Respiratory Flashcards
Key symptoms to ask about during respiratory history?
- dyspnoea
- cough (productive v dry)
- chest pain
- wheeze
- haemoptysis
- calf tenderness/swelling
- systemic Sx (fever, night sweats, weight loss, fatigue)
Which systemic symptoms to ask about during respiratory history?
- fatigue (lung cancer, COPD)
- fever (pneumonia)
- night sweats (TB)
- weight loss (lung cancer, end-stage COPD)
Name four medications which can cause respiratory s/e
- ACEi: dry cough
- oestrogen-containing medication: inc. risk of PE
- immunosuppressants: eg methotrexate can cause pneumonitis
- B-blockers: can cause broncho-constriction
Name some respiratory causes of dyspnoea
- COPD
- asthma
- pneumonia
- COVID-19
- lung cancer
- PE
- pneumothorax
- bronchitis
Five common symptoms of PE?
- acute dyspnoea
- pleuritic chest pain
- cough, haemoptysis may also be present
- syncope and dizziness
- leg swelling, tenderness and redness
Name four causes of a productive cough
- pneumonia
- COPD
- cystic fibrosis
- bronchiectasis
Name five causes of a non-productive cough
- ACE-i
- asthma
- GORD
- COVID-19
- pulmonary fibrosis
Name six causes of a wheeze
- asthma
- COPD
- severe allergies
- airway obstruction
- pneumonia
- bronchitis
Why may hobbies be relevant for a respiratory history?
Bird-keeping can increase risk of developing allergic extrinsic alveolitis, aka ‘bird-fancier’s lung’
What are some medications commonly prescribed to patients with respiratory disease?
- short-acting beta-2-agonist inhalers
- long-acting beta-2-agonist inhalers
- inhaled corticosteroids
- short-acting anti-muscarinic inhalers
- long-acting anti-muscarinic inhalers
- oral steroids
- theophylline
- antibiotics
- anticoagulants
Why is travel relevant in a respiratory history?
- if symptoms are suggestive of infective aetiology such as TB
- to assess risk for PE (long-haul flights)
Which occupations might be relevant in a respiratory history?
- exposure to allergic/asthma triggers eg animals, chemicals
- coal mining - pneumoconiosis
- farming - allergic extrinsic alveolitis
- shipyards/construction (asbestos exposure) - mesothelioma
Risk factors for COPD
- smoking
- indoor air pollution - usually in developing world
- alpha-1 antitrypsin deficiency
Most common examination findings for COPD
- tachypnoea
- wheeze on auscultation
- pursed lips breathing
Differential diagnoses of COPD and how to differentiate
asthma
- will have diurnal variation in symptoms and peak flow
- history of atopy
bronchiectasis
- expectorate larger volumes of sputum
- more frequent LRTIs
congestive cardiac failure
- orthopnoea and paroxysmal nocturnal dyspnoea
- history of CVD
lung cancer
- weight loss
- haemoptysis
tuberculosis
- drenching night sweats
- weight loss
Main investigations for COPD
Spirometry - <70% Pulse oximetry - aim for 88-92% Sputum cultures - for exacerbations ECG - cor pulmonale CXR - hyperinflation
Management for COPD
conservative:
- smoking cessation
- flu vaccine
- management of RF
medical:
- inhalers: SABA/SAMA, LABA and LAMA, LABA and LAMA and ICS
Typical clinical features for asthma
- wheeze
- cough
- breathlessness
- episodic/diurnal variation
Important areas to cover in asthma history?
- triggers
- occupation
- exacerbation frequency
- personal/family history of atopy
- best expected/most recent PEFR
- treatment adherence
- smoking - active and passive
Common examination findings for asthma
- relevant medical equipment e.g. inhalers, spacer etc.
