Asthma and Dyspnea, Pleural Effusion, Pneumothorax, Hydrocephalus Flashcards
Asthma is a global disease currently affecting over 300 million individuals worldwide
•Annually there are an estimated 250,000 deaths from asthma, many of which may be preventable
•Asthma is a burden on patients’ lives and the healthcare system
•It is important to assess asthma control to prevent exacerbations
•With the right treatment approach, asthma care can be improved
True or false
True
What is asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.
Diagnosis of asthma is based on?
•The diagnosis of asthma should be based on:
●A history of characteristic symptom patterns
●Evidence of variable airflow limitation, from bronchodilator reversibility testing or other tests
•
Document evidence for the diagnosis in the patient’s notes, preferably before starting controller treatment
●It is often more difficult to confirm the diagnosis after treatment has been started cuz after treatment had started the person will be looking fine as if nothing happened
Asthma is usually characterized by?
Airway inflammation is chronic
•Asthma exacerbations are episodic true or false
Difference between COPd and asthma
Name six features of asthma
Asthma is usually characterized by airway inflammation and airway hyperresponsiveness, but these may not be necessary or sufficient to make the diagnosis of asthma.
•Usually show variability
•
True
Asthma - reversible airway obstruction (unlike COPD which is not reversible
Asthma is a variable disease – –severity varies from day to day, –differences between morning and evening –Seasonal variation in some –Can change in an individual over time –Recurrent –Reversible - symptoms resolve spontaneously or with medication
What is the pathophysiology of asthma
Asthma is a chronic inflammatory disease of medium and small airways. This manifests as:
•Mucosal oedema, epithelial shedding, bronchial inflammation, - Bronchial hyperresponsiveness, bronchoconstriction.
•Mucous gland hypertrophy, mucous hypersecretion.
•Airway Remodelling - Smooth muscle hypertrophy, basement membrane thickening, and fibrosis
Smooth muscle dysfunction causes bronchial hyper reactivity,bronchoconstriction(caused by mucosal edema),hyperplasia (causing cell proliferation and epithelial damage),inflammatory mediators release
Airway inflammation remodeling causes inflammatory cell activation,mucosal edema,cell proliferation and epithelial damage,basement membrane thickening
Name ten factors influence asthma development and expression
And name six factors that worsen asthma
Host Factors
●Genetic
- Atopy
●Gender
●Obesity
Environmental Factors ● Indoor allergens • Outdoor allergens • Occupational sensitizers • Tobacco smoke • Air Pollution • Respiratory Infections • Diet • Excercise
Allergens – HDM, cockroach, pets, pollen, •Respiratory infections •Exercise •Hyperventilation •Emotions •Weather changes •Air pollutants eg. Sulfur dioxide •Food, additives, drugs
What history will an asthmatic patient present w
Name three associated disorders
Can be diagnosed on the basis of symptoms
•Symptoms - Recurrent
•Wakes the patient up at night, worse at night – due to diurnal variation of cortisol production
•Reversible - Relieved by bronchodilator use
•Associated disorders – nasal polyps, rhinosinusitis, Aspirin allergy
What is seen in the family history of atopy
What trigger factors can be talked about by the patient
What can be seen in the past medical history,social history, drug history
Family history of Asthma •FH Allergic rhinitis and associated sinus disease - Rhinosinusitis •Allergic / vernal conjunctivitis •Eczema •Aspirin/NSAID allergy
Trigger factors –
house dust mite(dust)
exercise, strong scents, smoke, pollen(seasonal)
Respiratory infections(URTI - viral)
change in weather, strong emotion
animal fur - pets
foods, drugs –aspirin, NSAIDS, beta blockers
Other PMH – Hypertension, diabetes, sickle cell disease, TB
•Social HX – Occupation, Smoking, Pets
•Drug HX – beta-blockers(incl. eye drops for glaucoma), Aspirin/NSAIDS
State five signs and five symptoms of asthma
