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MedEd Lectures > Cough > Flashcards

Cough Flashcards

1
Q

How is cough classified

A

Acute <3 weeks:
Dry - asthma, URTI, lung cancer (causing obstruction of bronchus), pulmonary oedema (secondary to HF), drug induced (ACEi), smoke/toxin inhalation, small PE, inhaled foreign body
Productive - LRTI (pneumonia), TB

Chronic (>8 weeks)
Dry - Asthma, COPD, lung cancer
Productive - Bronchiectasis, TB, lung cancer (if congenital: CF)

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2
Q

Give examples of URTI

A
  1. pharyngitis
  2. laryngitis
  3. tracheitis
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3
Q

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?

Asthma
Pneumonia
Chronic sinusitis
Bronchiectasis

A

Bronchiectasis

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4
Q

What are the most common causative organisms of bronchiectasis

A
  1. H. influenzae
  2. S. pneumoniae
  3. S. aureus
  4. P. aeruginosa
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5
Q

Other than infections, what are the other causes of bronchiectasis

A
  1. immunodeficiency
    - HIV, immunoglobulin deficiency
  2. Genetic
    - CF, ciliary dyskinesia, alpha 1 anti trypsin deficiency
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6
Q

Other than infections, what are the other causes of bronchiectasis

A
  1. immunodeficiency
    - HIV, immunoglobulin deficiency
  2. Genetic
    - CF, ciliary dyskinesia, alpha 1 anti trypsin deficiency
  3. Connective tissue disorders
    - rheumatoid arthritis
  4. aspiration/inhalation injury
  5. Inflammatory bowel disease
    - Crohn’s disease, UC
  6. Focal body obstruction
    - foreign body, tumour
  7. Post infectious
    - childhood respiratory infections due to viruses, mycobacteria infection or severe bacterial pneumonia, exaggerated response to inhaled Aspergillus fumigatus
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7
Q

Essentially, what are the strong risk factors for bronchestasis

A
  1. cystic fibrosis
  2. host immunodeficiency
  3. previous infections
  4. congenital disorders of the bronchial airways
  5. primary ciliary dyskinesia
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8
Q

What are the symptoms of bronchiectasis

A
  1. persistent cough
  2. mucopurulent sputum (green or rusty coloured)
  3. SOB (decubitous)
  4. Haemoptysis (less common)
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9
Q

What are the signs of bronchiectasis

A
  1. Crackles on auscultation
  2. squeaks and pops on inspiration
  3. presence of underlying disorder
  4. fever
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10
Q

What are the investigations for bronchiectasis

A
  1. observations
    - pulse oximetry may show hpoxaemia
  2. CXR
    - first line
  3. high resolution CT
    - GOLD STANDARD
  4. FBC
    - raised WBC, eosinophils indicates aspergillosis
  5. sputum culture
  6. pulmonary function
    - reduced FEV1, elevated RV/TLC
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11
Q

What is the gold standard investigation for bronchiectasis

A

high resolution CT

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12
Q

How do you test for cystic fibrosis

A

sweat sodium chloride concentration or genetic testing

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13
Q

How do you test for alpha-1 anti-trypsin deficiency

A

Serum alpha-1 anti-trypsin level

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14
Q

How do you test for an exaggerated response to inhaled Aspergillus fumigatus

A

Skin prick test for Aspergillus fumigatus for patients with elevated IgE

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15
Q

What features of a CXR suggest bronchiestasis

A

Tram track sign

- dilated, thickened walls

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16
Q

What features of a CT suggest bronchiectasis

A

Signet ring sign/string of beads sign

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17
Q

What is the management plan for bronchiectesis

A
  1. Exercise, improve nutrition
  2. Airway clearance therapy
    - postural drainage, percussion
  3. Inhaled bronchodilator
    - salbutamol
  4. Inhaled hyperosmolar agent
    - hypertonic saline
  5. some patients may need antibiotics
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18
Q

What is the prognosis for bronchiectesis

A

Irreversible

- prognosis depends on severity and recurrence of exacerbation

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19
Q

What are the complications of bronchiectesis

A
  1. Haemoptysis
  2. respiratory failure
  3. cor pulmonale
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20
Q

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?

