Cough Flashcards
1
Q
Differences between the common cold and influenza
A
Incubation period - cold = 12hrs to 5 days, influenza is 1-3days
Fever- +/- in cold but >38 in influenza
Cough - develops later in common cold compared with influenza
Sore throat - more so in cold than influenza
Rhinitis/sneezing/rhinorrhoea - in cold not influenza
Muscle aches - influenza not colds
Toxaemia - only may develop in influenza
Causes - COmmon cold (rhinovirus common, parainfluenza, influenza B,C, Coronavirus, RSV.) Influenza A and B.
2
Q
population susceptible to influenza
A
Aged, young, pregnant, immunosupsed, diabetes, chronic disease
3
Q
Incubation and contagious periods for influenza
A
incubation 1-3 days
Contagious = 24hr prior to symptoms and 7 days after
4
Q
Progression of influenza
A
acute onset of fever, headache, shivering, generalised muscle aching
5
Q
Clinical criteria for influenza in an epidemic
A
High fever >38 + 1 respiratory symptom and 1 systemic symptoms dry cough sore throat coryza prostration or weakness myalgia headache rigors or chills
6
Q
Presentation of influenza in children
A
abdominal pain and diarrhoea or rash
7
Q
Complication of influenza
A
Secondary bacterial infection
Pneumonia due to staphylococcus aureus
Encephalomyelitis - rare
Depression - common
8
Q
Mx of influenza
A
Advice
bed rest until fever gone
analgesics - paracetamol adn aspirin
Fluids - maintain high intake
House arrest/isolation - from before start of symptoms to symptoms finish. Contacts as well
Anti viral agents if inidicated eg severe
Neuraminidase inhibitors within 36 hours of onset and given for 5 days
Prevention - Flu shot.
9
Q
Causes of Haemoptysis
A
Red flags and requires investigation Common Causes Acute infection - URTI 24%, Acute or chronic bronchitis 17% - commonest Bronchiectasis 13% TB Uncommon - cancer Lobar pneumia pulmonary infarction, PE FB Cardiac - LVHR, Mitral stenosis anticoagulant therapy Rare causes goodpasture syndrome blood disorders trauma
10
Q
Causes of productive cough
A
bronchiectasis - massive pus, chronic, hx of pneumonia
COPD - FEV/FCV
pneumonia
FB
Lung cancer - haemoptysis, slow progressive cough
TB - haemoptysis
Lung abscess
Chronic bronchitis - Chronic cough for 3 month out of 12 over 2 years
Asthma - especially at night
11
Q
Causes of non productive cough
A
ACE inhbitor non Asthmas? post infectious cough Lung cancer intersitial fibrosis Sarcoidiosis hyper sensitive pneumonitis bronchiolitis: inspiratory wheeze and consolidation, really young kids Psycogenetic cough Morning cough - Smokers
12
Q
Cause of cough + wheeze in children
A
URTI - most common Croup Pneumonia Bronchiolitis Heart failure acute asthma tuberculosis viral induced wheeze whooping cough Inhaled Foreign body
13
Q
Presentation of URTI
A
Coryza, breathlessness, cough, wheeze, or noisy breathing
14
Q
Presentation of croup
A
barking cough and stridor
15
Q
Presention of pneumonia in child
A
Fever, cough, respiratory distress, chest or abdominal pain, Intercostal recession, crackles and signs of consolidation
16
Q
Presentation of bronchiolitis
A
Yellow flag -
17
Q
Presentation of acute asthma in child
A
Yellow flag - Known asthmatic, Hx of atopy, wheeze, cough
18
Q
Presentation of tuberculosis in child
A
Red flag - Contact with TB, not immunised with BCG, haemoptysis, night sweats.