SIGNS •Often none – in between attacks •Barrel chest - Hyperinflated lungs •Tachpnoea, accessory muscles(neck, abdomen), sit upright •Tachycardia, BP – may go up •Hyperresonance •Reduced BS – silent chest if severe •Rhonchi (diffuse, variable, exp +/- insp
How is asthma diagnosed using variable airflow limitation
Confirm presence of airflow limitation
●Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
●FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children
•Confirm variation in lung function is greater than in healthy individuals
●The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma
●Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted)
●Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)
●Significant increase in FEV1 or PEF after 4 weeks of controller treatment
●If initial testing is negative:
•Repeat when patient is symptomatic, or after withholding bronchodilators
•Refer for additional tests (especially children ≤5 years, or the elderly)
No single definitive test to make a diagnosis of asthma
•Diagnosis is therefore made based on a combination of features
True or false
Name six investigations for asthma
True
FBC, eosinophils, ESR
•Stool RE – exclude helminthiasis
•Skin prick tests – shows atopy
•Specific Ig E – eg. to HDM, grass pollen, cockroach antigen - interpretation similar to skin prick test
•CXR(chest X ray) to exclude differential diagnosis, complications
Name five differentials for asthma
And three complications of asthma
Wheezing is also found in other conditions, for example:
●Respiratory infections
●COPD
●Upper airway dysfunction
●Endobronchial obstruction
●Inhaled foreign body
•Wheezing may be absent during severe asthma exacerbations (‘silent chest’)
Pneumothorax
•Sub-cutaneous emphysema
•Respiratory failure
How is asthma managed
Education
•Allergen avoidance
•Preventer/controller medication
•Reliever medication
•Regular follow-up – guided self management plan
•Rarely Immunotherapy – if single antigen trigger
How is clinical control of asthma defined
No (or minimal)* daytime symptoms ● No limitations of activity ● No nocturnal symptoms ● No (or minimal) need for rescue medication ● Normal lung function (FEV1, PEFR) ● No exacerbations \_\_\_\_\_\_\_\_\_ * Minimal = twice or less per week
What are the levels of asthma control and state the characteristics of each
a.Controlled (All of the following) b.Partly Controlled (Any measure present in any week) c.Uncontrolled
Characteristics:
- Daytime symptoms
a. None (twice or less/week)
b. More than twice/week
c. Three or more features of partly controlled asthma present in any week - Limitations of activities
c. None
b. Any
c.Three or more features of partly controlled asthma present in any week
Nocturnal symptoms/awakening
a. None
b. Any
c.Three or more features of partly controlled asthma present in any week
- Need for reliever/ rescue treatment
a. None (twice or less/week)
b. More than twice/week
c.Three or more features of partly controlled asthma present in any week
- Lung function (PEF or FEV1)
a. Normal >80%
b. < 80% predicted or personal best (if known)
c.Three or more features of partly controlled asthma present in any week
- Exacerbations
a. None
b. One or more/year*
c. One in any week†
What is the GINA assessment of symptom control
A.Symptom control
In the past 4 weeks, has the patient had: Well-controlled Partly controlled Uncontrolled •Daytime asthma symptoms more than twice a week? Yes No None of these(well controlled) 1-2 of these(Partly controlled) 3-4 of these(Uncontrolled) •Any night waking due to asthma? Yes No •Reliever needed for symptoms* more than twice a week? Yes No •Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
•Assess risk factors at diagnosis and periodically
•Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
•Exacerbations
•Fixed airflow limitation
•Medication side-effects
In the Assessment of risk factors for poor asthma outcomes risk factors for exacerbation includes, Risk factors for fixed airflow limitation include?, Risk factors for medication side-effects include?