Bloods (FBC, CRP)
CXR
CT
Pulmonary function

A

CXR

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21
Q

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?

Staphylococcus aureus
Mycoplasma pneumoniae
Streptococcus pneumoniae
Pseudomonas aeruginosa
Legionella pneumophila
A

Streptococcus pneumoniae

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22
Q

What are the causative organisms for HAP

A
  1. Pseudomonas aeruginosa
  2. Escherichia coli
  3. klebsiella pneumoniae
  4. acinetobacter species
  5. Staphylococcus aureus (MSSA)
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23
Q

What are the causative organisms for atypical pneumonia’s

A
  1. Mycoplasma pneumoniae
  2. Chlamydophila pneumoniae
  3. Legionella pneumophila
  4. Coxiella burnetii (zootonic pathogen)
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24
Q

What are the signs of pneumonia

A
  1. productive cough
    - coloured sputum
  2. SOB
  3. pain on inspiration
    - pleuritic
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25
Q

What are the symptoms of pneumonia

A
  1. Fever
  2. Confusion
  3. Dull percussion
  4. Bronchial breathing on auscultation
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26
Q

What are the investigations for pneumonia

A
  1. Observations
  2. Bloods
    - FBC and CRP
  3. Sputum sample
    - microscopy and culture
  4. CXR (most important)
    - consolidation
    - alveolar opacification
    - air bronchograms
    - lobular vs. multilobar
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27
Q

Treatment plan for pneumonia is based on which scoring system

A

CURB65

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28
Q

Treatment plan for pneumonia

A 
CURB65
C confusion 
U urea >7mmol/L
R resp rate >30 
B BP <90/60 mmHg 
>65 years old

1 point each

0-1: treat at home if possible
2: consider hospital treatment
3 or more: severe, consider ITU

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29
Q

Based on the CURB65 score, which antibiotics can be used to treat pneumonia

A 
low severity (0-1): oral amoxicillin 
Moderate (2): oral/IV amoxicillin + macrolide 
High severity (3+): IV Co-Amoxiclav + macrolide
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30
Q

What is the prognosis of pneumonia

A

CURB score
0-1: <1%
2: 5-15%
3 or more: 20-50%

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31
Q

What are the complications of pneumonia

A
  1. Septic shock
  2. C. difficile infection from antibiotic use
  3. Death from heart failure, respiratory depression in the elderly or severely unwell
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32
Q

What are the 4 mechanisms of entry of pneumonia causing pathogens

A
  1. inhalation (viral + atypical)
  2. Aspiration of URT (upper respiratory tract infections) secretions
  3. Haematogenous from local infection (e.g. endocarditis)
  4. Direct extension from local foci (TB via lymphatics)
33
Q

What is the single best investigation for diagnosing pneumonia

A

CXR

  1. Consolidation
  2. alveolar opacification
  3. Air bronchograms
  4. lobular vs multilobular
34
Q

Atypical pneumonias: Legionella

What is its transmission method

A
  1. Found in aqueous environments - transmitted through inhaled water droplets
    (e. g. air conditioning, whirlpool spas, contaminated water supplies, recent plumbing work)
  2. Legionella Pneumonia = legionnaire’s disease
35
Q

Atypical pneumonias: Legionella

What is non-pneumatic legionella referred as

A

Pontiac fever

36
Q

Atypical pneumonias: Legionella

What is its presentation

A
  1. Prodromal (early sign) flu-like symptoms which include fever, malaise, myalgia
  2. Dry cough (can become productive)
  3. GI symptoms (nausea, D+V)
37
Q

