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Oxford Cases in Medicine > Oxford Respiratory Cases > Flashcards

Oxford Respiratory Cases Flashcards

1
Q

Questions r.e. a persistent cough (6)

A
  1. Acute or chronic
  2. Constant or intermittent
  3. Productive or Dry
  4. Is there blood
  5. Timing
  6. Character
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2
Q

Time periods to classify acute and chronic?

A

<3 weeks = acute

>8 weeks = chronic

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3
Q

Relevance of an intermittent cough?

A

Suggests an extrinsic cause

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4
Q

Sputum colours of various conditions:

  • COPD
  • Infection
  • Asthma
  • Bronchiectasis/ lung abscess
A

COPD - frothy white
Infection - green/yellow
Asthma - can sometimes be yellow
Bronchiectasis/ lung abscess - green/rust coloured

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5
Q

Presentations of blood in sputum and what they mean. (3)

A

Blood streaked sputum - infection or bronchiectasis
Pink and frothy sputum - pulmonary oedema
Frank blood - TB, PE, malignancy, bronchiectasis, wegeners granulomatosis (rare)

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6
Q

Timing of cough and related DDx (2)

A

Asthma - worse at night, and with trigger factors (cold, exercise, time of year)
Pulmonary oedema/GORD - lying flat (at night), relieved with pillows

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7
Q

Character of cough and related DDx (4)

A

Wheezy - airway obstruction- asthma/copd
Bovine - vocal cord paralysis
Gurgling - bronchiectasis
Whooping - pertussis

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8
Q

Directed questions about specific triggers of cough (7)

A 
Travel - TB
Smoking 
Asthma 
Allergies 
Rhinitis/sinusitis 
Drug Hx - ACE-i's
Hx of GORD
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9
Q

Specific factors to give you clues about cough (4)

A

FLAWS (fever, lethargy, anorexia, weight loss, (night) sweats)
Breathlessness - COPD, Asthma, pneumonia, pulmonary oedema
Chest pain (particularly pleuritic) - pneumonia, pneumothorax, pulmonary embolism, viral pleurisy, muscle strain from coughing, rib #.
Wheeze - obstruction of the airways - asthma, COPD, tumour.

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10
Q

With an infection of respiratory origin, you should look for… (4)

A

Systemically unwell? - febrile, sweating, tachycardia

Respiratory distress? - tachypnoea, difficulty completing sentences, accessory muscle use, cyanosis, confusion (remember CURB 65 - confusion, urea, RR, BP)

Tender cervical lymphadenopathy? - in a patient with a cough, this suggests upper respiratory tract

Lungs - reduced chest expansion, focal dull percussion note, breath sounds and vocal resonance

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11
Q

Particular things to look for when examining a COPD patient…(4)

A

Chest wall deformity (barrel chested)

Intercostal recession (severe COPD)

Signs of right sided heart failure - cor pulmonale - peripheral oedema, raised JVP, loud P2 heart sound, tricuspid regurgitation

Asterixis (flapping tremor due to CO2 retention)

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12
Q

Blood tests to order (for suspected pneumonia) (4)

A

ABG - slightly elevated CO2 might be normal if COPD

Full blood count - WCC should be raised in infection, with a neutrophilic if the causative agent is bacterial

CRP

U&Es - deranged if she’s dehydrated and not perfusing her kidneys adequately.

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13
Q

Imaging for COPD/infective exacerbation

A

CXR - consolidation (possibly lobar) or pneumothorax

ECG - rule out ischaemia or AF secondary to pneumonia. May also show right heart strain in some patients with COPD

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14
Q

CURB - 65 scoring

A 
Confusion - AMTS <8/10
Urea - >7mmol/l
RR - >30
BP - <90 systolic, <60 diastolic 
>65 years old
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15
Q

Complications of Pneumonia (4+2)

A

Spread of infection:

  • pleural effusion
  • empyema
  • abscess
  • septicaemia

Damage to local structures:

  • bronchiectasis
  • pneumothorax
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16
Q

Signs and symptoms of pneumothorax (7)

A 
Sudden breathlessness
Tachycardia 
Low sats 
High response rate 
Unilateral chest expansion
Area of hyper-resonance 
(apyrexial)
Tension pneumo - tracheal deviation
17
Q

How is a pneumothorax managed?

A

Based on:

  • whether it’s primary or secondary
  • age

If the rim of air is >2cm, then insert a chest drain

Primary - 1-2cm - discharge if not out of breath. If +ve, then aspirate, and drain if fail

Secondary - <1cm - o2 and admit for 24g. 1-2cm - aspirate/drain and admit for 24h. >2cm - insert chest drain.

