Oxford Respiratory Cases Flashcards
Questions r.e. a persistent cough (6)
- Acute or chronic
- Constant or intermittent
- Productive or Dry
- Is there blood
- Timing
- Character
Time periods to classify acute and chronic?
<3 weeks = acute
>8 weeks = chronic
Relevance of an intermittent cough?
Suggests an extrinsic cause
Sputum colours of various conditions:
- COPD
- Infection
- Asthma
- Bronchiectasis/ lung abscess
COPD - frothy white
Infection - green/yellow
Asthma - can sometimes be yellow
Bronchiectasis/ lung abscess - green/rust coloured
Presentations of blood in sputum and what they mean. (3)
Blood streaked sputum - infection or bronchiectasis
Pink and frothy sputum - pulmonary oedema
Frank blood - TB, PE, malignancy, bronchiectasis, wegeners granulomatosis (rare)
Timing of cough and related DDx (2)
Asthma - worse at night, and with trigger factors (cold, exercise, time of year)
Pulmonary oedema/GORD - lying flat (at night), relieved with pillows
Character of cough and related DDx (4)
Wheezy - airway obstruction- asthma/copd
Bovine - vocal cord paralysis
Gurgling - bronchiectasis
Whooping - pertussis
Directed questions about specific triggers of cough (7)
Travel - TB Smoking Asthma Allergies Rhinitis/sinusitis Drug Hx - ACE-i's Hx of GORD
Specific factors to give you clues about cough (4)
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.
With an infection of respiratory origin, you should look for… (4)
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
Particular things to look for when examining a COPD patient…(4)
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)
Blood tests to order (for suspected pneumonia) (4)
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.
Imaging for COPD/infective exacerbation
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
CURB - 65 scoring
Confusion - AMTS <8/10 Urea - >7mmol/l RR - >30 BP - <90 systolic, <60 diastolic >65 years old
Complications of Pneumonia (4+2)
Spread of infection:
- pleural effusion
- empyema
- abscess
- septicaemia
Damage to local structures:
- bronchiectasis
- pneumothorax
Signs and symptoms of pneumothorax (7)
Sudden breathlessness Tachycardia Low sats High response rate Unilateral chest expansion Area of hyper-resonance (apyrexial) Tension pneumo - tracheal deviation
How is a pneumothorax managed?
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.
3 most common causes of a chronic cough in a non smoker
Asthma
Post nasal drip
GORD
Ix for a dry chronic cough (2)
PEF or FEV1 (asthma)
-FEV1 - >15% increase following bronchodilator
Chest radiograph (lung cancer)
Dry cough day and night, no triggers, high BMI - Dx?
GORD
GORD - how to confirm Dx?
therapeutic trial with PPI, and advise weight loss
Which drug causes a dry cough? Why?
ACE-i’s (enalapril/ramipril)
Inflammatory Bradykinins, normally broken down by ACE, irritate the lungs.
Happens in 10-20% of patients.
Squaomous cell carcinoma of the lung is seen where on a chest radiograph?
Hilar areas
Cause for a persistent, dry cough after pneumonia?
Often happens after pneumonia, particularly viral. Likely no specific problem.
