Cough Flashcards
Acute ddx of cough
Dry
=> asthma, ACEi drugs, heart failure, URTI (laryngitis, pharyngitis)
Productive
=> pneumonia (LRTI), TB
Chronic ddx of cough
Dry
=> asthma, lung cancer, GORD, mesothelioma
Productive
=> COPD, bronchiectasis, lung cancer, cystic fibrosis
Sx and signs of pneumonia
Typical
- fever, SOB, cough w/ green sputum, chest pain (pleuritic), confusion
Atypical
- hepatitis, myalgia, diarrhoea, headache, dry cough
Signs
- bronchial breathing, increased vocal resonance, course bibasal crackles, dull auscultation, decreased chest expansion
Ix for pneumonia
Basic obs
Sputumb MCS
Pleural fluid MCS
Bloods: ABG, CRP, FBC
CXR: lobar/bronchpneumonia/consolidation/air bronchograms
Complications of a pneumonia
Sepsis
Empyema
Pneumothorax
Lung abscess
Pleural effusion
How may a lung abcess present?
Swinging fevers, persistent pneumonia, foul-smelling sputum
Often Staph. aureus
How do you assess whether a pneumonia needs to be admitted?
CURB-65
C onfusion < 8 AMTS
U rea > 7 mmol/L
R R > 30
B P < 90/60 mmHg
> 65 age
1 = outpatient, 2 = short stay, 3+ = inpatient; ITU
Acute mx of a pneumonia
Oxygen, sit pt up
IV fluids
CPAP if required (type I resp failure)
Surgical drainage (if abscess/empyema)
Which Abx are used for CAP organisms?
Strep. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
=> Amoxicillin
=> Co-amoxicalv if severe
Which organisms form cavitating lesions?
Klebsiella
Staph. aureus
Which Abx are used for HAP organisms?
Klebsiella, Staph. aureus, Pseudomonas aeruginosa
=> Staph: flucloxacillin + gentamycin (aminoglycoside)
=>MRSA: vancomycin (glycopeptide)
Which Abx are used for atypical organisms?
Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia psittaci
=> clarithromycin (macrolide)
Which atypical organism does the following point towards?
a) Owns pet birds
b) Transverse myelitis O/E
c) Came back from a long holiday and is hyponatraemic
a) Chlamydia psittaci
b) Mycoplasma pneumoniae
c) Legionella pneumophila (AC in hotels)
Which Abx are used for aspiration pneumoniaes?
Anaerobes from gut flora include Strep. pneumoniae, Staph. aureus
=> Metronidazole (nitroimidazole)
Signs + sx of TB
Fever, lethargy, wt loss, night sweats, cough w/ green sputum, haemoptysis, lympahdenopathy dissemination of TB
Ix for TB
Basic obs
Bloods
- increased WCC, CRP, blood cultures, ABG
Sputum MCS x3 samples
- Ziehl-Neelsen stain to enable visualisation of acid-fast bacili
Lymph node biopsy
- caseating granuloma
Mantoux/tuberculin shin test (TST) + IGRA
- cannot distinguish between active + latent TB, requires intact immune system
CXR
What might a TB CXR show?
Consolidation (patchy/heterogenous)
Bihilar lymphadenopathy
Upper lobe scarring
Cavitating lesions
Pleural effusions
If miliary => nodular shadowing
RFs of TB
Smoking, travel, South Asians/Indian/Bangladesh, immunocompromised (HIV pts)
Causes of bronchiectasis
Congenital
- cystic fibrosis
- primary ciliary dyskinesia (sinusitis, PCD, situs inversus)
- Young’s syndrome (bronchiectasis, sinusitis, infertility)
Acquired
- TB, measles, pneumonia
- pertussis, immunocompromised
- allergic bronchopulmonary aspergillus
Signs and sx of bronchiectasis
Bibasal crackles, clubbing
Haemoptysis, wt loss, fever, chest pain, chronic green cough and sputum, SOB
Ix of bronchiectasis
Bloods
- increased WCC, CRP, ABG (resp failure?)