18
Q

3 most common causes of a chronic cough in a non smoker

A

Asthma
Post nasal drip
GORD

19
Q

Ix for a dry chronic cough (2)

A

PEF or FEV1 (asthma)
-FEV1 - >15% increase following bronchodilator
Chest radiograph (lung cancer)

20
Q

Dry cough day and night, no triggers, high BMI - Dx?

A

GORD

21
Q

GORD - how to confirm Dx?

A

therapeutic trial with PPI, and advise weight loss

22
Q

Which drug causes a dry cough? Why?

A

ACE-i’s (enalapril/ramipril)
Inflammatory Bradykinins, normally broken down by ACE, irritate the lungs.
Happens in 10-20% of patients.

23
Q

Squaomous cell carcinoma of the lung is seen where on a chest radiograph?

A

Hilar areas

24
Q

Cause for a persistent, dry cough after pneumonia?

A

Often happens after pneumonia, particularly viral. Likely no specific problem.

25
Q

Why might lung cancer patients have a bovine cough?

What type of lung cancer does this?

A

Recurrent laryngeal nerve palsy - more common on the left - nerve has a longer intrathroacic route that loops around the arch of the aorta.

Pancoast apical lung tumour

26
Q

Following chest radiograph, what imaging modality is used to dx lung cancer?

A

CT

27
Q

Causes of Haemoptysis? (surgical sieve)

A

Infective:
-TB, bronchitis, pneumonia, lung abscess, (infective exacerbation of COPD)

Neoplastic

Vascular
-pulmonary infarction

Inflammatory
- Wegener’s, good pasutres

Traumatic
- iatrogenic (biopsy), wounds (#)

Endocrine
- none

Degenerative
- bronchiectasis

Metabolic
- none

Drugs

  • warfarin
  • crack cocaine use

Most common being infective - pneumonia and infx exacerbation of COPD

28
Q

Qu’s to ask re haemoptyisis?

A

WHAT?

Frank blood?
- vascular problem such as ruptured blood vessel (cancer, TB, bronchiectasis)

Blood streaked?
- any infx. However in the context of large volumes of sputum, this suggests bronchiectasis

Pink and frothy?
- pulmonary oedema

PROGRESSION
Fast? - PE, erosion of cancer into pulmonary vessel

Insidious? - Ca. or bronchiectasis

29
Q

Further questions re cough?

A

Dry or productive of sputum?
Fever?
Weight loss?
pleuritic chest pain?
SOB?
Extrapulmoary features of Lung Ca such as bone pain?
Cushingoid features (small cell secreting acth)
Hypercalcaemia related symptoms (polyuria, polydipsia, hypotonia, hyporeflexia) as a result of a PTHrP secreting tumour.
Muscle weakness - eaton lambert syndrome - associated with small cell lung cancer
Haematuria/Oliguria - conditions that affect the lungs and kidneys simultaneously - Goodpasture’s syndrome, vasculitidies, SLE

30
Q

Ix (blood tests) for haemoptysis?

A

FBC, CRP, U&Es, clotting screen, calcium, phosphate, and ALP (bone mets?), liver enzymes

31
Q

Ix for lung ca.?

A

Radiograph, cytology of sputum and bronchoscope washings, CT scan (staging)

32
Q

Typical Hx and S+S for PE

A

Haemoptysis, pleuritic chest pain (pain on deep inspiration) - not reproduced by pressing on the ribs (and no trauma to the ribs)

33
Q

Ix and Rx for PE

A

Based on wells score

  • <4 - use d dimer to exclude
  • > 4 CTPA

Rx - LMWH and warfarin - stop when the INR reaches 2-3.

If massive PE (SBP <90mmHg) - alteplase

34
Q

TB.. specific measures to be thought of? (6)

A

1) Micro need to look for acid fast bacilli
2) It is a notifiable disease
3) Place the patient in isolation
4) test for HIV - often concurrent infection
5) Spread to other organs - meningeal irritation, bone or joint pain (particularly in weight bearing joints - Pott’s # in the spinal column), dysuria or pelvic pain (GU infx)
6) if the diagnosis is confirmed, refer the patient to the TB service, which offers specialised care.

35
Q

Kartagener’s syndrome is a triad of 3 things… (3) in patients with primary ciliary dyskinesia.

A

Bronchiectasis
Sinusitis
Situs inversus

Oxford Cases in Medicine (2 decks)

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