- cyanosis
- cough
- audible wheeze
- fine tremor
- tachycardia
- polyphonic expiratory wheeze
Differential diagnoses of asthma
Resp: bronchiectasis, COPD, fibrosis, PE, infection, lung cancer
GI: gastro-oesophageal reflux
Cardio: HF
Misc: allergic rhinitis, foreign body inhalation
Management of asthma
step-wise intervention:
- all those w/ symptoms - SABA inhaler PRN
- add low dose ICS
- add LABA
- inc. ICS or LTRA
Risk factors for lung cancer
- smoking - main RF
- air pollution (both indoor and outdoor)
- family history of cancer, esp. lung cancer
- male sex
- radon gas (normally affects miners)
Typical history of lung cancer
- unexplained cough for at least 3 weeks (w/ or w/o haemoptysis)
- unintended weight loss
- new-onset dyspnoea
- pleuritic chest pain
- bone pain due to metastases
- fatigue
Typical examination findings of lung cancer
- cachexia (extreme weight loss and muscle wasting)
- finger clubbing
- dullness on percussion
- cervical lymphadenopathy
- wheeze on auscultation
Differential diagnoses of lung cancer
- TB
- metastasis to lungs from other sites
- sarcoidosis
- granulomatosis with polyangiitis
- non-Hodgkin’s lymphoma
First-line investigation for suspected lung cancer
CXR - may show single or multiple opacities, pleural effusion and/or lung collapse
Typical features of pleural effusion history
- breathlessness
- cough
- pleuritic chest pain
Typical features of pleural effusion on examination
- possible reduced chest movement
- palpation of trachea may reveal deviation away from affected side
- reduced chest expansion on affected side
- stony dullness on percussion of affected side
- breath sounds and vocal resonance are reduced or absent on affected side
Differential diagnoses for pleural effusion
- infection e.g. TB or pneumonia
- malignancy w/o effusion
- PE
- pneumothorax
First-line investigation for pleural effusion
- CXR - shows unilateral or bilateral effusion
Treatments for pleural effusion
- diuretics in HF
- antibiotics in infection
- pleural fluid aspiration of chest drain insertion
Risk factors for PE
- recent surgery
- recent fractures
- recent immobility
- personal/family history of clotting disorder, PE or DVT
- obesity
- malignancy
- infection
- pregnancy
- HRT or oral contraceptive pill
Common examination findings for PE
- tachypnoea
- tachycardia
- hypotension
- evidence of DVT
- pleural rub
- cyanosis
Investigations and procedures for PE
- ABG - normally low PaO2 and normal/low PaCO2
- CXR - often normal
- Well’s score
How is a definitive diagnosis of PE made?
Using a CT pulmonary angiogram
What is the aetiology of TB?
Infection by M.tuberculosis (most common), M.bovis and M.africanum
Infection through droplet inhalation (coughing and sneezing)
After exposure, TB is engulfed by macrophages in lung - if infection is not cleared - TB develops
Main risk factors for TB
- close contact with infected individual
- demographics - ethnic minorities, travel in high prevalence areas (India and sub-Saharan Africa), extremes of age and homelessness
- medicines and conditions such as: alcohol/drug dependency, immunosuppression, malignancy, diabetes and long term steroid use
Typical symptoms of TB
- general: fever, lethargy, anorexia, weight loss, enlarged tender lymph nodes
- resp: cough, sputum (dry, then purulent or blood-stained, breathlessness, pleuritic chest pain
- other: urinary Sx, joint pain, headaches, reduced GCS, chest pain, abdominal pain and bloating, rash
Most common cause for CAP?
Strep. Pneumoniae
Pneumonia risk factors?
- Age – under 16 and over 65
- Co-morbidities
- COPD
- HIV
- Diabetes mellitus
- Cystic fibrosis
- Congestive HF
- Bronchiectasis
- Nursing home residents
- Smoking
- Excess alcohol
- IV drug use
- Immunosuppressant therapy – prolonged corticosteroids
Clinical signs of pneumonia?
- Crackles ± wheeze
- Pleural rub
- Bronchial breath sounds
- Increased vocal resonance
- Dull to percussion
- Consolidation