19
Q
Presentation of viral induced wheeze in child
A
wheeze with URTI, some progress to asthma, may respond to bronchodilators
20
Q
Presentation of inhaled foreign body
A
toddlers, Hx of choking, unilateral wheeze, sudden onset
21
Q
Cause of cough in child without breathlessness
A
Gastro-oesophogeal reflux Post nasal drip - commonest causes of persistent cough Trachea-Oesophageal fistula Passive smoking Cystic fibrosis
22
Q
Cause of chronic cough in first few months of life
A
Milk inhalation/reflux
Asthma
23
Q
Causes of chronic cough in toddler/preschool child
A
Asthma, Bronchitis whooping cough Cystic fibrosis Croup FB inhalation Tuberculosis Bronchiectasis
24
Q
Causes of chronic cough in early school years
A
Asthma
Bronchitis
Mycoplasma pneumonia
25
Causes of chronic cough in adolescence
Asthma
Psychogenic
smoking
26
Red flags to look out for in a presentation of cough
```
Age >50yr
smoking Hx
Asbestos hisotry exposure
Persistent cough
Overseas travel
TB exposure
Haemoptysis
Unexplained wt loss
Dyspnoea
```
27
Probabillty diagnosis in a cough presentation
URTI or acute bronchitis or persistent coughing with URTI due to sinusitis with postnasal drip. or chronic bronchitis. smoking
28
Serious disorders not to be missed in a presentation of cough
Bronchial carcinoma (P/C worsening cough or bovine cough), pneumocystis jiroveci in HIV pt, foreign body. Asthma in childern (PC noctnatal cough without wheeze). LV Heart failure, cystic fibrosis, pneumothorax
29
Pitfalls to look out for in diagnosing cough
```
Atypical pneumonias
GORD - night cough
Smoking
Bronchiectasis
Whooping cough
Interstitial lung disorders
Sarcoidosis
```
30
Masquerades to consider in cough
Drugs
31
IS the pt trying to tell me something with this cough presentation
Anxiety and habit
32
Thing to ask about in a cough history
```
Duration
Character
Pattern/timing
sputum production, volume, colour, smell, blood
Associated symptoms - chest pain, fever, SOB, Abdo pain, meals, wheezing,
Features of infection
Feature of cancer
Sick contacts
Travel or occupation exposture
PmHx - Asthma, heart disease
Medication
FMHx- asthma, cystic fibrosis, TB
SoHx - pets, smokers,
```
33
Thing to look for when examining a pt with cough
GI
Respiratory distress - grunting, nasal flaring, intercostal recession, tachypnoea, speaking in full sentences
Addition noise - wheeze, stridor, cough
Cyanosis,
Horner syndrome - constricted pupil, ptosis
Vitals - tachypnoea, fever
Resp
Signs of consolidation - reduced AE, crackles, bronchial breathing, dullness on percussion and reduced expansion
Lymphodenopathy in the neck.
Sputum - colour, consistency, presence of particular matter
CVS
signs of congenital heart disease - ??
Peripheral
signs of chronic respiratory condition - finger clubbing, chest deformity
34
Signs and symptoms of acute Bronchitis
cough and sputum are the main symptoms
wheeze and dyspnoea
scattered wheeze on auscultation
+/- fever or haemoptysis(uncommon)
35
Investigation for acute bronchitis
Not needed. Clinical diagnosis
36
Tx for acute bronchitis
Acute - Improve spotaneouly in 4-8 days in health patient
Symptomatic treatment
Inhaled bronchodilators if wheeze?
