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Medicine year 3- EOCP > Breathlessness- core conditions 3 > Flashcards

Breathlessness- core conditions 3 Flashcards

1
Q

Pneumonia: history and examination

A

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

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2
Q

Pneumonia: symptoms

A
  • 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
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3
Q

Causes of pneumonia

A

Causes of hospital acquired pneumonia: E.coli, S.aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa
Causes of community acquired pneumoniae: S.pneumoniae, H.influenzae

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4
Q

Pnemonia- investigations

A
  • Bedside: Obs
  • Bloods: FBC, U&Es, CRP, blood/sputum culture
  • Imaging: CXR - look for areas of opacification (consolidation)
  • CURB65 score
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5
Q

CURB-65 scoring system [mortality rate in hospital]

A
  • 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
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6
Q

CRB65 score [mortality risk in GP]

A

• 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

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7
Q

Pneumonia management CAP

A
  • 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
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8
Q

Pneumonia management HAP

A
  • 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
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9
Q

What do you do 6 weeks after initial pneumonia presentation

A

You do a chest x-ray to make sure there isnt a tumour hidden by the consolidation

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10
Q

Pathological stage of pneumonia

A
  • First 24hrs
  • Cellular exudates replace the alveolar air.
  • Capillaries in the surrounding alveolar walls become congested.
  • Pleurisy occurs - results in coughing & deep breathing
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11
Q

Red hepatization stage of pneumonia

A
  • 2-3 days after consolidation
  • Lungs become hyperaemic
  • Consistency of the lungs is similar to the liver
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12
Q

Grey hepatization stage of pneumonia

A
  • 2-3 days after red hepatization
  • Avascular stage
  • Fibrinopurulent exudates cause compression of the capillaries
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13
Q

Resolution stage of pneumonia

A

Resolution of the pulmonary architecture

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14
Q

Why should you stop a PPI prior to Abx treatment

A

Increases risk of C.difficile

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15
Q

What two infections are likely to cause an acute sore throat

A

Acute pharyngitis, tonsilitis

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16
Q

Causes of respiratory tract infections

A

Rhinovirus, adenovirus, coronavirus, S.pyogenes, H.influenza, Moraxella catarrhalis

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17
Q

What scoring systems are used in acute sore throat to decide if antibiotics are needed

A

FeverPAIN, Centor score

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18
Q

FeverPAIN score

A
  • 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.
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19
Q

Centor criteria

A
  • 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
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20
Q

Natural history of pneumonia

A

• 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

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21
Q

Symptoms of respiratory tract infections

A
  • Sore throat
  • Cough/cold
  • Fever
  • Muscle ache
  • Enlarged lymph nodes
  • Inflamed tonsils/exudate
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22
Q

Management of respiratory tract infection

A
  • If scored highly on FeverPAIN/centor, Antibiotics give: Phenoxymethylpenicillin or clarythromycin.
  • Paracetamol, ibuprofen
  • Fluids, rest
  • Dilfam spray - locally acting analgesic & anti-inflammatory
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23
Q

Influenza- clinical features

A
  • quick onset of symptoms, usually self-limiting
  • dry cough, coryza, sore throat
  • headache, fever, malaise
  • GI symptoms
  • photophobia, conjunctivitis, pain on eye movement
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24
Q

Influenza- clinical investigations

A
  • Usually clinical diagnosis
  • Testing limited to outbreaks or if person has complications. Includes viral PCR, rapid antigen testing and viral culture of sputum/swabs
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25
Q

Influenza management

A

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

26
Q

Causes of chest pain

A
  • 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
27
Q

Things to ask about with chest pain

A
  • 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
28
Q

Chest pain- initial investigation

A
  • ECG- initial and serial (in and out of pain, response to GTN spray/ analgesia)
  • Cardiac monitor
  • Nurse in a high dependency area
  • Send troponin
29
Q

ST elevation- myocardial infarction

A
  • 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
30
Q

Non ST elevation MI

A
  • 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
31
Q

Unstable angina

A
  • 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
32
Q

STEMI initial management

A
  • 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
33
Q

Stable angina

A

Insufficient blood flow to the heart muscle from the narrowing of a coronary artery

34
Q

Stable angina- examination

A
  • Clinical examinations: anaemia, valve disease
  • Baseline investigations: ECG
  • Anatomical test: CT coronary angiogram, Invasive angiogram
  • Functional test: Stress echo, Perfusion scan, Stress cardiac MRI
35
Q

Stable angina treatment

A
  • GTN spray
  • Statin according to QRISK 3 score
  • An antianginal agent
  • Aspirin
36
Q

Palpitations

A

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

37
Q

Conditions which cause palpitations

A
  • Atrial flutter
  • Atrial fibrillation
  • Supraventricular tachycardia
  • Ventricular tachycardia
  • Ventricular fibrillation
    -AV block
  • Asystole
38
Q

Palpitations- examination

A
  • 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
39
Q

Palpitations- Investigations

A
  • 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
40
Q

Atrial fibrilation- long term management

A
  • Rate or rhythm control
  • Address risk factors: hypertension, overweight, sleep apnoea
  • Avoid triggers: caffeine, alcohol
  • Stroke prophylaxis
41
Q

AF and stroke

A

AF increases the risk of stroke by 5 times, due to thromboembolism from left atrium. Should be put on anticoagulants to reduce the risk.

42
Q

Dizziness and syncope conditions

A
  • Acute illness: infection, acute coronary syndrome, bleeding, dissection of the aorta, pulmonary embolism
  • Causes of syncope: neurally mediated, orthostatic, cardiac arrhythmias, structural
43
Q

Management for syncope

A
  • Cardiac monitor
  • Send baseline bloods
  • FBC, U and E
44
Q

Difference between a single lead and 12 lead ECG

A

Single lead
- Narrow QRS
- R waves over healthy tissue
- Isoelectric ST segments
- Upright T waves

12 lead
- Anatomy
- Pattern recognition

45
Q

ECG: Axis estimation

A
  • 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
46
Q

ECG: QRS complexes

A
  • Width (normal <120ms): damage to wiring (bundle branch block)
  • Q waves (>0.03 seconds)- dead tissue if it goes down
  • Size- ventricular hypertrophy
47
Q

ECG: ST segment

A

Elevation: infarction
Depression: ischaemia
Should be flat

48
Q

ECG: Anteroseptal infarction and Established anterolateral infarction

A

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

49
Q

Posterior infarct and Left bundle branch block and Deep T wave

A

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

50
Q

CXR: assessing heart size

A

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

51
Q

CXR: when is there adequate penetration

A

If you can see the spine through the hear

52
Q

Consolidation: something in the airspace

A

• Pus: pneumonia
• Fluid: pulmonary oedema
• Blood: haemorrhage
• Shows as white fluffy area- may no longer see the heart border and the hemidiaphragm

53
Q

CXR: Heart failure

A

• 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

54
Q

CXR: Pneumothorax

A

• 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

55
Q

CXR: Pleural effusion

A

• 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

56
Q

CXR: NG tube placement

A

• 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

57
Q

Pneumoperitoneum

A

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

58
Q

Impact of breathlessness

A

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

59
Q

CBT

A

• Cognitive: mind i.e. thoughts, images, dreams, memories
• Behaviour: what we do or choose not to do
• Therapy: a method of treating a problem

60
Q

Breathlessness: CBT- 5 areas assessed

A

• 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.’

Medicine year 3- EOCP (27 decks)

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