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Respiratory OSSE > Dyspnoea > Flashcards

Dyspnoea Flashcards

1
Q

What are the symptoms of COPD?

A

Progressive dyspnoea over a period of years
Slowly worsening exercise tolerance
Chronic productive cough (may be unproductive), typically worse in the morning and after exercise
May be comorbidities; exacerbations present with fever, subacute increase in dyspnoea, increased sputum production, change in sputum character;
Severe degree of impairment in young patient or patient with minimal or no smoking history suggests alpha-1 protease deficiency

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2
Q

What are the signs of COPD?

A

Facial plethora (fullness of the face + pink) Cyanosis
Laryngeal height of 4 cm or more
Pursed lip breathing,
Hyper-expanded chest, Prolonged exhalation,
Rhonchi, and wheeze; may be clubbing
Severe cases: resting or exercise hypoxaemia; may be pulsus paradoxus, mental state changes

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3
Q

What first line investigations would you consider in COPD?

A

Spirometry: decreased forced expiratory volume in the first second of expiration (FEV1), decreased FEV1/forced vital capacity (FVC) ratio
Pulmonary function tests: increased residual volume (RV), increased total lung capacity (TLC), decreased carbon monoxide diffusing capacity
ABG: hypoxaemia, hypercapnia

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4
Q

What other investigations would you consider in COPD?

A

Chest x-ray: increased lung volume, flattened hemidiaphragms may be present

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5
Q

What are the risk factors for COPD?

A

Current or prior history of smoking
Family history of COPD,
Childhood respiratory infections
Occupational exposure to smoke, fumes, chemicals; may be comorbidities; exacerbations present with fever, subacute increase in dyspnoea, increased sputum production, change in sputum character; severe degree of impairment in young patient or patient with minimal or no smoking history suggests alpha-1 protease deficiency

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6
Q

What are the symptoms of congestive cardiac heart failure?

A 
Orthopnoea
Paroxysmal nocturnal dyspnoea
Exertional dyspnoea,
Dyspnoea may be chronic with acute exacerbations
Chest pain
Ankle swelling
Rapidly progressive failure
Dyspnoea dominates the clinical picture
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7
Q

What are the signs of congestive cardiac heart failure?

A

Distended neck veins, Fine bibasal rales, Displaced apex beat,
S3 gallop rhythm, Peripheral oedema, may be increased abdominal girth, may be cyanosis and altered mental state

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8
Q

What first line investigations would you consider in congestive cardiac failure

A

Chest x-ray: cardiomegaly, bilateral lower lobe shadowing, pleural effusion, enlarged hilar vessels, upper lobe diversion, fluid in horizontal fissure, Kerley B-lines
More
echocardiogram: valvular heart disease or regional/global wall motion abnormalities
B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP): elevated

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9
Q

What other investigations would you consider in congestive cardiac failure?

A

serum electrolytes: may be hyponatraemia
bedside ultrasonography: may demonstrate the presence of B-lines
ECG: no specific pattern associated with heart failure exacerbation; Q wave, ST segment depressions, T wave inversion, left bundle branch block, and rhythm changes (atrial fibrillation and flutter) can all be seen
cardiac enzymes: may be elevated, as a reflection of myocardial strain and injury

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10
Q

What are the symptoms of asthma?

A

episodic wheezing, cough, chest tightness and dyspnoea, symptom variability - may be seasonal, or following viral infection or exposure to aeroallergen, cool air, or exercise; possible history of other atopic diseases; onset of symptoms normally in childhood

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11
Q

What are the signs of asthma?

A

may be normal in between exacerbations, prolonged expiratory phase, wheeze, and rhonchi; acute severe asthma attack may include: severe breathlessness (including too breathless to complete sentences in one breath), tachypnoea, tachycardia, silent chest, cyanosis, accessory muscle use, altered consciousness or collapse

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12
Q

What are the first lines investigations that you would do in asthma?

A

peak expiratory flow rate (PEFR): may be reduced; may be variability of measurements recorded at different times of the day
spirometry: may be decreased forced expiratory volume in the first second of expiration (FEV1), decreased FEV1/forced vital capacity (FVC) ratio; may show positive bronchodilator reversibility of obstructive spirometry results; may be normal
fractional exhaled nitric oxide test (FeNO): elevated FeNO (≥40 parts per billion) supports the diagnosis of asthma

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13
Q

What other investigation would you consider in asthma?

A

bronchoprovocation testing: airway hyper-responsiveness
FBC: normal or elevated eosinophils and/or neutrophilia
immunoassay for allergen-specific IgE: may be positive for allergen
skin prick allergy testing: may be positive for allergen
6-week trial of inhaled corticosteroids: symptomatic and objective improvement in response

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14
Q

What are the symptoms of pneumonia?

A

sudden or sub-acute onset of fever, chills, cough, pleuritic chest pain, and dyspnoea; cough typically produces purulent sputum, but may be dry in some viral pneumonias and early bacterial pneumonia; onset is more insidious in fungal and tuberculous infections

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15
Q

What are the signs of pneumonia?

