Breathlessness- core conditions 3 Flashcards
Pneumonia: history and examination
History: pleuritic chest pain, productive cough, fever, SOB, Possible confusion
Examination
- Tachypnoea
- Fever
- Decreased chest expansion on affected side
- Dullness to percuss on affected side
- Bronchial breath sounds on affected side
- Crackles on affected side
- Increased vocal resonance on affected side
Pneumonia: symptoms
- Pleuritic pain
- Dry cough, then purulent
- Shallow rapid breathing
- Possible confusion
- Loss of appetite, low energy and fatigue
- Probable preceding viral infection
- Rapidly more ill, temp up to 39.5 degrees
Causes of pneumonia
Causes of hospital acquired pneumonia: E.coli, S.aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa
Causes of community acquired pneumoniae: S.pneumoniae, H.influenzae
Pnemonia- investigations
- Bedside: Obs
- Bloods: FBC, U&Es, CRP, blood/sputum culture
- Imaging: CXR - look for areas of opacification (consolidation)
- CURB65 score
CURB-65 scoring system [mortality rate in hospital]
- Confusion (AMTS<=8)
- Raised blood urea nitrogen >=7 mmol/L
- Respiratory rate >30
- Blood pressure <60 diastolic or <90 systolic
- Age >=65
- Score 0-1 = low risk
- Score 2 = moderate risk
- Score 3-5 = high risk
CRB65 score [mortality risk in GP]
• Confusion [AMTS 8 or less]
• Raised respiratory rate [30 or more]
• Low BP [DBP <60mmHg or SBP <90mmHg]
• Aged 65 or more
- Stratified for risk or death:
• 0: low risk [<1% mortality]
• 1 or 2: intermediate risk [1-10% mortality
• 3 or 4: high risk [>10% mortality
Pneumonia management CAP
- Maintain airway, support breathing, high flow O2 if needed
- Antibiotics asap (adjust after microbiology results) PO:
- Low risk patient: Amoxicillin (or doxycycline)
- Moderate risk patient: Amoxicillin + Clarythromycin
- High risk patient: Co-amoxiclav + Clarythromycin
Pneumonia management HAP
- Maintain airway, support breathing, high flow O2 if needed
- Antibiotics asap (adjust after microbiology results):
- Low/moderate risk patient: Co-amoxiclav PO
- High risk patient/severe infection: Piperacillin or ceftazidine or cetriaxone IV
What do you do 6 weeks after initial pneumonia presentation
You do a chest x-ray to make sure there isnt a tumour hidden by the consolidation
Pathological stage of pneumonia
- First 24hrs
- Cellular exudates replace the alveolar air.
- Capillaries in the surrounding alveolar walls become congested.
- Pleurisy occurs - results in coughing & deep breathing
Red hepatization stage of pneumonia
- 2-3 days after consolidation
- Lungs become hyperaemic
- Consistency of the lungs is similar to the liver
Grey hepatization stage of pneumonia
- 2-3 days after red hepatization
- Avascular stage
- Fibrinopurulent exudates cause compression of the capillaries
Resolution stage of pneumonia
Resolution of the pulmonary architecture
Why should you stop a PPI prior to Abx treatment
Increases risk of C.difficile
What two infections are likely to cause an acute sore throat
Acute pharyngitis, tonsilitis
Causes of respiratory tract infections
Rhinovirus, adenovirus, coronavirus, S.pyogenes, H.influenza, Moraxella catarrhalis
What scoring systems are used in acute sore throat to decide if antibiotics are needed
FeverPAIN, Centor score
FeverPAIN score
- Fever
- Purulence
- Attends rapidly (within 3 days)
- Inflamed tonsils
- No cough/coryza
- Score 0-1 = no ABx, Score 2-3 = consider/back up Abx prescription, Score 4-5 = immediate Abx.
Centor criteria
- Lymph Nodes enlarged
- Exudate on tonsils
- Absence of cough
- Fever
- Add 1 if <15 y/o, minus 1 if >44 y/o.
- Require score of 3 for Abx
Natural history of pneumonia
• 1 week – fever resolved
• 4 weeks – chest pain & sputum production substantially reduced
• 6 weeks – cough & breathlessness substantially reduced
• 3 months – most resolved but fatigue may be present
• 6 months - most people back to normal
Symptoms of respiratory tract infections
- Sore throat
- Cough/cold
- Fever
- Muscle ache
- Enlarged lymph nodes
- Inflamed tonsils/exudate
Management of respiratory tract infection
- If scored highly on FeverPAIN/centor, Antibiotics give: Phenoxymethylpenicillin or clarythromycin.