ABX if evidence of acute bacterial infection with fever and increase sputum volume and sputum purulence
amoxycillin 8 hr ly for 5 days or doxycycline
37
Common causes of community acquired pneumonia in adults
```
Viral
- RSV, Influenza, para influenza, adenovirus, Coxackie virus
Bacteria
- Streptococcus pneumoniae
- Haemophilus influenza
- Moraxella catarrhalis
mycoplasma pneumoniae
```
38
Factors that increase risk of pneumonia
```
>50 yrs old
alcoholism
asthma
chronic obstructive pulmonary disease
dementia
heart failure
immunosuppression
indigenous background
institutionalisation
seizure disorders
smoking
stroke
Predisposing factors- Congenital abnormalities of bronchi, Foreign body, recurrent aspiration , Cystic fibrosis
```
39
Prevention of pneumonia
```
Prevention = vaccination
Pneumococcal conjugate (13vPCV)or (23vPPV) high risk. at 2, 4, 6 months (12-18 months ATSI)
Pneumococcal polysaccharide (23vPPv) for medically at risk and ATSI). 4,15, 50,65+yrs
Haemophilus influenzae type B. 2, 4, 6, 12months
Yearly influenza vaccine
```
40
Symptoms of pneumonia in Adult
```
Symptoms
- often hx of viral infection
1-3 days history of the following - acute onset
High fever, night sweat, riggers
Pleuritic chest pain
rusty sputum
unilateral, whole lobe or segment
Cough dry - very loose productive cough.
Confusion
```
41
Symptoms of pneumonia in child
```
Children with short hx of
fever, cough, or
tachypnoea, nasal flaring, lower chest indrawing or recession, consolidation or effusion, or
persistent fever or
fever and upper abdominal pain.
Grunting common in infants
```
42
Red flags of bacteria cause of pneumonia in children
```
Signs of sepsis
Lethargic and unwell
Temp >38.5
go off their food
Signs of respiratory distress
Noisy breathing
Cough may be absence
Tachycardia especially if higher than fever should make it
```
43
Red flags of pneumonia in adults
```
fever > 38 and constant sweats
Age 65yr
Brown, rusty, colour sputum
Tachycardia hypotensive, tachypnoea, low O2 sat 90% and can’t speak in full sentences
Asthma or COPD hx
Multiple risk factos: smoker, diabetic
From tropic region
Evidence of sepsis
confusion
```
44
Signs to look for on examination of pt with pneumonia
GI - Increased work of breathing, pallor, greyish appearance if shocked, cough, may be leaning forward to relieve pleuritic chest pain, tripod position
Vitals- Tachypnoea, tachycardia, hyperpyrexia, reduced O2 saturation, possible increase BP if not shocked, reduced BP if shocked, BMI, BSL,
Hands; prolonged capillary refill time
Face: central and peripheral cyanosis
Neck; carotid pulse volume and character
Resp: I. Accessory muscle usage, intercostal rescission, reduced air entry.
P - increased tactile fremitus and reduced chest expansion.
P - dull over affected area.
A- crackles heard over effected area, bronchial breath sounds over consolidation and increased vocal resonance.
Abdo -
Legs -warm and well perfused, cap refill, oedema
45
Complication of pneumonia
```
Lung abscess - rare
Pleuritis
Pleural effusion
Pleural adhesions
Fibrosis
Emphysema
Spread of infection e.g. septicemia, meningitis, infective endocarditis, arthritis
Empyema - irregular
Bronchiectasis
Pneumothorax
Lung fibrosis
Atelectasis
Scar cancer (adenocarcinoma)- rare
complications more likely with serotype 3 pneumococci
Most heal without complications.
```
46
How to determine severity of pneumonia
```
CURB 65
Confusion 1
BUN >7mmol/L 1
RR >30 1
BP 65 1
Score
0-1 = outpatient
2 = Short stay
3-5 = hospital
```
47
What is the way to determine if pneumonia patient needs ventilation
```
SMARTCOP
less then 50
Systolic BP 24 (30 (>50) =1
Multi lobar CXR =1
Albumin less then 35g/L =1
RR 25 or more 1
Tachycardia greater then 124 =1
Confusion =1
O2 less then 93% = 2
pH 7.35 less = 2
0-2 points - low risk of ventilation
3-4 points - moderate risk
5-6 points - High risk
7 or more - very high risk.