Ever intubated for asthma
•Uncontrolled asthma symptoms
•Having ≥1 exacerbation in last 12 months
•Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter)
•Incorrect inhaler technique and/or poor adherence
•Smoking
•Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
•No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
•Frequent oral steroids, high dose/potent ICS, P450 inhibitors
PEFR/FEV1
•Mild – >80% of best, or predicted
•Moderate – 60-80%
•Severe – <60% true or false
True
What ar ethe types of asthma medications
Rescue medication/ relievers – are bronchodilators
•Beta 2 agonists eg salbutamol, terbutaline
•Anticholinergic drugs eg. ipratropium bromide
•Theophylline, aminophylline
•Inhaled preferred to oral
•Nebulized, IV for acute severe attack
Which medication are preventer or controller medicines
Which of the drugs are never used alone
Inhaled corticosteroids (ICS) eg. fluticasone, beclomethasone, budesonide
•Systemic corticosteroids eg. Oral prednisolone, IV hydrocortisone
•Long acting beta agonist (LABA)in combination with ICS - never used alone
- 12 hour bronchodilatory effect synergistic with steroid action
eg. salmeterol + fluticasone, formeterol + budesonide
•Leukotriene antagonists eg. Montelukast, zafirlukast
How to glucocorticoids and LABA work
LABA + ICS
•Complementary effects of Glucocorticoids and LABA
- glucocorticoids upregulate beta receptor recognition by beta agonist
- LABA improve uptake of glucocorticoid (steroid) into the cell nucleus
What’s r ethe side effects of the treatments
Side Effects •Salbutamol •Aminophylline •Prednisolone •Anticholinergics •LABA – salmeterol, formoterol •LTA – montelukast, zafirlukast
Which clinical outcomes ate measured in the follow up assessment
Follow-up Assessment •Clinical outcomes measured are: •change in FEV1 or PEFR (morning, evening) •daytime/nighttime symptoms •symptom-free days •frequency of use of rescue medication •limitation of normal activities •exacerbations - frequency of exacerbations
What is the asthma control test
The ACT questionnaire asks patients to report, for the previous 4 weeks, on:1 –Limitations to activities –Shortness of breath –Night-time awakening –Use of rescue medication –Perception of control
What are the signs of acute severe asthma
What are the signs of imminent respiratory arrest
Signs of severe attack:
y Inability to complete full sentences in one breath
y Rapid pulse > 110/minute in adults and adolescents or >130/
minute in children 2-5 years
y Rapid respiration > 30/minute in adults and adolescents or or >
50/minute in children 2-5 years
y Peak Expiratory Flow Rate (PEFR) is reduced < 50% of expected
(for age, sex and height)
Speech- incomplete sentences •Sensorium – agitation, confusion, restlessness •RR > 30 / min •Pulse rate >110/ min •(pulsus paradoxus) •PEFR <50% y Signs of a life-threatening attack are: y Cyanosis y Pulsus paradoxus y Silent chest on auscultation y Drowsiness or confusion y Exhaustion y Peak Expiratory Flow Rate (PEFR) less than 33 % of expected value y SpO2 less than 92% on room air
~~~
Imminent resp arrest
•Cyanosis, Coma
•Poor respiratory effort
•Silent chest
•Bradycardia – late
•PEFR < 33%
•Hypoxaemia O2 sat<90%, PaO2<60mmHg(8kPa), PaCO2>45mmHg(6kPa), pH falls mechanical ventilation
What is the criteria for severe asthma and life threatening asthma
Severe asthma PEFR <50%
–Can’t complete sentences
–RR > 30/min
–Pulse > 110/min
•Life threatening asthma PEFR <33%
–Silent chest,cyanosis, feeble respiratory effort
–Exhaustion, confusion, coma
–Bradycardia, hypotension
How is acute severe asthma
Managed. And if there are signs of life threatening attack
Acute severe asthma,maintenance –2-4 hrly neb salbutamol –(4-6 hrly neb ipratropium 24hrs) –6hrly hydrocortisone 24hrs –30-40mg prednisolone mane daily –Aminophylline infusion 24-48hrs
Check O2 sat - if signs of life threatening attack
–Pulse oximetry <92%
–ABGs PaO2 <8kPa, low pH – repeat within 2hrs
–ICU – prepare for intubation and ventilation if deteriorating symptoms PaO2 fails to improve or PaCO2 starts to rise
What is the function of the respiratory system
Anatomy of the respiratory system
What are the natural defenses of the respiratory system
Function
–takes up oxygen and expels carbon dioxide.
–conveys air from the mouth and nose to the lungs
•Anatomy - divided into upper and lower respiratory tracts.
- The natural defenses of the respiratory system
- Control of breathing, central, peripheral
- Variations in breathing, during exercise, sleep
Define difficulty in breathing
State four other things dyspnea (difficulty breathing)can be mistaken for
An awareness of the effort of breathing (dyspnoea) – usually but not necessarily an increase in rate
Discomfort in breathing
•‘SHORTNESS OF BREATH’, ‘CHEST TIGHTNESS’
•‘AIR HUNGER’, ‘CAN’T CATCH MY BREATH’
Palpitations
•Chest pain or discomfort
•Tiredness/fatigue on exertion
Dyspnea is Commonly called shortness of breath
•Dyspnea is often difficult or labored breathing
True or false
True
Name some ways of assessing or grading dyspnea
Explain the NYHA classification
NYHA classification
•1 – not dyspnoeic (on normal activity)
•2 – on moderate exertion, (eg. climbing a flight of stairs) comfortable at rest.