- Paracetamol, ibuprofen
- Fluids, rest
- Dilfam spray - locally acting analgesic & anti-inflammatory
Influenza- clinical features
- quick onset of symptoms, usually self-limiting
- dry cough, coryza, sore throat
- headache, fever, malaise
- GI symptoms
- photophobia, conjunctivitis, pain on eye movement
Influenza- clinical investigations
- Usually clinical diagnosis
- Testing limited to outbreaks or if person has complications. Includes viral PCR, rapid antigen testing and viral culture of sputum/swabs
Influenza management
If uncomplicated:
- supportive care, fluids, analgesia, rest
- ensure they’ve had their influenza vaccine for the current season
If complicated or if high risk patient (immunosuppressed or pregnant or elderly): oral antiviral given: Oseltamivir
Causes of chest pain
- Cardiac ischaemia: stable angina, unstable angina, myocardial infarction, aortic stenosis, Hypertrophic cardiomyopathy
- Pericarditis
- Aortic dissection
- Pulmonary embolism
- Pneumonia
- Pneumothorax
- Gastro-oesophageal reflux
- Hiatus hernia
- Oesophageal spasm
- Oesophageal ruputure
- Pancreatitis
- Cholecystitis
- Musculoskeletal
- Costochondritis
- Shingles
- Anxiety
Things to ask about with chest pain
- PMH: chronic kidney disease, diabetes, rheumatoid arthritis, hypertension, hypercholesterolaemia
- Smoking
- Family history: angina or heart attack in a first degree relative <60
- Drug history: OTC and illegal, cocaine, steroids, antipsychotics
Chest pain- initial investigation
- ECG- initial and serial (in and out of pain, response to GTN spray/ analgesia)
- Cardiac monitor
- Nurse in a high dependency area
- Send troponin
ST elevation- myocardial infarction
- Complete occlusion of coronary artery
- Rapid myocardial cell death
- Early reperfusion- primary angioplasty, thrombolysis
- Dual antiplatelet therapy- aspirin plus ticagrelor or prasugrel
- Secondary prevention: beta blocker, statin, ACE-inhibitor
Non ST elevation MI
- Partial occlusion of the coronary artery
- Myocardial cell death- Troponin is released
- Dual antiplatelet therapy- Aspirin plus ticagrelor or clopidogrel
- Anti-thrombotic: Fondaparinux or LMWH
- Risk stratification: Early coronary angiography vs conservative management
- Secondary prevention: beta-blockers, statins, ace inhibitors
Unstable angina
- Partial occlusion of coronary artery- critical stenosis
- No myocardial cell death- Troponin is normal
- Dual antiplatelet therapy- Aspirin plus ticagrelor or clopidogrel
- Anti-thrombotic- Fondaparinux or LMWH
- Risk stratification- early coronary angiography vs conservative management
- Secondary preventin- beta blocker, statin, ace inhibitor
STEMI initial management
- Dual antiplatelet therapy
- Opiate analgesia
- Nitrate
- Reperfusion (primary angioplasty AKA percutaneous coronary intervention (PCI) )
- Fondaparinux/ Low molecular weight heparin
- Secondary prevention: Beta blockers, ACE-inhibitors, Statins
Stable angina
Insufficient blood flow to the heart muscle from the narrowing of a coronary artery
Stable angina- examination
- Clinical examinations: anaemia, valve disease
- Baseline investigations: ECG
- Anatomical test: CT coronary angiogram, Invasive angiogram
- Functional test: Stress echo, Perfusion scan, Stress cardiac MRI
Stable angina treatment
- GTN spray
- Statin according to QRISK 3 score
- An antianginal agent
- Aspirin
Palpitations
The sensation of abnormal heart rhythm. May be rapid, strong or irregular. May relate to Cardiac arrhythmias, normal variation in heart rhythm, abnormal apprecial of normal heart rhythm i.e. in response to anxiety, exercise or poor sleep
Conditions which cause palpitations
- Atrial flutter
- Atrial fibrillation
- Supraventricular tachycardia
- Ventricular tachycardia
- Ventricular fibrillation
-AV block - Asystole
Palpitations- examination
- If episode resolved its likely to be normal
- If ongoing assess pulse rate and regularity as well as signs of haemodynamic compromise
- Assess for heart murmur
Palpitations- Investigations
- Baseline ECG- if the episode is resolved its likely to be normally, small number of rare conditions known as ‘chanelleopathies’ that are associated with sudden cardiac death
- Diagnosis relies upon capturing an episode on ECG
- Cardiac monitor
Atrial fibrilation- long term management
- Rate or rhythm control
- Address risk factors: hypertension, overweight, sleep apnoea
- Avoid triggers: caffeine, alcohol
- Stroke prophylaxis
AF and stroke
AF increases the risk of stroke by 5 times, due to thromboembolism from left atrium. Should be put on anticoagulants to reduce the risk.