```
48
Ix for pneumonia
```
CXR - consolidation
FBC - Neutrophilic
ABG
U and E
Sputum culture
Antibody titres if diagnosing mycoplasma pneumonia
```
49
Tx for mild pneumonia
Out patient
| Amoxycillin/clavulanate 12hr ly for 7 days or Doxycycline 200mg loading dose and 100BD (or roxithromycin)
50
Tx for moderate pneumonia
| And who is an automatic moderate
Hospitalise
Tropical or non tropical
- Non tropical - IV benzylpenicillin and doxycycline (amoxycillin)
- Topical - Ceftrixone IV and Gentamicin IV, +/- Doxycycline
51
Criteria of severe pneumonia and tx for it
guidelines for severe - CORB 2 or more, SMARTCOP 5 or more
altered mental state
rapidly deteriorating course
RR>30
HR >125
BP 20 x10^9L
Non tropical Abi - azithromycin + cefotaxime or ceftriaxone
Topical - Meropenem or Piperacillin + tazobactam (PIPTAZ) + Azithromycin.
52
How soon should follow up happen after consult of pneumonia
RV in 24-48 hrs
53
Tx of pneumonia in children
almost all those 70, intermittent apnoea, not feeding
older children - RR>50, Grunting, signs of dehydration
Both groups - O2 sat 24m penicillin or roxithromycin
Severe - flucloxacillin IV + cefotaxime IV +/- roxithromycin
54
Causes of lung cancer
Smoking
Occupational exposure = asbestosis, nickel, chromates, mustard gas, arsenic coal tar distillation
Fibrosis/scarring = TB, Pneumoconiosis, honey comb lung - Adenocarcinoma
Radioactive gases = Radon, atomic bomb survivors
Genetic predisposition = P450 gene polymorphisms
Idiopathic
55
What risk does being a smoker give you in lung cancer?
90% related to smoking
Heavy smoker - 60 fold increase risk
2 packs/day/20yr
>100 fold increase risk when combined with asbestos, coal, radon etc..
56
What are the commonest types of lung cancer
Small cell carcinoma ~20%
Adenocarcinoma ~50%
SCC ~30%
57
Pathogenesis of lung cancer
```
smoking/ carcinogens
3p/EGFR mutations
Dysplasia
More mutations (KRAS, C-Myc)
infiltration
Spread
Metastases
```
58
Age of presentation and symptoms of lung cancer
```
age commonly 50-70
Local
Cough 42%
Chest pain 22%
Wheezing 15%
haemoptysis 7%
Dyspnoea 5%
General
Anorexia, malaise
wt loss - unexplained
other
Unresolved chest infection
Hoarseness
Symptoms for metastases
Brain - Headache, personality change, seizures, limb weakness/sensory loss, vomiting
Liver - Jaundice (late sign)
Bone - Back pain, rib pain
```
59
Sign to examine for lung cancer
GI: hoarseness, Weight loss, cachexia, fever, active cough +/- haemoptysis, cigarettes, endocrine stigmata (cushingoid appearance)
Vital signs: Tachypnoea, febrile, hypotensive/ hypertensive, ↓O2 saturation, cachexia (low BMI), ↓BSL (paraneoplastic insulin)
Hands: Clubbing +/- hypertrophic pulmonary osteoarthropathy (HPO)(NSCC), anaemia signs (chronic disease), intrinsic muscle wasting (abduction and adduction weakness), wrist tenderness (brachial involvement), CO2 retention flap, tar staining etc.