Atypical pneumonias: Legionella

What investigations need to be done

A
  1. sputum culture
  2. urinary antigen detection
  3. Hyponatraemia
  4. CXR looking for bi-basal consolidation
38
Q

Atypical pneumonias: Legionella

What is the treatment

A

IV fluroquinolones (ciprofloxacin)
OR
macrolide
(clarithromycin)

39
Q

What are atypical pneumonia

A

are caused by atypical organisms that are not detectable on Gram stain and cannot be cultured usinf standard methods

40
Q

Atypical pneumonias:
Pneumonocystis Jirovercii
What is it and how is it treated

A
  • Caused by pneumocystis pneumonia (PCP)
  • Opportunist fungal infection and is an AIDS defining illness
  • Recurrent bacterial pneumonias is a risk factor
  • Seen in HIV + pts
  • significant weight loss is a risk factor too
    Treatment:
    High dose Co-Trimoxazole
41
Q

Atypical pneumonias:
Pseudomonas Aeruginosum
What is it and how is it treated

A
  • Seen in patients with bronchiectasis or cystic fibrosis
    Treatment:
    Piptazobactam (Piperacillin + Tazobactam)
42
Q

Atypical pneumonias:
Mycoplasma Pneumonia
How does it present and what are the risk factors

A
  • Insidious onset
  • Persistent cough
  • low grade fever
  • red cell agglutinins and transverse myelitis
  • commonly seen in close community settings e.g. boarding schools, universities, army bases
43
Q

Atypical pneumonias:
Mycoplasma Pneumonia
What are the investigations and findings

A

CXR
worse clinical picture than patient symptoms
PCR for suspected M. Pneumonia
Historically - cold agglutinins

44
Q

Atypical pneumonias:
Mycoplasma Pneumonia
What is its treatment

A

macrolide such as erythromycin/clarithromycin

45
Q

Atypical pneumonias:
Staph Aures
What are its risks

A
  • commonly seen in intravenous drug users (IVDU)

- can arise from blood-borne spread of organisms from infected tissue can lead to septicaemia

46
Q

Atypical pneumonias:
Staph Aures
What are the investigations and findings

A

CXR: Patchy areas of consolidation that break to form abscesses which appear as cysts

47
Q

Atypical pneumonias:
Staph Aures
What is its treatment

A

Flucloxacillin (Vancomycin if MRSA)

48
Q

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?

Admit and give IV co-amoxiclav + macrolide
Admit and give oral amoxicillin
Admit for observations
Give him a smoke cessation leaflet
Send home with oral amoxicillin and advise to return if he becomes severely unwell

A

Send home with oral amoxicillin and advise to return if he becomes severely unwell

because his CURB65 score is only 1

49
Q

Define TB

A

An infectious disease caused by Mycobacterium tuberculosis. In many cases, M tuberculosis becomes dormant before it progresses to active TB

50
Q

What is the epidemiology of TB

A

9th leading cause of death worldwide

85% of deaths in African region and South-East Asia Region

51
Q

How is TB transmitted

A

TB is transmitted via aerosol droplets

52
Q

What are the risk factors for TB

A
  1. recently travelled to Asia, Latin America or Africa
  2. Immunosuppression
  3. Malnutrition
  4. Alcoholism
53
Q

What are the symptoms of TB

A
  1. Cough
    2-3 weeks duration which changes from dry to productive
  2. Drenching night sweats
  3. FLAWS
  4. haemoptysis
    <10% of patients (usually advanced stage)
54
Q

What are the signs of TB

A
  1. Fever
  2. Crackles, bronchial breathing on auscultation
  3. Erythema nodosum
55
Q

What are the investigations for TB

A
  1. Observations
  2. CXR
  3. sputum smear
    - for acid-fast bacilli
    - using Ziehl-Neelson staining
    - on Lowenstein-Jensen agar
    - TB showing up as bright red
  4. Nucleic acid amplification test (NAAT)
56
Q

Define lung cancer

A

Carcinoma (malignancy of epithelial cells) arising from cells lining the lower respiratory tract

