Core Clinical Problems Flashcards
What are some causes of a cough?
- Common cold (coryza)
- COPD
- Cough-variant asthma
- Lung cancer
- Bronchiectasis
How are coughs differentiated in terms of onset?
- Acute = most likely vascular problem, blockage of artery/vein
- Sub-acute = most likely infection e.g. LRTI, pneumonia
- Chronic = most likely chronic bronchitis, bronchiectasis
Does duration of a cough vary?
Yes, depending on pathology
- Viral infections: 5-7 days
- Bacterial infections: ~10 days
- Mycobacterial infections: very long time
- Pertussis: ~3 months
What are associated symptoms with a wet cough?
- Fever
- Weight loss
- Pain
- Haemoptysis
- Breathlessness
What is the pain in bronchiectasis described as?
A metal bar pressing against the chest
When is a sputum culture carried out?
SPUR - when infection is Severe, Persistent, Unresponsive to treatment or Recurrent
When will lung cancer cause a cough?
- If tumour is very large
* If tumour close to carina
What individuals most commonly suffer from a chronic dry cough?
- Often post-menopausal women
- Cough started as LRTI, LRTI abated but cough persisted
- Cough triggered by speaking on telephone, laughing, eating, etc
- Patients often worried about cancer
What are the differential diagnoses for a chronic dry cough?
- Serious pathology - cancer, ILD
- drug reaction - ACE inhibitors
- reflux oesophagitis
- perennial rhinitis
- cough variant asthma (eosinophilic bronchitis)
What is the pathophysiology of a dry, chronic cough?
- Heightened cough reflex is the primary abnormality
* Cough reflex can be heightened due to lowered threshold or increased stimulation in the respiratory tract
What is the prognosis for a chronic dry cough?
Cough that is present for over a year is very unlikely to resolve (it becomes a habitual cough)
What is the general definition of a chronic dry cough?
Non-productive cough for over 8 weeks
How is chronic dry cough managed in primary care?
- CXR
- Spirometry for suspected COPD
- Smoking cessation
What is the primary care treatment of chronic dry cough?
- Reflux oesophagitis – Lansoprazole, Gaviscon
- Eosinophillic bronchitis (cough varient asthma) – bronchodilators
- Perennial rhinitis – nasal drip
What are the red flags of lung cancer?
- Cough
- Weight loss
- Haemoptysis
- Pain
What is the treatment for chronic cough regardless of aetiology?
- Smoking cessation
- Stop ACE
- Lansoprazole 30mg, ranitidine 300mg and Gaviscon Advance
- Qvar (beclomethasone - ICS)
- Nasal steroid
What is secondary care treatment of chronic dry cough?
- Gabapentin
- Pregabalin
- Amitriptyline
- Opiates
- Baclofen
What are causes of breathlessness?
- Anaemia
- Hyper-ventilation syndrome
- Angina
- PE
- Asthma and lung diseases
- Heart failure
What are the different components of breathlessness?
- Oxygen transport
- Mechanical disadvantage
- Respiratory drive
- Perception of breathing
What is oxygen uptake?
Ability of the body to uptake and utilise oxygen
How is oxygen uptake calculated?
Fick equation
VO2 = CO x (CaO2 - CvO2)
When is VO2 max reached?
When oxygen consumption remains at steady state despite increase in workload
What is the oxygen uptake of the average male?
45ml/kg/min
What is the oxygen uptake (VO2) of athletes?
Athletes have higher peak VO2s
What conditions can cause mechanical restriction of the lungs?
- Motor neurone disease
- obesity
- plueral effusion
- Guillian-Barre
- hyperinflation
What condition is related to respiratory drive?
Ondine’s curse
What is perception of breathing?
Hey breathing is associated with things like heart failure
How does the time of breathlessness relate to the cause?
- Instant: pneumothorax, PE
- Acute: Asthma, MI, pneumonia, cardiac tamponade
- Sub-acute: pleural effusion, pulmonary vasculitis
- Chronic: COPD, ILD, pulmonary hypertension, anaemia
What are investigations for breathlessness?
- Spirometry
- Peak flow
- CXR
- CT
- VQ scan
What is the likely diagnoses of a 26 y/o woman who has episodic breathlessness that comes on 5-10 mins. Can be very limiting and is usually worse in mornings or after exercise. Also has a cough and a wheeze and wakes at night with these. What further investigations would you recommend?
- Likely diagnosis: Asthma
* Investigations: peak flow, spirometry
What is the likely diagnoses of a 68 y/o male who has sudden onset SOB, severe symptoms, nothing makes it better. Has a sharp pain accompanied by haemoptysis. What further investigations would you recommend?