Face: Apical / Pancoast’s tumour = Horner’s syndrome - meiosis, ptosis, lack of sweating, SVC Obstruction = plethora, cyanosis, periorbital oedema. Eyes: exophthalmos, conjunctival injection, venous dilation, Laryngeal nerve palsy (hourse voice)
Neck: Tracheal compression + deviation, SVC Obstruction = JVP raised (not pulsatile), Pemberton’s sign positive (raise arms 1 min – become plethoric and have resp distress), Supraclavicular or axillary lymphadenopathy
Respiratory: Signs of: Lobar collapse, pneumonia, pleural effusions, Fixed inspiratory wheeze, Mediastinal /tracheal compression = stridor (sound over trachea) + respiratory distress, Paralysis of phrenic nerve = dullness on percussion of base (ipsilateral side) + absent breath sounds, Tender ribs +/- bony tenderness (with tumour infiltration)
Lower extremities: Clubbing, anaemia signs
60
Complications of lung cancer
Pancoast tumour - destory first 2 ribs due to location
Horner’s syndrome - involves sympathic nerves
Epilepsy - due to CNS involvment - metastasis to brain
lung collapse
61
Investigation for lung cancer
Cytology (sputum and pleural fluid, bronchial lavage)
Chest X-ray
Biopsy or percutaneous fine needle aspiration
Bronchoscopy and thoracotomy
Tumour markers - epithalial, neuro, endo.
```
Other
CT for staging
F-deoxyglucose PET or PET/CT - staging
Radionuclide bone scan - metastasis
Lung function/spirometry - testing suitability for lobectomy
```
62
DDX of solitary pulmonary nodule on xray
```
Common
Bronchial carcinoma
Solitary metastasis
Granuloma eg TB
Hamartoma
less common
Bronchial adenoma
AV
Hydatid
other
```
63
Tx for lung cancer
NSCLC - curative resection in surgery then chemotherapy.
| SCLC - Surgery not an option as 80% are metastasis at time of diagnosis. Chemotherapy extend LE by 3-20 months
64
Side effects of chemotherapy in lung cancer
```
GI function is general interrupted and hair loss is common
Faitgue
pain
sores in mouth and throat
Diarrhea/constipation
loss of appetites
Nausea and vomiting
Blood disorders - commonly anaemia
changes in thinking and memory.
```
65
Predisposing conditions for Bronchiectasis
```
Congenital
primary ciliary dyskinesia
Cystic fibrosis
Congenital hypogammaglobulinaemia
Acquired
infection in childhood, such as whooping cough, pneumonia or measles
Localised disease such as a foreign body, a bronchial adenoma or tuberculosis
Allergic bronchopulmonary asperillosis
```
66
Symptoms of Bronchiectasis
```
Chronic cough that worse on walking
Mild disease = yellow or green sputum only after infection
advanced disease
profuse purulent offensive sputum- green, yellow
persistent halitosis (bad breath)
recurrent febrile episodes
Malaise, wt loss
Sputum production related to position
PmHx - pneumonia,
Haemoptysis
```
67
Signs of bronchiectasis
```
GI - cachexia
Vitals -fever
Hands - Clubbing (severe cases)
Face - sinusitis, cyanosis
Neck - tracheal midline
Resp
Commonly affects lower lobe but may have one or more lobes at once
I - slight reduction in chest expansion
P - normal or decrease vocal femitus
P - may be resonant or dull.
A - Late inspiratory coarse crackles +/- localised wheeze. bronchial breath sounds.
```
68
Ix for Bronchiectasis
Sputum culture = mix of normal flora - bacteria don’t cause it they just grow once it is blocked. Done to exclude TB
Streptococcus pneumoniae, pseudomonas aeruginosa, Haemophilus influenzae (commonest)
Spirometry meter
Diagnosed = CT scan to visulise larger bronchi
CXR - normal or bronchial changes
Cytology - rule out neoplasm
69
Tx for bronchiectasis
Explanation and preventative advise
Postural drainage eg lie over side of bed with head and thorax down for 10-20 minutes 3 times a day
ABx according to organism - need to eradicate infection to halt progress of disease
Amoxycillin or Doxycycline
Bronchodilators indicated if evidence of bronchospasm.
Treat underlying cause.