•3 – on mild (minimal) exertion eg. on having a bath, on talking, moving from room to room,
•4 – Dyspnoeic at rest
Medical Research Council dyspnoea scale
Modified Borg dyspnoea scale
Subjective measurement of breathlessness
-Exercise tolerance – the distance a patient can walk before having to stop to rest
•Functional status
Explain the MrC (medical research council)dyspnoea scale
Grade Degree of breathlessness related to activities
•1 Not troubled by breathlessness except on strenuous exercise
•2 Short of breath when hurrying or walking up a slight hill
•3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
•4 Stops for breath after walking about 100m or after a few minutes on level ground
•5 Too breathless to leave the house, or breathless when dressing or undressing
What is mMRC
mMRC - a questionnaire that consists of five statements about perceived breathlessness
Explain the subjective measure f breathlessness
the visual analogue scale (VAS), a horizontal line with two anchor points, one at each extreme, and
•the Borg scale of perceived exertion which has been modified for breathlessness measurement – modified Borg dyspnoea scale
What is the Modified Borg dyspnoea scale
When are the Borg scored measured
What does a score of zero and a score of ten mean
Use of the scale
Measures patient’s perception of dyspnoea
•Borg scores for perceived breathlessness are measured before and after a test (eg. shuttle walking test) or treatment
•On a scale of 1 – 10, with a score of zero being no breathlessness at all and a score of 10 being maximal breathlessness.
•Good for comparison at review, after treatment, or follow-up to determine trend
What is the scale for the Borg rating scale of perceived dyspnea
Modified Borg Rating Scale for Perceived Dyspnea
•0 Nothing at all
•0.5 Very, very slight shortness of breath
•1 Very mild shortness of breath
•2 Mild shortness of breath
•3 Moderate shortness of breath or breathing difficulty
•4 Somewhat severe
•5 Strong or hard breathing
•6-7 Severe shortness of breath or very hard breathing
•8-9 Extremely severe
•10 Shortness of breath so severe you need to stop
What is functional status
Chronic dyspnoea affects functional status which affects quality of lifetrue or false
Functional status is an individual’s ability to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-at being, Graded 1-4
True
Which body systems can cause dyspnea
Cardiovascular system (CVS) - heart •Respiratory – lungs and breathing mechanism •Abdomen •Central nervous system (CNS) – centres in the brain and periphery that control breathing
What will you get for your history if a patient comes w dyspnea
Name some associated respiratory and cardiovascular symptoms and other symptoms that can be associated w dyspnea
Onset may be sudden, but usually they note a slowly progressive difficulty in completing a common task
•Dyspnoea
–On exertion, at rest
–Mild, moderate exertion
–Exercise tolerance – distance one can walk before the need for rest
•Dyspnoea scales – to measure the degree of dyspnoea
RESP
•Cough, chest pain (typically pleuritic), wheeze
•Smoking history
•Fever, night sweats, weight loss
CVS
•Palpitations, breathing worse on lying flat,
•leg swelling, chest pain (angina)
Other system disorders
•Gross abdominal distension
•Neurological disease affecting muscles of respiration
•Disease affecting central controls of respiration,
•Metabolic abnormalities
What are the main differentials for dyspnea
Heart or Lung?
