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Phase 2b > Resp: History + Exam/Tests > Flashcards

Resp: History + Exam/Tests Flashcards

1
Q

Describe the grades in the MRC Dyspnoea Scale

A

1: Only SOB on severe exercise
2: SOB when hurrying on a level surface/walking up slight hill
3: walks slower than most people on that level/stops after a mile or so/stops after 15 minutes walking at own pace
4: stops for breath after walking 100 yards/few minutes on level ground
5: too breathless too leave house/when dressing or undressing

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2
Q

Why is occupation important to ask about? Which occupations are key?

A

exposure to irritants/dust/cigarette smoke/pollutants causes lung disease

baker, metal workers, asbestos exposure (joiner, steel, shipworks, navy), lab work, pet stores

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3
Q

What questions should be asked about a wheeze?

A 
onset - does it accompany/occur at different times to breathlessness?
duration?
on inspiration/expiration?
alleviating/exacerbating factors?
diurnal variation? at night?
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4
Q

DD of wheeze

A

obstructive lung diseases - asthma, COPD, bronchiectasis

on inspiration > extra-thoracic e.g. tracheal tumour
on expiration > intra thoracic obstruction (small airways)

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5
Q

What questions should be asked about breathlessness?

A

How is the patient normally? Is this acute, chronic, acute on chronic?
Onset, timing, duration, variability, diurnal variation, intermittent (some days completely normal)?
Exacerbating factors e.g. allergic triggers, exertion, cold
Receiving factors e.g. rest, medication
Associated symptoms e.g. cough, sputum, haemoptysis, pain, wheeze, night sweats, weight loss, oedema?
Severity: at rest, only on exertion, limiting ADLs?
Progression: stable, progressive, speed, exacerbations?

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6
Q

Which lung disease is characteristic of having huge variation from day to day and much worse symptoms at night?

A

asthma

often some completely normal days = pathognomonic, other days are terrible

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7
Q

What questions should be asked about a cough?

A

onset, timing, duration
variation: recent change in chronic cough, diurnal variation?
productive (with sputum)/unproductive (dry + tickly)?

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8
Q

When does a cough become chronic?

A

lasted >2 months

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9
Q

What questions should be asked about sputum?

A

onset, timing, duration, variation, diurnal variation
colour, haemoptysis?
consistency: viscous, mucous, purulent, frothy?
quantity
odour

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10
Q

What might rusty sputum be indicative of?

A

pneumococcal pneumonia

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11
Q

What might frothy pink sputum be indicative of?

A

pulmonary oedema

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12
Q

What might green sputum be indicative of?

A

infection (due to neutrophils)

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13
Q

What disease might large volumes of sputum be indicative of?

A

large volumes = large cystic changes in bronchi

= bronchiectasis

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14
Q

What might odorous sputum be indicative of?

A

bronchiectasis, lung abscess

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15
Q

What should always be suspected with haemoptysis?

A

lung tumour!

especially with history of smoking/old age

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16
Q

What questions should be asked about haemoptysis?

A

origin - differentiate haemoptysis from haematemesis, was it coughed up?
onset, timing, duration, variation?
quantity?
colour - fresh blood or dark altered blood?
consistency - liquids, clots, mixed with sputum?
sputum?
chest pain?
recent trauma to chest or elsewhere?
recent/current DVT?
weight loss, fever, night sweats, tiredness/malaise, collapses/blackouts/falls?
breathlessness?
bleeding or bruising elsewhere?

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17
Q

When asking about collapses/blackouts/falls in a pt with haemoptysis, what condition is being considered?

A

severe pulmonary HTN

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18
Q

What questions should be asked about chest pain?

A

Remember may have a cardiac cause

SOCRATES
associated with breathlessness or cough?

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19
Q

What does pleuritic chest pain feel like? Where does it indicate the disease is?

A

very localised, sharp, as if stabbed in side
often on cough/inspiration

indicates pleural disease, not lung

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20
Q

What respiratory conditions should be asked about in the PMH? Why?

A

pneumonia > can lead to bronchiectasis/PF
tuberculosis > can reactivate
severe measles/whooping cough > can lead to bronchiectasis
asthma

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21
Q

What other non/resp conditions and surgeries should be asked about in the PMH? Why?

