Respiratory

Question 1

IMT 2 in a general respiratory clinic.

Mrs Bruth, a 65-year-old woman who has been referred by her GP with a productive cough, wheeze and shortness of breath on exertion.

smoking for the last 30 years, at least 10-20 cigarettes each day.

Her past medical history includes hypertension which she takes amlodipine for.

She has noticed 2-3 kg of weight loss over the last 12 months.

historyor qustions

Answer 1

Open questions first :-

Onset of symptoms

Duration of the symptoms - intermittent or persistent through out the day

Relieving or exacerbating factors

ANY SIMILAR PRESENTATION LIKE THIS IN THE PAST BEFORE -such as with infection

Question 2

Close a with the cough

Answer 2

Is the cough dry or productive

Colour of the sputum

Intermittent or persistent

ANY OTHER SYMPTOMS ASSICIATED WITH THE COUGH- such as chest pain

Question 3

Closed q of SOB

Answer 3

How many times in a day or week do you get SOB

DOES OT OCCUR
WITH REST OR
EXERTION

ANY POSITIONAL
SOB

How long does the SOB last and how it is managed

Question 4

other history to ask ?

Answer 4

if the weight loss was intentional

if she grew up in the uk - for risk of tb

her occupation and where she lives any risk of asbestosis , does she live where pollution is high

any family history of cardiorespiratory illnesses

FINALLY I WOULD END THE HISTORY TAKING WITH A DETAILED SYSTEM REVIEW

and discuss with them their ideas , concerns and expectations

Question 5

making the diagnosis

Answer 5

so i would like to first start of with basic bedside investigtaion - if the patient is having productive cough i would like to send some for sputum analysis
ECG
I would like to also do a peak experitroy flow test
PULSE OXIMETRY

bloods - FBC , UE , CRP , LFT, coagulation screen

i would like to also first send the patient for a CXR -
looks out for signs of opacity and hyperinflation =
= Flattened hemidiphragms
= Hyperlucent lungs ( less bronchovascular markings per cm2)
=More than 6 anterior or 10 posterior ribs in the mid-clavicular line at the lung diaphragm level.

depending on these results i would be able to have more clarity on his presentation

with also discussing with a senior I would send him for a pulmonary function test
SERIAL PEAKFLOW MEASUREMENT
and also a CT chest

Question 6

ddx

Answer 6

COPD
lung malignancy
infection
late onset asthma
BRONCHIECTASIS

Question 7

managment for COPD

Answer 7

ny previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

No asthmatic features/features suggesting steroid responsiveness
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA

Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS

stop smoking

ltot if po2 <7.3
or less than 8 if there is polycethemia , peripheral edema , pulmonary hypertension

Question 8

management of acute copd ?

Answer 8

back to back nebulisers

hydrocortisone

theophyline

Question 9

oxygen supplementation in COPD ?

Answer 9

give oxygen at 24% (via a Venturi mask) at 2-3 L/minute or at 28% (via Venturi mask, 4 L/minute)