•Determine the likely system involved – by obtaining additional information
•Common causes – heart failure, asthma, COPD, pneumonia, pleural effusion
Pneumonia •Pleural effusion •Pneumothorax •Asthma •COPD •Pulmonary Embolism •Pneumoconiosis •Interstitial lung disease
What are the variations in respiration and breathing patterns
Go look on the slides for how they look like on a graph and look on slides for the scenarios ,how to manage em ,differentials,how to assess,examination findings cuz the theory will come from this topic
Normal:regular and comfortable at a rate of 12/20 breaths per minute
Tachypnea
Bradypnea :slower than 12/20 breaths per minute
Kussmaul : rapid,deep,labored
Cheyne-Stokes:varying periods of increasing depth interspersed by apnea
Biot’s pattern:irregularly interspersed (place at intervals) periods of apnea in a disorganized sequence of breaths
What are the types of COPd
How will you manage a patient w dyspnea
Admit a patient w dyspnea if there’s an infection true or false
Name five common bacteria pathogens that cause upper respiratory diseases and lower respiratory diseases along with their differentials
upper respiratory tract includes the nose, throat, pharynx, larynx, and bronchi. True or false
The upper respiratory tract refers to following airway structures: nasal cavities and passages (sinuses), pharynx, tonsils, and larynx (voice box). Trachea (windpipe) and lungs with its substructures bronchi, bronchioles, and alveoli make up the lower respiratory tract. True or false
The epiglottis separates the URT and LRT
Emphysema
Bronchitis
Antibiotics-if infection
Analgesia -of fever or pain
Put on oxygen
Upper:
Streptococcus pyogenes. (Pharyngitis,
Rhinovirus (common cold, Acute Sinusitis.
Adenovirus. Infection,Allergic Rhinitis.,
Corynebacterium diphtheriae (diphtheria)
adenovirus(infection)
Lower: Pneumonia caused by Streptococcus pneumoniae. Staph aureus Bronchitis Tuberculosis Bronchiolitis
Which lung is bigger than the other and why
What is a classical sign of acute pulmonary syndrome
Salbutamol is a bronchodilator true or false
I’m severe acute asthma wheezing sounds are more prominent true or false
The right lung is bigger
It has three lobes while the left has two lobes
Chest pain radiating to the back,bipedal edema
Symptoms of asthma
Accessory muscles of respiration
Chest pain or chest tightness
Shortness of breath
Coughing
Trouble sleeping caused by shortness of breath
Sternocleidomastoid Pectoralis major and minor Latissimus dorsi Serratus anterior Transversus abdominis External oblique Internal oblique Rectus abdominis
What is atopy
Asthma is what kind of genetic disease and what kind of hypersensitivity reaction
A form of allergy in which a hypersensitivity reaction such as exczema or asthma may occur in a part of the body not in contact w the allergen
Polygenic multifactorial disease
Type IV Hypersensitivity reaction
What is spirometry
What is it used for
GINA means global initiative for asthma
Method of assessing lung function by measuring volume of air that the patient is able to expel from the lungs after maximal inspiration
FEV-1(forced expiration volume in one second) over forced vital capacity(FVC)
Good in differentiating between obstructive airway disorders (COPD,asthma,bronchiectasis,emphysema cystic fibrosis) and restrictive diseases (fibrotic lung disease,pneumoconiosis,pulmonary edema,lobectomy,parenchymal Lung tumor)
Used to assess reversibility with a bronchodilator if considering asthma as a cause of obstructive airway disease
SABA is stopped 6hoirs prior to test
LABA is stopped 12 hours prior to test
At what age is asthma and SCd diagnosed
Asthma is common in which gender
If a mum had asthma it’s likely to be transmitted to her ?
Which drugs are used for lung diseases maturation
What drug is given in severe asthma
After two years
After six months
Male
Male child
Aminophylline and theophylline
Leukotrienes
When is omalizumab used
Omalizumab, a humanized monoclonal antibody that binds circulating IgE antibody, is a treatment option for patients with moderate to severe allergic asthma whose asthma is poorly controlled with inhaled corticosteroids and inhaled long-acting β2 agonist bronchodilators.
Specifically, omalizumab may be used if patients have a positive skin test result for an allergy caused by an aeroallergen, reduced lung function (less than 80% of normal) as well as frequent asthma symptoms and must have had at least two severe ‘exacerbations’ of asthma.
First line treatment for patients with persistent asthma is
Inhaled corticosteroids
And beta 2 agonists are for intermittent asthma
•Elderly woman 79yr, diagnosed with lung cancer. Progressively worsening breatlessness, no fever or cough, chest pain right lateral
State the ,complications and associate d symptoms, Signs too,Ddx,history you can get,examination findings
Medications you can use
Complications:
Pleural effusion
Differentials:
Differential Diagnoses Bacterial Pneumonia Bronchitis Carcinoid Lung Tumors Mycoplasmal Pneumonia Pleural Effusion Pneumothorax(could be pneumothorax instead of repeatinglung cancer cuz it’s already been stated in the question that she has lung cancer) Small Cell Lung Cancer (SCLC) Superior Vena Cava Syndrome in Emergency Medicine Tuberculosis (TB) Viral Pneumonia
History:
Patients may also complain of a cough. The pain is often initially pleuritic but may become dull and aching with time. Occasionally the pain is more prominent in the back and shoulder. The degree of dyspnea may increase over time as the pneumothorax increases in size.