A

cardiac disease > can lead to pulmonary disease
immunocompromised e.g. HIV, medication, post-transplant > predispose to infections

dental surgery > aspiration of purulent material/tooth fragments
abdominal, pelvic, orthopaedic surgery > risk factors for DVT, PE

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22
Q

What cardiac symptoms should be asked about specifically?

A

angina
orthopnoea
paroxysmal nocturnal dyspnoea

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23
Q

What drugs are important to think about? Why?

A 
inhalers, O2 therapy 
steroids > opportunistic infections
antibiotics > pneumonitis
amiodarone > PF
beta-blockers > asthma exacerbation, worsen airway obstruction = wheeze
NSAIDs > asthma exacerbation
methotrexate > pneumonitis, sometimes fibrosis
contraceptive pill > DVT, PE
slimming pills > pulmonary HTN

ACE inhibitors > SE dry cough
antiplatelets (ticagrelor) > SE unexplained breathlessness

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24
Q

What questions are important to ask in the social history?

A

occupation - industrial hazards e.g. dust, asbestos
smoking - pack yrs, weed
pets esp birds > infection, hypersensitivity reaction
overseas travel > TB
living conditions - damp
alcohol
exercise, ADLs, independence?
hobbies - birds, horses (farmer’s lung), electronics (asthma), cars/spray paint

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25
Q

What conditions are important to ask about in the family history?

A

allergic conditions e.g. asthma
alpha-1-antitrypsin deficiency > emphysema, COPD
primary cilia dyskinesia > emphysema

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26
Q

What kind of conditions commonly have systemic symptoms that affect the lungs, often first?

A

rheumatological

e.g. Raynaud’s, joint pain/swelling muscle aches, myositis

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27
Q

What key symptoms are important to check in a systems enquiry?

A

rheumatological
dry eyes/mouth > Sjorgens, sarcoidosis
acid in back of throat > acid reflux
polyuria - hypercalcaemia > sarcoidosis, multiple system disease

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28
Q

What signs are looked for in general inspection of the bed/patient?

A
  1. bed - inhalers, nebulisers, o2 mask, sputum pot
  2. colour
  3. breathing
    • purse-lipped breathing > COPD
    • cough, wheeze, stridor, laboured, tachypnoea
  4. comfort, position
  5. nutritional state
    • obesity > obstructive sleep apnoea, Pickwickianism
    • weight loss > systemic/cancer/depression
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29
Q

What is the difference between wheeze and stridor?

A

wheeze - expiratory whistling nose

stridor - inspiratory noise = BAD

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30
Q
  1. Inspection - what to look for in the hands?
A
  1. clubbing > LUNG CANCER (esp in smokers), PF, bronchiectasis, emphysema, CF
  2. tar staining
  3. wasting of intrinsic muscles > T1 nerve invasion by lung cancer?
  4. temperature, oedema
  5. tremor - flapping asterixis > resp failure, fine with beta- agonists
    • often in 1 hand, push extended hands back to trigger
  6. pulse - rate, rhythm, characters, pulsus paradoxus
    > bounding in CO2 retention
  7. whilst doing resp rate, rhythm, pattern, effort
  8. blood pressure
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31
Q

Which disease is clubbing NOT found in and therefore if present, must indicate a more serious cause?

A

COPD

likely indicates lung cancer

32
Q

What is pulsus paradoxus? What does it indicate?

A

exaggeration of normal decrease in BP during inspiration

can detect beats on auscultation of the heart during inspiration that can’t be palpated at the radial artery due to a fall in BP

> severe obstructive airways, cardiac tamponade

33
Q
  1. Inspection - what to look for in the neck?
A

raised JVP > cor pulmonale
- raised non-pulsatile JVP > SVC obstruction due to lung cancer (causing oedema)

oedema of face/neck

34
Q
  1. Inspection - what to look for in the face?
A

eyes:
- Horner’s syndrome
- chemosis (conj oedema > hypercapnia 2’ COPD)
- conjunctival pallor > anaemia

face + mouth:

  • facial swelling > SVC obstruction
  • dental caries > lung abscess 2’ inhalation of debris
  • central cyanosis (bottom of tongue, lips)
35
Q
  1. Inspection - what to look for on the chest?
A
  1. shape
    • barrel chest > hyper inflated in emphysema
    • severe kyphoscoliosis/kyphosis > restrictive disease
    • pectus excavatum (funnel chest)
    • pacts carinatum (pigeon’s chest) +/- Harrison’s sulci
  2. symmetry, scars - surgery, radiotherapy, muscle wasting, pleural catheters, aspiration wounds
  3. dilated veins > SVC obstruction i.e. lung CANCER mets
  4. movements
    • rate, pattern, symmetry
      • prolonged exp + normal insp > narrowed airways
    • chest vs abdominal diaphragmatic breathing
    • use of accessory muscles > severe COPD
    • recession (more in children) > partial laryngeal/tracheal osbtruction
36
Q

How can lung cancer lead to SVC obstruction?