57
Q

What are the 4 main categories of lung carcinoma

A
  1. Small cell (strong association with smoking, highly malignant, may produce endocrine hormones e.g. ACTH or ADH)
  2. Non small cell (80% of all lung carcinomas)
    - Adenocarcinomas (45% of NSCLC, peripheral in lungs, associated with non-smokers)
    - Squamous cell carcinoma (25-30%, later mets)
    - Large cell carcinoma (10% - centrally)
  3. Metastases
  4. Mesothelioma
58
Q

What is the risk factor for lung cancer

A
  1. Smoking (85% of lung carcinomas)
  2. exposure to tobacco smoke, radon gas or asbestos
  3. COPD
59
Q

What is the epidemiology of lung cancer

A
  • Most common cause of cancer mortality worldwide with 17.6% of the world total
  • Lung cancer is the third most common cancer type in Europe, with NSCLC accounting for 80% of all lung cancer cases
60
Q

The metastases from which 2 carcinomas are most common causes of breast cancer

A

Breast and colon carcinomas

61
Q

What are the symptoms or Lung cancer

A
  1. fLAWs
  2. cough
    haemoptysis
  3. SOB
62
Q

What are the signs of Lung cancer

A
  1. Horner’s syndrome
  2. Cachexia
  3. Anaemia
  4. clubbing
  5. paraneoplastic syndromes
    e.g. ADH secretion leading to SIADH which can lead to hyponatremia
    or
    ACTH secretion which leads to Cushing’s
  6. May have wheeze, crackles, dullness to percussion, reduced breath sounds
63
Q

What is the single best investigation for lung cancer

A

Biopsy

64
Q

What are the investigations that can be used to diagnose lung cancer

A
  1. Observations
  2. CXR
  3. CT
  4. Sputum cytology
    low sensitivity so not routinely used but necessary when determining chemotherapy
  5. Bronchoscopy
  6. Biopsy
    Often required for definitive diagnosis
65
Q

What are the CXR features of small cell lung cancer (SCLC)

A

central mass
hilar lymphadenopathy
pleural effusion

66
Q

What are the CXR features of non small cell lung cancer (NSCLC)

A 
Variable 
may detect single or multiple pulmonary nodule(s)
pleural effusion 
lung collapse 
mediastinal or hilar fullness
67
Q

Define mesothelioma

A

it is an aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium or tunica vaginalis

68
Q

What environmental exposure is directly linked to mesothelioma

A

asbestos

69
Q

What 2 conditions can asbestos cause

A
  1. asbestosis

2. mesothelioma

70
Q

What is asbestosis

A

Diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres

This is when asbestos fibres remain in the alveoli

Strong correlation to smoking

71
Q

How does asbestos cause mesothelioma

A

Asbestos fibres become lodged in the lining of the lungs

it has a weak correlation to smoking

72
Q

What are the symptoms of mesothelioma

A
  1. Dry cough
  2. SOB
    (FLAWS)
73
Q

What are the clinical signs of mesothelioma

A

Muffed breath sounds on auscultation

as a result of pleural effusion

74
Q

What are the investigations for mesothelioma

A
  1. CXR
  2. CT
    - thickened pleural plaques
75
Q

What are the investigations for asbestosis

A
  1. CXR
  2. CT
    - advanced asbestosis appears as excessive whiteness in the lung tissue
    - severe =: honeycomb appearance
76
Q

What genetic mutation leads to cystic fibrosis

A
  • Autosomal recessive

- Defect in the Cystic Fibrosis Transmembrane Conductance regulator on chromosome 7

77
Q

The inflammation caused by cystic fibrosis can lead to what

A

bronchiectasis

78
Q

What causative organisms of pneumonia are commonly found in individuals with cystic fibrosis

A

Archetypal microbe: pseudomonas Aeruginosa
Staph Aures
Strept pneumoniae
H influenza

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