A

fever, tachycardia, tachypnoea, crackles, may be focal chest signs of consolidation: dullness on percussion, decreased chest expansion, bronchial breathing; may be signs of effusion: focal decreased breath sounds, and decreased fremitus; less frequently, jaundice; severe cases: hypoxaemia, cyanosis, altered mental state, and respiratory failure

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16
Q

What first line investigations would you do in pneumonia?

A

chest x-ray: lobar infiltrate, cavitation, interstitial infiltrates
sputum Gram stain and culture: may demonstrate presence of bacteria

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17
Q

What other investigations would you do in pneumonia?

A

procalcitonin: elevated in bacterial pneumonia
FBC: elevated WBC with/without neutrophilia and left shift may be present
LFTs: elevated serum transaminases may be present with atypical pneumonia
ABG: hypoxaemia and respiratory alkalosis may be present in severe pneumonia
blood cultures: may be positive for specific organism
serum urea or serum urea/serum albumin ratio: elevated levels of either test predict poor prognosis

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18
Q

What other differentials should you consider?

A

ACS
Stable Angina
Anxiety and Panic Attack

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19
Q

What are the symptoms of Interstitial lung disease?

A

slowly progressive dyspnoea and a chronic, dry cough

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20
Q

What are the signs of interstitial lung disease?

A

dry crackles; hypoxaemia, cyanosis, and clubbing may be present

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21
Q

What are the risk factors for interstitial lung disease?

A

smoking, rheumatological diseases, exposure to solvents, organic dust, and moulds, chemotherapy and radiotherapy, and certain medications, although many cases are idiopathic

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22
Q

What first line investigations would you consider in interstitial lung disease?

A

chest x-ray: diffuse reticulonodular changes, decreased lung volume
CT chest: diffuse reticulonodular changes

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23
Q

What other investigations would you consider in interstitial lung disease?

A

lung biopsy: interstitial pneumonitis
pulmonary function tests: restrictive pattern; isolated reduction in carbon monoxide diffusing capacity may be the first sign

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24
Q

What are the symptoms of bronchiectasis?

A

chronic cough, chronic daily purulent sputum production, and dyspnoea; possible history of prior pulmonary infections or viral pneumonias in childhood

25
Q

What are the signs of bronchiectasis?

A

prolonged expiratory phase, crackles, rhonchi, and wheeze; clubbing, cyanosis, and hypoxaemia may be present

26
Q

What first line investigation would you consider in bronchiectasis?

A

chest x-ray: thickened airways, irregular opacities (predominantly in lower zones), areas of atelectasis
high-resolution CT chest: thickened airways, irregular opacities (predominantly in lower zones), areas of atelectasis, bronchial dilation, tram-tracking, lack of airway size tapering
pulmonary function tests: obstructive ventilatory deficit

27
Q

What are the symptoms of non-infective pneumonitis?

A

fever, chills, cough (dry or productive), and dyspnoea; myalgias, pleuritic chest pain, and night sweats may be present;
History of radiation to chest 1 to 6 months before presentation in radiation pneumonitis;
Episodes of clouded consciousness, choking, and aspiration in aspiration pneumonitis;
Exposure to organic antigens (e.g., bath tub, birds, hay) in hypersensitivity pneumoniti

28
Q

What are the signs of non-infective pneumonitis?

A

crackles; wheeze and rhonchi less common; hypoxaemia and respiratory failure may be present in severe cases

29
Q

What first line investigation would you consider in non-infective penumonitis?

A

chest x-ray: alveolar infiltrates
CT chest: patchy, nodular infiltrates
bronchoalveolar lavage: eosinophilia in eosinophilic pneumonitis

30
Q

What other investigation would you consider in non-infective pneumonitis?

A

bronchoscopic biopsy: granulomata in hypersensitivity pneumonitis

31
Q

What are the symptoms of acute bronchitis?

A

upper respiratory tract symptoms; cough; prolonged coughing and dyspnoea (especially on exposure to cold air, exercise, or irritants) may occur

32
Q

What are the signs of acute bronchitis?

A

fever, cough, inability to take deep breaths (‘cough readiness’); lung examination may be normal or reveal rhonchi and wheeze

33
Q

What first line investigations would you consider in acute bronchitis?

A

none: clinical diagnosis

34
Q

What other investigation would you consider in acute bronchitis?

A

chest x-ray: may be helpful to exclude pneumonia, other causes of cough and fever

35
Q

What are the symptoms of pulmonary embolism?

A

sudden-onset dyspnoea and chest pain; may be pre-syncope or syncope, haemoptysis, palpitations, may be asymptomatic; possible history of previous venothromboembolic disease, inadequate anticoagulation, immobilisation, admission to hospital, travel, vascular access, leg injury, malignancy, or childbirth

36
Q

What are the signs of pulmonary embolism?

A

tachycardia, tachypnoea, may be hypotension, cyanosis, hypoxaemia, and neck vein engorgement, may present with lower extremity oedema

37
Q

What other investigations would you consider in pulmonary embolism?