Sudden,Sharp,unilateral pain, The pain is usually made worse by breathing in (inspiration).
Clinical exam:
Vital sign abnormalities in patients with pneumothorax can include tachycardia, tachypnea and, depending on the severity, hypoxia and hypotension. Sinus tachycardia is the most common early finding.
diminished or absent breath sounds, air entry may be absent(auscultation),hyperresonance with percussion (the side with the pneumothorax will resonate more), asymmetric chest wall excursion (decreased excursion on the affected side), and loss of tactile fremitus on the affected side of the chest.respiratory distress,sometimes clubbing. There is trachea deviation
Associated symptoms:(pneumothorax) sharp pain when inhaling pressure in the chest that gets worse over time blue discoloration of the skin or lips increased heart rate rapid breathing confusion or dizziness
Diagnosis:
pneumothorax is generally diagnosed using a chest X-ray. In some cases, a computerized tomography (CT) scan may be needed to provide more-detailed images. Ultrasound imaging also may be used to identify a pneumothorax.
Treatment:
Treatment options may include observation, needle aspiration, chest tube insertion(chest tube thoracostomy),nonsurgical repair or surgery. You may receive supplemental oxygen therapy to speed air reabsorption and lung expansion.
Complications:
The complications of pneumothorax include effusion, hemorrhage, empyema; respiratory failure, pneumomediastinum, arrhythmias and instable hemodynamics
Symptoms: for lung cancer
Feeling tired for no reason
Weight loss
Cough
Signs:
Common physical examination findings of lung cancer include decreased/absent breath sounds, pallor, low-grade fever, and tachypnea. Appearance of the Patient Lethargic Emaciated Confused Upper body obesity Vital Signs Vital signs are generally within normal limit, but patients with severe disease may present with: Low-grade fever Decreased SPO2 Tachypnea Tachycardia Hypotension Skin Pallor Jaundice HEENT Jaundice Lymphadenopathy Visual defects Rounded face Increased fat around the neck Neck Neck examination of patients with lung cancer is usually normal. Lungs Decreased/absent breath sounds Heart Cardiovascular examination of patients with lung cancer is usually normal. Abdomen Discomfort on palpation Hepatomegaly Ascites Back Back examination of patients with lung cancer is usually normal. Genitourinary Genitourinary examination of patients with lung cancer is usually normal. Neuromuscular Bone pain Fractures (usually in the vertebrae, femur, pelvic bones, and the ribs) Cranial nerve palsies Extremities Clubbing of fingers Swelling of hands and feet Weakness Hemiplegia Shoulder pain (caused by a Pancoast tumor) Thinning arms and legs References
39 year old Kwame. Sudden onset SOB, orthopnea in a patient with severe hypertension. Diagnosed 3 years ago but not regular with his medication.
State the ddx,likely history(associated symptoms )and physical examination,management ,complications
Left ventricular failure Bacterial pneumonia Myocardial infarction Respiratory failure Acute Kidney injury Refer to lecture notes of heart failure
Associated symptoms: Increased heart rate Easy fatiguability Coughing Wheezing
Management of HF Prop patient up – to relieve pulmonary congestion •Give Oxygen •High flow, high-concentration •Non-invasive positive pressure ventilation •CPAP: 5 – 10mmHg •Give Loop Diuretics •60 – 120mmHg IV Furosemide •Give Nitrates •IV Glyceryl trinitrate 10-200ug/min
Investigations: Echocardiogram ECG Serum urea and creatinine FBC Thyroid function test
Symptoms: for LHF Pulmonary edema Orthopnea Reduced JVP Pitting edema
Factors that worsen jr IV fluid overload Drugs Infections Arrhythmia Pulmonary embolism
55 yr old bank manager. Sudden onset severe chest pain and SOB Collapsed at work and rushed to hospital. Fully conscious, sweating
State the ddx,likely history(associated symptoms)and physical examination,management ,complications of each ddx
Myocardial infarction
Pulmonary embolism
Aortic dissection
Arrhythmia
MI-symptoms
1.Chest pain
central or epigastric chest pain radiating to the arms, shoulders, neck, or jaw.
