Cough Flashcards by Eilish Irvine

Acute ddx of cough

Dry
=> asthma, ACEi drugs, heart failure, URTI (laryngitis, pharyngitis)
Productive
=> pneumonia (LRTI), TB

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Chronic ddx of cough

Dry
=> asthma, lung cancer, GORD, mesothelioma
Productive
=> COPD, bronchiectasis, lung cancer, cystic fibrosis

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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

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Ix for pneumonia

Basic obs
Sputumb MCS
Pleural fluid MCS
Bloods: ABG, CRP, FBC
CXR: lobar/bronchpneumonia/consolidation/air bronchograms

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Complications of a pneumonia

Sepsis
Empyema
Pneumothorax
Lung abscess
Pleural effusion

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How may a lung abcess present?

Swinging fevers, persistent pneumonia, foul-smelling sputum
Often Staph. aureus

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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

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Acute mx of a pneumonia

Oxygen, sit pt up
IV fluids
CPAP if required (type I resp failure)
Surgical drainage (if abscess/empyema)

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Which Abx are used for CAP organisms?

Strep. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
=> Amoxicillin
=> Co-amoxicalv if severe

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Which organisms form cavitating lesions?

Klebsiella
Staph. aureus

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Which Abx are used for HAP organisms?

Klebsiella, Staph. aureus, Pseudomonas aeruginosa
=> Staph: flucloxacillin + gentamycin (aminoglycoside)
=>MRSA: vancomycin (glycopeptide)

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Which Abx are used for atypical organisms?

Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia psittaci
=> clarithromycin (macrolide)

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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)

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Which Abx are used for aspiration pneumoniaes?

Anaerobes from gut flora include Strep. pneumoniae, Staph. aureus
=> Metronidazole (nitroimidazole)

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Signs + sx of TB

Fever, lethargy, wt loss, night sweats, cough w/ green sputum, haemoptysis, lympahdenopathy dissemination of TB

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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

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What might a TB CXR show?

Consolidation (patchy/heterogenous)
Bihilar lymphadenopathy
Upper lobe scarring
Cavitating lesions
Pleural effusions
If miliary => nodular shadowing

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RFs of TB

Smoking, travel, South Asians/Indian/Bangladesh, immunocompromised (HIV pts)

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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

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Signs and sx of bronchiectasis

Bibasal crackles, clubbing

Haemoptysis, wt loss, fever, chest pain, chronic green cough and sputum, SOB

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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