A

D-dimer: elevated

CT angiography: presence of embolus

38
Q

What first line investigations would you consider in pulmonary embolism?

A

ventilation-perfusion (V/Q) scan: V/Q mismatch
ABG: may show hypoxaemia and hypocapnia
chest x-ray: usually normal, but may show peripheral, triangular opacity (Hampton’s hump), regional oligaemia (Westermark sign), or enlarged pulmonary artery (Fleischner sign); may also demonstrate a pleural effusion
echocardiogram: right ventricular wall hypokinesis (McConnell’s sign) may indicate a major embolus
ECG: may show atrial arrhythmias, tachycardia, new right axis deviation, new right bundle branch block, S wave in lead I, Q wave with T-wave inversion in lead III
serum brain natriuretic peptide (BNP): may be elevated or normal; insensitive/non-specific for diagnosis; useful for prognosis, may predict a major embolus

39
Q

What are the symptoms of pleural effusion?

A

symptoms depend on rate of fluid accumulation and fluid volume; pleuritic chest pain and a dull ache may be present

40
Q

What are the signs of pleural effusion?

A

asymmetrical chest movement, ‘stony’ dullness to percussion, decreased fremitus, and absent breath sounds are typical in pleural effusion; examination may be normal in pleural tumours

41
Q

What first line investigations would you consider in pleural effusion?

A

chest x-ray: blunting of costophrenic angle and opacification of lower lung field in pleural effusion; pleural thickening in pleural tumours

42
Q

What other investigations would you consider in pleural effusion?

A

bedside ultrasonography: may demonstrate the presence of hypoechogenic fluid or hyperechogenic pleural tumour

43
Q

What are the symptoms of anaemia?

A

symptoms depend on severity and acuity of anaemia; presentation ranges from insidious onset of exertional dyspnoea to severe dyspnoea at rest; associated symptoms related to impaired oxygen delivery to tissues (confusion, lethargy, syncope, coma) and compensatory mechanisms (palpitations, bounding pulses) occur

44
Q

What are the signs of anaemia?

A

characterised by nail-bed and conjunctival pallor; jaundice and hepatosplenomegaly may be present in haemolytic anaemia

45
Q

What first line investigations would you consider in anaemia?

A

FBC: low haemoglobin

46
Q

What are the symptoms of GORD (gastro-oesophageal reflux disease)?

A

presents with heartburn, overt regurgitation of gastric contents into the throat, and dysphagia; nausea, odynophagia, and chest pain may be present; symptoms are typically post-prandial, occur in supine position, and may be associated with certain foods

47
Q

What are the signs of GORD?

A

typically normal

48
Q

What first line investigations would you consider in GORD?

A

oesophagoscopy: oesophagitis, erosions, mucosal metaplasia

49
Q

What other investigations would you consider in GORD?

A

24-hour pH monitoring: periods of low oesophageal pH

50
Q

What are the symptoms of ascites?

A

insidious-onset weight gain and increased abdominal girth; possible history of liver disease (e.g., viral hepatitis, liver cirrhosis) or alcohol abuse

51
Q

What are the signs of ascites?

A

stigmata of chronic liver disease (e.g., spider naevi, palmar erythema) and jaundice are usually present; abdominal examination reveals abdominal distension and distended abdominal wall superficial veins

52
Q

What first line investigation would you consider in ascites?

A

none: clinical diagnosis

53
Q

What other investigation would you consider in ascites?

A

abdominal ultrasound: ascitic fluid

chest x-ray: pleural effusion, elevated hemidiaphragms, small lung volume

54
Q

What are the symptoms of thyroid disease?

A

thyrotoxicosis presents with dyspnoea, decreased exercise tolerance, sweating, heat intolerance, fatigue, diarrhoea, urinary frequency, and weight loss; hypothyroidism and associated slowing of metabolism manifests with cold intolerance, constipation, and weight gain; women with hypothyroidism may experience oligomenorrhoea or amenorrhoea; snoring may appear or worsen with the development of hypothyroidism

55
Q

What is the signs of thyroid disease?

A

signs of thyrotoxicosis include tachycardia (e.g., atrial fibrillation), tachypnoea, widened pulse pressure, warm and sweaty skin, exophthalmos, lid lag, and neck goitre; anxiety, restlessness, and agitation may also be present; signs of hypothyroidism include dry skin, generalised oedema, hypertension, and mental slowing

56
Q

What are the first line investigations that you would consider in thyroid disease?

A

serum thyroid-stimulating hormone (TSH): elevated in hypothyroidism, decreased in hyperthyroidism

57
Q

What other investigation would you consider in thyroid disease?

A

serum free T3 and free T4: elevated in hyperthyroidism, decreased in hypothyroidism

58
Q

What are the differentials for haemoptysis?

A 
Acute/Chronic Bronchitis
Pulmonary TB
Lung Abscess 
Pneumonia
Primary Lung Cancer 
Lung Metastasis
Anticoagulation 
Pulmonary Thromboembolism 
Bronchiectasis

Respiratory OSSE (2 decks)

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