Academic Week 3 Flashcards
What are the important questions to ask about breathlessness in the HPC?
Duration, constant or intermittent, lifestyle effects and are there any exacerbating or relieving factors.
What are the causes of breathlessness?
These can be divided into chest wall problems and parenchymal disease.
Chest wall: Hyperventilation syndrome, hypothalamic lesions, neuromuscular disease, kyphoscoliosis, ankylosing spondylitis, pleural effusion and bilateral diaphragm paralysis.
Parenchymal disease: COPD, asthma, bronchiectasis, cystic fibrosis, pneumonia, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, tumours, sarcoidosis, pneumothorax, pulmonary oedema, PE and anaemia.
What does duration of breathlessness indicate?
Short: PE, asthma, pneumothorax or pulmonary oedema
Intermediate: Pulmonary oedema, pneumonia, asthma, pleural effusion or anaemia
Long: Chronic airflow obstruction, tumours, IPF or anaemia.
What is orthopnoea?
Breathlessness when lying flat but relieved by sitting upright. This is common in patients with severe fixed airway obstruction.
What is paroxysmal nocturnal dyspnoea?
The is a feature of pulmonary oedema from left ventricular failure. It is an attack of severe shortness of breath and coughing that wakens someone from sleep. They may go to the window or have many pillows.
Don’t mistake this for nocturnal asthma.
What does the colour of sputum indicate?
White or grey: Smoking, simple bronchitis and asthma
Yellow/Green: Acute bronchitis, chronic bronchitis, asthma, bronchiectasis or cystic fibrosis.
Frothy blood streaked sputum may indicate pulmonary oedema.
Describe the importance of haemoptysis
All haemoptysis is important but the most important differential is carcinoma of the bronchus. Repeated small haemoptysis every few days over a period of weeks is likely bronchial carcinoma.
What is stridor?
This is a harsh inspiratory and expiratory noise.
What drugs can exacerbate asthma?
Aspirin and other NSAIDs, Beta blockers and ACE inhibitors.
What are the pulmonary causes of clubbing?
Bronchial carcinoma, empyema, lung abscess, bronchiectasis, cystic fibrosis, asbestosis and some chronic pulmonary infections
What are the cardiac causes of clubbing?
Congenital cyanotic heart disease, tetralogy of fallot and bacterial endocarditis
What non pulmonary/cardiac causes of clubbing are there?
Idiopathic/familial, cirrhosis, ulcerative colitis, Crohn’s disease and coeliac disease.
Describe some of the features of severe exacerbations of asthma
Unable to complete sentences, tachycardia, tachypnoea and peak flow below 50% of predicted.
Life-Threatening asthma presents with silent chest, cyanosis, bradycardia, exhaustion, peak flow below 33% predicted and SATs below 92%.
What is the MRC (Medical Research Council) dyspnoea scale?
This describes the disability associated with breathlessness.
1 - Not troubled by breathlessness except on strenuous exercise
2 - Short of breath when walking fast on flat or walking up a slight incline
3 - Walks slower than most people on the level, stops after a mile or so or 15 minutes.
4 - Stops for breath after walking 100 yards or a few minutes on the flat
5 - Too breathless to leave the house or breathless when dressing
What does to NYHA score indicate? (New York Heart Association)
This is a score used to assess the severity of functional limitation in a patient with heart failure.
1 - Ordinary physical activity does not cause fatigue, breathlessness or palpitations (no limitation)
2 - Patients are comfortable at rest. Ordinary activity results in fatigue, palpitations, breathlessness, or chest pain. (Slight limitation)
3 - Although patients are comfortable at rest, less than ordinary activity will lead to symptoms (Marked limitation)
4 - Symptoms of congestive heart failure are present at rest and there is increased discomfort with any activity. (Severe limitation)
What are the important aspects of a fracture history?
Mechanism of injury, when, where and why.
Always check for locking, weakness, numbness and parenthesia.
Do they have conditions which predispose them to fractures such as Parkinson’s, Osteoporosis, alcoholism, diabetes, thyroid disease or epilepsy.
What drugs are important in an orthopaedic history?
Steroids, breast or prostate cancer treatments, anti-epiletics, progesterone only contraception and any drug which may cause falls.
Smoking, alcohol and recreational drugs will slow healing.
What system should be used to read an orthopaedic X-ray?
A - Adequacy, anatomy, alignment and asymmetry B - Bone density C - Cartilage D - Deformity E - Erosions S - Soft tissues
How should fractures be treated?
Emergency treatment is to work through the ATLS protocols. Pain control, assess NV status, soft tissues and wound status. If it is an open wound they will need the BAPRAS guidelines. Photograph, remove contaminants, clean with a sterile soaked gauze, relocate, splint, treat associated injuries and then radiograph.
How does non-inflammatory arthritis present?
This is mainly osteoarthritis and it presents with internal and periarticular derangements in the meniscus, ligaments, tendons and labrum. Neuropathic arthritis is seen in Charcot foot.
Osteoarthritis typically effects the hips, knees, neck and hands. There are symptoms of pain and stiffness which are worse on imitating movement and towards the end of the day. It will worsen with activity. Night pain is a bad sign and there is usually a history of gradual onset.
How does inflammatory arthritis present?
This is autoimmune including gout, psoriatic, reactive, ankylosing spondylitis or IBD associated. In rheumatoid there is obvious swelling and deformity of the finger joints.
Inflammatory osteoarthritis such as RA presents with significant early morning stiffness which improves with activity. There is often a symmetrical distribution and a history of an acute onset.
What are the red flag symptoms for arthritis?
Unremitting pain, systemic upset or a significant history of steroid use or cancer.
How does osteoarthritis present on X-ray?
Reduced joint space, asymmetrical, osteophytes, joint line sclerosis and subchondral cysts.
How should osteoarthritis be treated?
Pharmacology should only be offered if lifestyle changes have failed.
Paracetamol and then NSAIDs should be offered as first line. Topical diclofenac and intra-articular joint infections are more specific treatments. Oral steroids should NOT be given.
Surgical options include debridement, osteotomy, arthroplasty (joint replacement) and arthrodesis.
What is the recommended daily intake of sodium and water?
70-100mmol of sodium and 1.5-2.5 litres of water are recommended.
Normal serum osmolarity is 280+/- 15mmol/kg
Why is water and sodium retention common in acute illness?
The increased physiological stress causes increased ADH secretion and activation of the RAAS system.
The renal function is impaired because there is raised urea, AKI causing reduced GFR, hypokalaemia and increased capillary permeability which causes albumin to leak.
What is a crystalloid IV fluid?
Crystalloid solutions are low molecular weight, dissolve completely in water, pass freely between intravascular and interstitial space and carry a risk of interstitial oedema.
Examples include dextrose and plasmalyte.
What is a colloid IV fluid?
These solutions have a large molecular weight, do not completely dissolve in water, do not pass freely between intravascular and interstitial compartments and have a significant amount of sodium and chloride. These remain in the intravascular space for a long time.
Examples include Gelatine, albumin and gelofusine.
What are the dangers of IV fluids?
The water and sodium excess can cause AKI. Excess chloride also causes renal vasoconstriction which can progress to UTI and cause acute illness.
Normal saline has dangers including hyperchloraemic acidosis, AKI, oedema, reduced gastric blood flow, increased blood loss from wounds and prolonged postoperative recovery.