A

pinching of the SVC due to intra-thoracic lymph node enlargement because of lung mets

37
Q
  1. What steps are done during palpation?
A
  1. check upper lobes: pads of fingers on clavicles, breath in, hands will roll into clavicles by -1cm
  2. check lower lobes/chest expansion: hands around lateral chest, thumbs together, exhale fully then chest will expand on inspiration
    • 3-5cm normal, <2cm abnormal
  3. check trachea + apex beat for deviation, feel for tracheal tug
  4. cervical lymph nodes
  5. tactile vocal fremitus: say 99, feel vibration with side of hands
38
Q

What can reduced chest wall movements indicate?

A

any lung/pleural chest wall disease

or: kyphoscoliosis, ankylosing spondylitis, neuromuscular disease

39
Q

What is a tracheal tug? In what disease does it occur?

A

feel below the cricoid cartilage > moves up on breathing in COPD, the cartilage moves down as the chest I hyperextended

40
Q

Does deviation of the trachea and apex beat occur towards or away from the pathology?

A

towards with PF/collapse

away from with tension pneumothorax/massive effusion

41
Q

In what diseases is transmission of tactile vocal fremitus reduced in?

A

transmission of vibrations are increased/more clear in consolidation as sounds travels faster through solid than air

transmission is decreased with an effusion/pneumothorax as the lung tissue becomes separated from the chest wall

42
Q
  1. How should the lung be percussed?
A

starting at the apices, from side to side anteriorly, comparing left and right
percuss every lobe
put finger horizontally across rib space

Posteriorly: over trapezius, 4-5 times each side, lateral chest walls (3-4 times each side) - avoid the scapula, ask pt to put hands on knees
Anteriorly: over clavicles, in mid-clavicular line (4-5 times each side)

43
Q

How should the lung sound on percussion? What does it sound like if there is pathology?

A

should sound resonant > implies aerated tissue
sounds dull if over an organ/pathology present > do vocal fremitus/resonance with stethoscope to confirm, will sound much louder

44
Q
  1. How should the lung be auscultated?
A

start at apices, diaphragm of stethoscope
auscultate from side to side anteriorly and laterally, compare both sides
with open-mouth breathing - ask to ‘take a deep breath each time I put the stethoscope on your chest’

  1. clavicle to 6th rib mid-clavicular line
  2. axilla to 8th rib mid-axillary line
  3. vocal resonance: say 99 whilst auscultating
  4. if area of consolidation suspected, perform whispering pectoriloquy: whisper 2-2-2
    on back: over trapezius, 4-5 times each side with pt bending forward with arms on knees
45
Q

What to listen for during auscultation?

A 
vesicular (normal) breath sounds (like rustling leaves)
bronchial breathing
rhonchi (wheezes)
crackles/crepitations
pleural rub
change in sounds after coughing
46
Q

Do crepitations change after coughing in secretory and fibrotic conditions?

A

secretions > crepitations alter after coughing

fibrotic conditions > no change

47
Q

What does vocal resonance allow discrimination between?

A

between dullness to percussion from pleural effusion and from consolidation

voice sounds are transmitted more effectively across an area of consolidation
transmission is reduced across pleural effusion/pneumothorax

48
Q

Why is whispering pectoriloquy done across an area of suspected consolidation?

A

whispers transmitted more loudly across and area of consolidation - listen for dramatic increase in volume

49
Q
  1. Repeat inspection, palpation, percussion and auscultation, where?
A

on the back with patient sitting forward

spine of scapula to 11th rib

50
Q
  1. What steps should be done at the end of the exam?
A

palpate ankles for oedema
check sputum pot: volume, consistency, colour, odour, haemoptysis
assess peak flow

51
Q

When is resonance lost and increased?