- Likely diagnosis: Pulmonary embolism
* Investigations: cannot tell if had PE from CXR, so carry out ECG, CT pulmonary angiogram
What will blood pressure in the pulmonary artery be for an individual with pulmonary embolism?
- BP will be much higher than normal (hypertensive) e.g. 98/44 mmHg as right side tries to overcome blockage by increasing pressure
- Patient will also be tachycardic
What is the likely diagnosis of an 80 y/o man who has gradually worsening SOB over 6-8 weeks, is a smoker, can barely walk to bathroom without getting breathless, needs to sleep with 3-4 pillow to prop up (orthopnoea), wakes up gasping for breath and needs to open window (PND). PMH includes coronary artery bypass following MI 20 years ago and COPD. He also has swollen lower limbs and his blue inhaler hasn’t been relieving SOB like it used to.
Likely diagnosis: pulmonary oedema
What is the treatment for pulmonary oedema?
Intravenous diuretics - to help kidneys remove excess fluid from body
What is the likely diagnosis of a 56 y/o female who had a PE 6 months ago and now has ongoing SOB? She has mild swelling of the ankles and is hypoxic on air (worse when she walks). She has normal spirometry but gas transfer is reduced to 54%.
Likely diagnosis: Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
What is the likely diagnosis of a 67 y/o female who has SOB with relatively little activity for many years? She sometimes gets tingling in her hands when she’s really breathless. What is the cause of this? Investigations showed she had normal CX, normal O2, normal ECG.
- Likely diagnosis: unlikely to be serious condition as has been present for many years - dysfunctional breathing/hyperventilation
- Cause of hand tingling - hyper-ventilation
How is dysfunctional breathing diagnosed?
- Diagnosed by exclusion
* Can be seen in complex physiology testing during exercise - CPET (cardiopulmonary exercise testing)
What is the treatment for dysfunctional breathing?
Breathing retraining techniques from physiotherapist can be helpful
Is haemoptysis always serious?
No, can simply be trauma from violent cough
What is the treatment for massive haemoptysis?
- maintain patient airway
- ensure adequate oxygenation
- fluid/blood resuscitation
- stabilise the patient
What structures are affected in massive haemoptysis?
- Bronchial - 85%
- Pulmonary - 10%
- Alveolar - 5%
What are the causes of haemoptysis?
The big 4 (I C peanut butter)
- Infection - tuberculosis
- Carcinoma (lung cancer)
- Pulmonary embolus
- Bronchiectasis
What is the treatment for the ‘big 4’ causes of haemoptysis?
- Lung cancer - diathermy, cryotherapy, radiotherapy
- Bronchiectasis - antibiotics, anti–fungals
- PE - anticoagulation, lung resection
- TB - quadruple therapy (RIPE), bronchial embolisation
What are rare causes of haemoptysis?
- AVMs (Osler-Weber-Rendu, hereditary haemorrhagic telangiectasia)
- Trauma
- Idiopathic pulmonary haemosiderosis (deposition of iron in the lungs)
- Wegener’s granulomatosis (type IV hypersensitivity)
- Goodpasture’s syndrome (type III hypersensitivity disease)
What is the likely diagnosis of a 25 y/o woman who is breathless, has a RR of 35 and bag full of medicine, including: azithromycin, prednisolone, creon, vitamins, tobramycin and DNA-ase
Cystic fibrosis
What is the likely diagnosis of a 25 y/o woman who present with wheeze, use of accessory muscles and is unable to finish a sentence in a single breath?
Asthma
What is the likely diagnosis of a 25 y/o woman who is coughing a lot, has greenish sputum and a temperature of 38.5*c?
Pneumonia
What is the likely diagnosis of a woman who has fallen off her horse and has been breathless ever since?
Fractured rib
What are the severity markers for asthma?
- Can’t finish sentence in single breath
- Peak flow (<50% severe)
- respiratory rate >30
- tachycardic
What are the signs of life-threatening asthma?
- Low level of consciousness
- RR > 30
- Bradycardia
- Silent chest (inability to breathe out - when listen to chest, can’t hear anything)
- Peak flow <33%
What is type 1 respiratory failure?
Low level of oxygen in the blood (hypoxemia) without an increased level of carbon dioxide in the blood (hypercapnia) - PCO2 is normal or low
What is type 2 respiratory failure?
Both oxygen and carbon dioxide are affected
- Low O2
- High CO2
What is a sign of chronic type 2 respiratory failure?
Sign is high HCO3 as it takes a while to build up in the body