Dizziness and syncope conditions
- Acute illness: infection, acute coronary syndrome, bleeding, dissection of the aorta, pulmonary embolism
- Causes of syncope: neurally mediated, orthostatic, cardiac arrhythmias, structural
Management for syncope
- Cardiac monitor
- Send baseline bloods
- FBC, U and E
Difference between a single lead and 12 lead ECG
Single lead
- Narrow QRS
- R waves over healthy tissue
- Isoelectric ST segments
- Upright T waves
12 lead
- Anatomy
- Pattern recognition
ECG: Axis estimation
- Normal axis is between aVl and aVf
- I is perpendicular to aVf
- II is perpendicular to aVl
- If I and II are positive then the axis is normal
ECG: QRS complexes
- Width (normal <120ms): damage to wiring (bundle branch block)
- Q waves (>0.03 seconds)- dead tissue if it goes down
- Size- ventricular hypertrophy
ECG: ST segment
Elevation: infarction
Depression: ischaemia
Should be flat
ECG: Anteroseptal infarction and Established anterolateral infarction
Anteroseptal infarction- ST elevation, large gap between QRS complexes
Established anterolateral infarction- tachycardic, no P wave. Varying distance between the QRS complexes suggesting atrial fibrillation. Abnormal axis. ST elevation
Posterior infarct and Left bundle branch block and Deep T wave
Posterior infarct- ST segment depression, normally an infarction causes ST segment elevation but not in the posterior aspect of the heart.
Left bundle branch block- sinus rhythm, broad QRS complex. Shows heart failure
Deep T wave inversion: negative T waves which are delayed. Repolarisation of the heart is abnormal
CXR: assessing heart size
Cant assess mediastinum or heart size on an AP X-ray
The heart should be less than half the size of the chest otherwise there may be a cardiomegaly
CXR: when is there adequate penetration
If you can see the spine through the hear
Consolidation: something in the airspace
• Pus: pneumonia
• Fluid: pulmonary oedema
• Blood: haemorrhage
• Shows as white fluffy area- may no longer see the heart border and the hemidiaphragm
CXR: Heart failure
• Cardiomegaly
• Upper lobe diversion- increased, thicker vessels in the upper lobes
• Interstitial oedema- hallmark is kerley B lines which are straight lines which come in from the edge of the chest wall
• Alveolar oedema- bilateral consolidation
• Pleural effusions
CXR: Pneumothorax
• Air with no vessels or lung marking going through it. Its above the lung as it collapses down
• The lung collapses down centrally
• Pushes the heart towards the other side in tension pneumothorax
• No lung markings beyond the crisp lung edge
CXR: Pleural effusion
• Uniform white opacity over the lung, block out the heart border and the costophrenic angle
• Meniscus which goes up the top
• Pleural effusion pushes the traches over
CXR: NG tube placement
• The tube follows a straight course down the midline of the chest to a point below the diaphragm
• The tube does not follow the path of a bronchus
• Tube is not coiled anywhere in the chest
• The tip of the tube is below the diaphragm
Pneumoperitoneum
Air lifts the diaphragm up. Shows there is air in the abdomen, only shown in an erect CXR. The patient needs to be sitting up for half an hour before its taken
Impact of breathlessness
Breathlessness has a significant impact on the patients quality of life: work, personal hygiene, communicating, socialising, house work, travelling and relationships
Psychological impact- anxiety and depression
CBT
• Cognitive: mind i.e. thoughts, images, dreams, memories
• Behaviour: what we do or choose not to do
• Therapy: a method of treating a problem
Breathlessness: CBT- 5 areas assessed
• Situation: any activity or even thought of activity
• Physical: Breathless +++, cough, hot/sweaty, heart races
• Behaviour: avoids activity if possible, sits down, turns on fan, shouts for support, stopped going out, Declinced PR
• Feeling: frightened, guilty, anxious, depressed, embarrassed
• Thoughts: ‘Im going to die’, ‘I cant do what I used to do’, ‘this is my last breath.’