70
Pathogenesis of TB
Mycobacteria entry respiratory tree and invade the alveolar macrophage via the mannose-capped glycolipids recognised by the macrophage’s mannose receptor.
Once inside the mycobacteria manipulate the endosome in 3 ways: Maturation arrest, Lack of acid pH, Ineffective phagolysosome formation
This leads to unchecked bacilliary proliferation that can lead to Bacteremia with seeding of multiple sites
Over time infected Alveolar macrophage APC to TH1 cells via MHC II the MTB antigen with cytokine IL-12 = activated TH1 cells-> IFN-gamma _> Activates Macrophage to increase Nitric oxide and free radical via iNOS = bactericidal activity
Activated Macrophages -> TNF, cytokiness that recruit monocytes = granuloma formation with sensitised T cells + Epithelioid macrophages and caseous necrosis
Usually heals with scar = Ghon complex
71
Diagnostic triad for TB
Malaise, cough, wt less +/- erythema nodosum
72
Classic symptoms of pulmonary TB
```
Cough chronic
SOB
Haemoptysis
Fevers
Night sweats
anorexia
weight loss
over a period of weeks to months
```
73
Signs of TB
```
Signs of Anaemia
Signs of SVC obstruction
Clubbing
+/- trachea divation
Cervical or axilla lymphadenopathy
Resp - decreased or absent BS, bronchial breathing, Signs of pleural effusion
```
74
Sign of anaemia
pallor, cool peripheral, conjunctiva pallor, hyperdyaminc apex beat, systolic flow murmur,
75
Signs of SVC obstruction
face is plethoric and cyanosi with periorbital oedema
Eyes may show exophthalmos, conjunctival injection and venous dilation in the fundi,
JVP elevated but not pulsatile
thyroid my be enlarge
suprclavicular lymphadenopathy
positive pemberton’s sign
dilated collateral vessels
76
Signs of pleural effusion
Displaced apex beat and trachea, ↓ expansion (ipsilateral side), Stony dullness on percussion, ↓ or absent breath sounds (+/- bronchial breathing),↓ vocal resonance
77
IX for TB
Need to have a high index of suspicion
CXR
sputum culture with acid fast stain
IFN - gamma release assays
78
Tx for TB
```
Notifiable disease
most can be treated as outpatient
Follow up monthly - Sputum smear and culture
Pharmacological
complicated multiple drug regimens over long period of time - 6 months
Isoniazid
Rifampin
Ethambutol
Pyrazinamide
use all 4 daily for 2 months then
Rifampicin +isoniazid daily for 4months
best done supervised on DOT 3 times a week.
```
79
What is symptomatic tx for cough and when is it indicated
indicated for acute self-limiting causes of cough eg acute viral infection
Recommended mixture based on clinical situation and should only be short term
eg pholcodine 1mg/ml, 10-15ml PO 3-4 times daily or
egCodeine 5mg/ml 5 ml PO 3-6 hourly.
80
When to refer a pt when they present with a cough
pt who need bronchoscopy to exclude bronchial carcinom
81
CORB
```
Measures severity level of pneumonia in GP setting
C - confusion
O - O2 9O%
R - RR greater then 30
Bp - less then 90 sBP
0= mild
1= Moderate
2 = Severe
```
82
Mild pneumonia
```
Age less then 50yr
HR less then 125
temp between 35-40
No comorbidityes e.g. cancer, CCF, Renal disease or CVD
CORB = 0
SMART COP less then 3
```
83
Moderate pneumonia
NOT mild
CORB less then 2
SMART COP less then 5
84
Severe pneumonia
not mild or moderate
CORB greater then 2
SMART COP greater then 4
85
Causes of Crackles/Crepitation
Pneumonia
Pulmonary oedema
Interstitial disease e.g. fibrosis
Bronchestatsis
86
Causes of Wheeze
Asthma
COPD - not the main features. Reduced AE is
Cardiac wheeze - pulmonary oedema