A

Lost in:

  • pleural effusion (stony dull)
  • consolidation/collapse/fibrosis
  • raised diaphragm
  • over heart and liver EXCEPT in emphysema when the lung hyperextends over them

Increased in: hyper resonance needs a chest strain

  • emphysema
  • pneumothorax (trauma)
52
Q

What are normal breath sounds like?

A

= vesicular
sound like rustling leaves
loudest on inspiration, fading smoothly into expiration and dying out

53
Q

What is bronchial breathing? When is it heard?

A

higher pitched with distinct inspiratory and expiratory phases
heard over fibrotic/consolidated lung, above a pleural effusion
associated with whispering pectoriloquy

54
Q

What does a wheeze suggest?

A

airway obstruction

55
Q

Where are crackles heard? What do they indicate?

A

more noticeable at bases (small airway closure)

caused by:

  • secretions in airway: clear or change on coughing
  • consolidation
  • fibrotic lung disease
  • heart failure
56
Q

What is spirometry?

A

method of assessing lung function by measuring the volume of air that the pt can expel from the lungs after a max inspiration

57
Q

What 4 things can spirometry measure?

A

FEV1: forced expiratory volume in 1 sec
FVC: forced vital capacity
FEV1/FVC ratio
PEF: peak expiratory volume

58
Q

How is the spirometry procedure done?

A

gain consent
performed sitting
pt inhales fully then exhales as hard as they can for as long as they can
encourage maximum effort, verbally encourage to keep exhaling

59
Q

What results do you need from a spirometry test?

A

at least 3 acceptable results
best 2 must be reproducible
maximum of 8 attempts

60
Q

How are the FEV1, FVC and ratio values affected by obstruction?

A

low FEV1
normal/low FVC
ratio <70%

61
Q

How are the FEV1, FVC and ratio values affected by restriction?

A

low FEV1 and FVC

normal ratio

62
Q

What medications can have an effect on the spirometry results?

A

inhalers - withheld prior to test

beta-blockers

63
Q

How to differentiate between asthma and COPD with spirometry?

A

reversibility test
give guideline recommended bronchodilator

asthma = fully reversible
COPD = little/no response in FEV1, may have greater changes in FVC or VC

significant reversibility is said to be:
>200ml AND 15% increase in baseline FEV1

64
Q

What are the 3 methods of measuring the lung volume?

A

body plethysmography
helium dilution
nitrogen washout

65
Q

How is the TLC affected in an obstructed and restricted lung?

A

increased in obstructed

decreased in restricted

66
Q

What us TLco?

A

Transfer factor and Diffusing Capacity > estimates O2 diffusing capacity and alveolar volume
helps differentiate between thoracic and extra-thoracic restriction

67
Q

What does a low TLco indicate?

A

alveolar capillary defect

68
Q

How are nebuliser antibiotics used as a PFT?

A

spirometry before and after
drop of >15% in FEV1 = significant response
check to see if antibiotics help - chest infections? bronchiectasis?

e.g. colomycin, gentamicin, tobramycin

69
Q

What is a bronchial challenge test? What medication is used?

A

Diagnosis or effectiveness of current treatment
measures degree of airway hyper-responsiveness using mannitol
spirometry before and after
+ve if FEV1 drops by 10% from one dose to next/15% drops from baseline

70
Q

What are the 3 exercise tests that can be done?

A

incremental shuttle walk test
6 minute walking test
CPET: cardiopulmonary exercise test

71
Q

What is a CPET? When is a CPET done?

A

assess if resp, cardiac or both are the cause of symptoms
cycle test
indications: major surgery, SOB, heart failure, exercise induced asthma

72
Q

Where is a capillary blood gas taken from? What does it measure?

A

ear lobe

PO2, PCO2, acid base status > type 1 or 2 resp failure?

73
Q

When is long-term O2 therapy considered? What is the aim with LTOT?

A

if SpO2 <92% on air at rest

aim is to raise pO2 to 8kPa

74
Q

What is pulse oximetry?

A

measures pulse and oxygen saturation of Hb

75
Q

What is the definition of oxygen saturation?

A

ratio of oxyhemoglobin to deoxyhaemoglobin

76
Q

How is obstructive sleep apnoea/nocturnal hypotension screened for?

A

overnight oximetry
measure recurrent rapid oxygen desaturations (ODI)
normal ODI <5

normal/mild oximetry score doesn’t rule out OSA, if still suspected > limited polysomnography
symptomatic? > Epworth sleepiness score >11

Phase 2b (3 decks)

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