Sweat test (?CF)
Sputum MCS (?pneumonia/TB)
CXR
High res. CT chest (signet ring sign)
Mx of bronchiectasis
Conservative
- airway clearance (chest physio, increased frequency oscillation devices, nebulised hypertonic saline)
- exercise
- good diet
- good hydration
Pharmacological
- inhaled salbutamol
- influenza flu vaccine, inhaled Abx (prophylactic)
- IV Abx (acute)
Complications of bronchiectasis
Persistent infections
Cor pulmonale
Respiratory failure
RFs for lung cancer
Increased age
SMOKING SMOKING SMOKING
Asbestos exposure
Break down the types of lung cancers (incl. distinguishing points)
Small cell (15%)
- ?endocrine cells
- SIADH, ectopic ACTH
Non-small cell (85%)
=> large cell
- epithelial cells
=> squamous carcinoma
- squamous cell epithelial cells
- PTHrp
=> adenocarcinoma (most common)
- goblet cells
- peripheral lung
Ix for lung cancer and what they might show
Basic obs
Bloods
- increased calcium (bone mets, PTHrp), increased ALP (bone mets), LFTs deranged (liver mets)
Sputum (cytology)
Bronchoscopy (enable biopsy)
CXR
- heterogenous consolidation
- bihilar lymphadenopathy, upper lobe scarring, cavitating lesions (SqCC), pleural effusions, coin shaped lesions
Staging => CT/MRI/PET
Lung cancer sx
Primary tumour
- night sweats, loss of appetite, cough, wt loss, SOB, haemoptysis
Local invasion
- superior vena cava obstruction, nervous system (Horner’s syndrome/left recurrent laryngeal cough; bovine cough)
Mets
- lymphadenopathy, hepatomegaly, blurry vision, headaches, bone pain, fractures
Presentation of a mesothelioma
Hx of asbestos exposure (occupational hazard)
FLAWS
Dry cough, SOB
Ix for mesothelioma
Basic obs
Pleural biopsy
Pleural fluid (cytology via thoracentesis)
Bloods (FBC, increased calcium (PTHrp), increased ALP (bone mets), LFTs deragned (liver mets))
CT chest/CXR (pleural thickening, pleural effusions, pleural plaques due to asbestos)
CT/PET/MRI (STAGING)
What is a mesothelioma?
Rare neoplasm of mesothelial cells of the pleura surrounding the lung
Can also affect peritoneum and pericardium
25 yo F presents to A&E with 2d hx of productive cough, SOB and fever.
The cough is worse at night. She’s reported having brought up green
mucus for the last 2 days. O/E you hear crackles throughout. On
further questioning you find out that she’s been diagnosed with cystic
fibrosis at birth and has had these symptoms in the past.
What is the most likely diagnosis?
A. Asthma
B. Pneumonia
C. Chronic sinusitis
D. Bronchiectasis
D. Bronchiectasis
25 yo F presents to A&E with 2d hx of productive cough, SOB and fever.
The cough is worse at night. She’s reported having brought up green
mucus for the last 2 days. O/E you hear crackles throughout. On
further questioning you find out that she’s been diagnosed with cystic
fibrosis at birth and has had these symptoms in the past.
What is the first line investigation for this patient?
A. Bloods (FBC, CRP)
B. CXR
C. CT
D. Pulmonary function
B. CXR
50 yo M smoker with multiple comorbidities (diabetes, HTN) presents to
A&E with 1d hx of confusion and productive cough with yellow sputum.
O/E he is apyrexial, BP 150/95 mmHG, HR 90 bpm, RR of 20 breaths
per min. His oxygen saturation is 96% at rest. There are crackles at the
left base.
What is the most likely causative organism in this case?
A. Staphylococcus aureus
B. Mycoplasma pneumoniae
C. Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Legionella pneumophila
C. Streptococcus pneumoniae
50 yo M smoker with multiple comorbidities (diabetes, HTN) presents to
A&E with 1d hx of confusion and productive cough with yellow sputum.
O/E he is apyrexial, BP 150/95 mmHG, HR 90 bpm, RR of 20 breaths
per min. His oxygen saturation is 96% at rest. There are crackles at the
left base.
How should we treat this patient?
A. Admit and give IV co-amoxiclav + macrolide
B. Admit and give oral amoxicillin
C. Admit for observations
D. Give him a smoke cessation leaflet
E. Send home with oral amoxicillin and advise to return if he becomes
severely unwell
E. Send home with oral amoxicillin and advise to return if he becomes severely unwell
What signs would you expect on physical examination of someone with
pneumonia?
a) Deviated Trachea, ↓ expansion, Dull to percussion
b) Bronchial Breathing, ↓ expansion, ↓ vocal resonance
c) Central Trachea, ↓ expansion, ↑ vocal resonance
d) Dull to Percussion, ↑ expansion, Pyrexia
c) Central Trachea, ↓ expansion, ↑ vocal resonance
A 55 year old man has a 3 day history of shivering, general malaise &
productive cough and is vomiting. The x-ray shows right lower lobe
consolidation. He is diagnosed with a moderate pneumonia, what is the
first line therapy?
a) Oral Amoxicillin
b) IV Co-Amoxiclav + Clarithromycin
c) Doxycycline
d) IV Amoxicillin + Clarithromycin
d) IV Amoxicillin + Clarithromycin
A 71 year old Gentleman is brought in by his carer with a 4 day history of a
fever and a cough. As you go to examine him he shouts and asks that you
leave his bedroom. His RR is 30, BP 103/68. The lab phones you a hour
later and let’s you know his urea is 7.8. Where would you manage this
patient?
a) Admit and treat
b) Treat at home
c) Consider ITU
d) Refer for palliative care
c) Consider ITU
Abx management for pneumonia based on severities
Low Severity – oral amoxicillin
Moderate – oral/IV amoxicillin + macrolide
High severity – IV Co-Amoxiclav + macrolide
25M presents to A&E with a fever and a cough. He says he has been
generally unwell over the last year . O/E he is acutely SOB with a RR of
28. You also note an incidental finding of purple patches on his nose.
What is the most likely causative organism?