The pain is described as crushing,tight,heavy,site of pain is central or anterior chest,radiates to throat ,jaw,arms or nowhere,exacerbation factors:exertion,anxiety,cold
Releiving factors: rest and nitrates
Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue and/or palpitations,shock
Shortness of breath: may be the patient’s anginal equivalent or a symptom of heart failure.
Physical examination for MI
Cardiovascular examination findings can vary enormously:
Low-grade fever, pale and cool, clammy skin.(sweating)
Dyspnea
Hypotension or hypertension can be observed depending on the extent of the myocardial infarction.
Third and fourth heart sound, systolic murmur if mitral regurgitation or ventricular septal defect develops, pericardial rub.
including pulmonary rales, peripheral oedema, elevated jugular venous pressure.
Management: Admit patient Prop up patient Nitroprusside Give analgesics (morphine or aspirin) Give oxygen
Complications of MI
Heart block,atrial arrhythmia
Pericarditis
Heart failure
Investigations: ECG Echocardiogram Cardiac enzymes Chest X-ray FBC Lipid profile
What are the ddx for chest pain
Ddx for chest pain and dyspnea
Ddx for chest pain:
Pulmonary embolism, myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax , Chronic obstructive pulmonary disease, hemothorax, pleural adhesions, pneumothorax,
Ddx for chest pain and dyspnea: MI Heart failure Pleural effusion Emphyema Pneumonia
State the ddx,likely history(associated symptoms)and physical examination,management ,investigations,complications of PE which is a ddx for chest pain and dyspnea
Symptoms
y Dyspnoea
y Pleuritic pain
y Cough
y Haemoptysis (due to pulmonary infarction)
y Presyncope, syncope or collapse (massive PE)
y Unilateral swelling of a limb
Signs
y Tachypnoea
y Tachycardia (may be regular or irregular)
y Bloodpressure-low/unrecordable(suggestsmassivePE),normalor
high
y Pleural effusion
y Low oxygen saturation on pulse oximetry <90%
y Pleural rub
y Cyanosis
y Unilaterally swollen calf or thigh of DVT
Chest pain which radiates to the back,blueish lips or nails,pallor,respiratory distress . Reduced breath sounds may be present.
Rales may be present.
Crackles may be present.
Pleural friction rub may be present.
Investigations y Chest X-ray y ECG y D-Dimer y CT Pulmonary angiogram y Echocardiography y Doppler Ultrasound of the affected limb and pelvis y FBC
Non-pharmacological treatment
y Elevate affected leg on a pillow if DVT present
y Apply compression stockings - after pain subsides if DVT present
y Surgical techniques e.g. embolectomy, inferior vena caval filters etc.
Pharmacological treatment
A. Clinical suspicion of pulmonary embolus
1st Line Treatment
y Oxygen, by face mask or nasal prongs or via non-rebreather mask (keep oxygen saturation > 95%)
And
Evidence Rating: [A]
y Morphine, IV, 5-10 mg stat.
And
y Enoxaparin, SC, Adults
1.5 mg/kg (150 units/kg) daily
Or
y Dalteparin, SC, Adult
200 mg/kg (max. 18,000 units) daily
Organisms that cause pneumonia
Streptococcuspneumonia
y Streptococcuspyogenes
y Haemophilusinfluenza
y Klebsiellapneumoniae
y Mycoplasma pneumonia and Legionella pneumophila (tend to occur
in epidemics)
y Staphylococcus aureus (in children after viral illness like measles, in
diabetics or in the elderly during ‘flu’ epidemics)
Signs and symptoms of pneumonia
Symptoms
y Fever - short history
y Productive cough
y Sputum - rusty or blood stained, yellowish, greenish
y Pleuritic chest pain - worse on deep breathing or coughing
y Breathlessness
y Sweating
y Muscle aches
y Elderlyandimmunocompromisedpatientsmayhaveminimumorno
symptoms
Signs
y Rapid breathing(inspection)
Intercostal recession and in drawing
y Grunting (in children)
y Use of accessory muscles of respiration and flaring of the nasal
margins(inspection)
y Lower chest wall indrawing (in children) reduced chest expansion (palpate on)
Central Trachea (palpation)
y Restricted movement of the affected side of the chest (due to pain)
y Fever
y Rapid pulse rate(palpation)
y Blood pressure may be normal or low
y Signs of consolidation or pleural effusion on chest examination
y Restlessness or confusion, drowsiness
y Low blood oxygen saturation by pulse oximetry < 92%
Crackling or bubbling noises (rales) made by movement of fluid in the tiny air sacs of the lung.
