenation through airways
CO2 dilates airway, so failure of lobar blood supply results in airway in that lobe constricting
How does lobar hypoxia affect arterioles
Constricts pulm arterioles and reduces blood supply to that lobe
What causes reduced Q
Reduced Q- parenchymal lung disease- infxn, inflmtn, process leading to fibrosis
What causes reduced V
Tumour, lobar pneumonia, pneumothorax, asthma
Why is CO2 usually not raised with Hypoxia * TIRF
CO2 mostly carried as bicardb with high capacity for transport, increased ventilation in normal areas can shift more co2 out
O2 is insolube and must be carried by Hb, saturated Hb can’t compensate
Causes of TIRF
V/Q mismatch
Mild to mod asthma, pulm oedem, lobar pneum, pneumoT, tumour in main bronchus, IPF
What does TIIRF suggest about V and lung tissues
Insuff lung vent overall
If pulm, means generalised severe airflow obst or V/Q mismatch andnot enough normal lung regions to correct CO2. Eg. Severe airway obstruction (COPD/ Asthma)
If extpul means globally impaired alv ventilation eg. opiates, head injury, neuropathy or myopathy (Eg. MND) , kyphoscoliosis ,
How does restrictice lung disease affect flow volume loop
It gets smaller, peak may get higher ( more squashed) as disease gets worse
What does high FeNO suggest
High prob of asthma
If FENO and Spirotmetry done but results still unclear, what should be done
Direct challenge tes, can use metacholine
Is there resp compensation for metabolic alkalosis
No
Main cause of resp acidosis
Hypoventilation
Causes of metabolic acidosis
DKA, lactic acidosis ( acid overproduction)
Renal failure ( decreased elimination)
Increased acid ingestion (drug overdose)
Bicarb loss ( diarrhoea)
Causes of resp alkalosis include
Hyperventilation
Raised ICP
Over-ventilation in ITU
Main causes of metabolic alkalosis are
Excessive vomitting, diuretic therapy, hypokalemia, bicarb ingestion
When to give NIV (BIPAP) in COPD
If progressively acidotic, heading towards decompensated TIIRF, higher risk of mortality
What do millary nodules in the lungs suggest and what else may be seen
TB, cavitation observed
Which zone are lung lesions more common in
Middle/ Lower Zone
Which zones do CMP and sillicosis affect more
Middle/ upper zones
Which zone is affected in Sarcoidosis
UZ nodules
What does airbronchogram suggest
INFXN
haematological cause of breathlessness
Anaemia
Causes of pulmonary hypertension
Narrowed, thickened or damaged pulmonary arteries or left heart disease reducing right heart flow
Sx and signs of pulm hypertension
SOB, weakness, fatigue, chest pain, syncope, haemoptysis,
May have ascites, elevated JVP, hepatomegaly, peripheral oedema, parasternal heave, TR/PR
Ix for pulmonary hypertension
Echocardiogram initial ix, ECG may show right vent strain
Mx for pulm hyperT
Treat underlying causes- duuretics if decompensated RHF
LTOT, Digoxin to improve cardiac output
Which type of heart fialure is pulm hypertension linked to
RHF
Causes of pulm hypertension
CTD, VTE, damage to pulm arteries lung or heart disease ,
Risk factors for pulm hyperT
Apart from above causes, obesity, sleep apnoea, bbeing female, family hx for PAH