a) Pseudomonas Aeruginosa
b) Strep Pneumoniae
c) Pneumocystis Jiroveci
d) Mycoplasma pneumoniae
c) Pneumocystis Jiroveci
HIV patients
55M presents with a cough and fever. He recently travelled to New York to
speak at a conference. After bloods revealed Na+: 130, you decide to test
the urine. What is the most likely causative organism?
a) Haemophilus Influenza
b) Pseudomonas Aeruginosa
c) Legionella Pneumophilia
d) Pneumocystis Jirovec
c) Legionella Pneumophilia
10F presents to A&E with a fever and a cough and O2 sats: 92%. Her
parents don’t seem worried as they are used to bringing her into hospital
for treatment for her respiratory illness
a) Pseudomonas Aeruginosa
b) Haemophilus Influenzae
c) Staph Aureus
d) Coronavirus
a) Pseudomonas Aeruginosa
A known IVDU is brought into A&E, he was found unconscious by two
friends who were worried he might have overdosed. You notice an
abscess in his groin. Temp: 39, HR 120, BP 90/50. You immediately admit
him.
a) Haemophilus Influenzae
b) Staph Aureus
c) Coronavirus
d) Legionella Pneumophilia
b) Staph Aureus
A 35 year old man presents to his GP with shortness of breath and a dry cough. Upon further questioning, he admits to generalised muscle aches and a fever. He suffers from eczema and takes potent steroid medications. The patient lives at home with his dog and pet parrots.
What is the most likely causative organism?
A Streptococcus pneumoniae
B Chlamydia psittaci
C Mycobacterium tuberculosis
D Haemophilus influenzae
E Legionella pneumophila
B Chlamydia psittaci
A 42 year old woman presents to her GP with a productive cough and a fever. She has breathlessness when walking up stairs and has lost 2kg in the past 2 weeks. Her enlarged cervical lymph nodes were biopsied, with the image from the histology showing a caseating granuloma.
What is the most likely causative organism?
A Streptococcus pneumoniae
B Chlamydia psittaci
C Mycobacterium tuberculosis
D Haemophilus influenzae
E Legionella pneumophila
C Mycobacterium tuberculosis
A consultant tells you that the patient in the side room is a 79 year old man who presented to A&E with respiratory distress. On inspection, he has finger clubbing and you can hear bibasal crackles when you listen with your stethoscope. His CT scan shows dilation of the terminal airways.
What is the most likely diagnosis?
A Pleural effusion
B Pneumonia
C Heart failure
D Pulmonary embolism
E Bronchiectasis
E Bronchiectasis
Literally dilation of the bronchi and bronchioles
A 75 year old woman presents to her GP with progressive shortness of breath and a productive cough. She has been a smoker all her life (20 cigarettes daily). Her blood and urine results are shown below.
Blood Na+ - 125mmol/L
Blood K+ - 4.7 mmol/L
Urine Na+ - HIGH
Urine osmalilty - HIGH
What is the most likely diagnosis?
A Mesothelioma
B Large cell carcinoma
C Squamous cell carcinoma
D Adenocarcinoma
E Small cell lung cancer
E Small cell lung cancer
A 59 year old man presented to the GP with a chronic non-productive cough. He has never smoked. Over the past two months, he has been losing weight but the patient attributed this to working longer hours as a construction worker.
What is the most likely diagnosis?
A Mesothelioma
B Large cell carcinoma
C Squamous cell carcinoma
D Adenocarcinoma
E Small cell lung cancer
A Mesothelioma
Male pt, lifelong smoker with cough and FLAWS
CXR shows lesion at central proximal bronchi
Which lung cancer?
Squamous cell carcinoma
- 20-25% lung Ca
- M>F, smokers
- spreads locally with late mets
Female pt, never smoked in her life with cough, bone pain and FLAWS
CXR shows peripheral lesion
Which lung cancer?
Adenocarcinoma
- 40% lung Ca, most common
- W>F, non-smokers
- has early mets
Pt, lifelong smokers with cough, FLAWS as well as flushed cheeks and diarrhoea
CXR shows lesion centrally in broximal bronchi
Which lung cancer?
Small cell carcinoma
- 15% lung Ca
- smokers
- paraneoplastic syndromes occur from neuroendocrine cells: SIADH, Cushing’s, hypo/hyperglycaemia, carcinoid syndrome, Lambert-Eaton syndrome
Male pts comes in with cough, FLAWS, and notes recently his chest has been getting bigger
CXR shows lesion peripherally in lungs
Which lung cancer?
Large cell carcinoma
- 5-10% lung Ca
- in men, gynaecomastia occurs due to beat-hCG secretion
- mets are late
If a chronic smoker with a cough and FLAWS also presented with one of the following, what do they have and why?
a) ptosis, miosis, anhydrosis
b) hoarse voice
c) one arm has wasted muscles, pains, paraesthesia and paraesis
Pancoast tumour
= occurs in apex of superior sulcus
= non-small cell carcinoma w/ smoking hx
a) sympathetic nerve invaded (Horner’s)
b) recurrent laryngeal nerve invaded
c) brachial plexus invaded