Increased tactile frematus (palpation)
Dull thuds heard when the chest is tapped (percussion dullness), which indicate that there is fluid in a lung or collapse of part of a lung.
Sounds made by rubbing of swollen (inflamed) lung tissue on the lining of the lung cavity (pleural friction rub).
Lack of breath sounds in a certain area of the chest, which may mean that air is not entering an area of the lung.
Wheezing, which usually means inflammation or spasm is present in the bronchial tubes.
“E” to “A” changes in the lungs (egophony). Your doctor may have you say the letter “E” while he listens to your chest. Pneumonia may cause the “E” to sound like the letter “A” when heard through a stethoscope.
Complications and investigations
Management of pneumonia
y Pleural effusion y Lung abscess y Empyema y Pericardial effusion/pericarditis y Pneumothorax particularly Staph. aureus infection, Pneumocystis jiroveci pneumonia y Meningitis y Septicaemia with multi organ failure y Adult respiratory distress syndrome (ARDS)
Investigations y FBC y C-reactive protein (CRP) y Chest X-ray y Sputum gram stain and culture and sensitivity y Ziehl-Neelsen stain for acid-fast bacilli (to exclude TB) y Blood culture and sensitivity y Blood urea and electrolytes
Treatment Treatment objectives y To identify patients at greater risk who require in-hospital management y To alleviate symptoms y To treat and eradicate the infection y To prevent and/or manage complications
Non-pharmacological treatment
y Nurse in comfortable position, usually with head raised
y Spongingtocontrolfever,especiallyinchildren<5years(whoareat
risk of febrile convulsions)
y Adequate oral hydration (if if it can be tolerated)
Pharmacological: Give antibiotics Give oxygen Iv fluids Analgesic
Types of tracheal deviation
Contralateral :will shift to the opposite side
Example:
Tension pneumothorax
Pleural effusion
Ipsilateral:will shift towards the side where the organ is
Pneumonectomy
Upper lobe fibrosis
What are the symptoms of pleural effusion and signs of it
How is it diagnosed
How is it treated
Chest pain
Dry, nonproductive cough
Dyspnea (shortness of breath, or difficult, labored breathing)
Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect),pleural friction rub,diminished breath sounds,fine crackles
Physical exam:
Dullness to percussion, decreased tactile fremitus, and asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion: Deviated trachea
The most common causes of transudative (watery fluid) pleural effusions include:
Heart failure
Pulmonary embolism
Cirrhosis
Post open heart surgery
Exudative (protein-rich fluid) pleural effusions are most commonly caused by: Pneumonia Cancer Pulmonary embolism Kidney disease
Chest x-ray
Computed tomography (CT) scan of the chest
Ultrasound of the chest
Thoracentesis (a needle is inserted between the ribs to remove a biopsy, or sample of fluid)
Pleural fluid analysis (an examination of the fluid removed from the pleura space)
Thoracoscopy
Treatment:
Treatment of pleural effusion is based on the underlying condition and whether the effusion is causing severe respiratory symptoms, such as shortness of breath or difficulty breathing.
Diuretics and other heart failure medications are used to treat pleural effusion caused by congestive heart failure or other medical causes. A malignant effusion may also require treatment with chemotherapy, radiation therapy or a medication infusion within the chest.
A pleural effusion that is causing respiratory symptoms may be drained using therapeutic thoracentesis or through a chest tube (called tube thoracostomy).
For patients with pleural effusions that are uncontrollable or recur due to a malignancy despite drainage, a sclerosing agent (a type of drug that deliberately induces scarring) occasionally may be instilled into the pleural cavity through a tube thoracostomy to create a fibrosis (excessive fibrous tissue) of the pleura (pleural sclerosis).
Pleural sclerosis performed with sclerosing agents (such as talc, doxycycline, and tetracycline) is 50 percent successful in preventing the recurrence of pleural effusions
