Respiratory Flashcards
Which serum electrolyte is likely to be raised in a patient with active TB?
Increased serum calcium due to activated macrophages which produce calcitriol (active form of vit D)
What are causes of shortness of breath?
Respiratory Cardiac Anatomical Shock Anaemia
What is an expiratory wheeze?
Musical / whistling sound
Narrowing / obstruction of small airways
Causes: Inflammation - asthma, COPD, allergic reaction
Secretions blocking lumen - infection
Physical blockage - tumour, foreign body
What is stridor?
High-pitched, harsh, vibrating noise Inspiratory Turbulent airflow in large airways Trachea, larynx Emergency
What are your differential diagnoses for SOB?
Bronchial Inflammation: Infection / Pneumonia, Asthma, COPD, Bronchiectasis
Fluid in Airways: Pulmonary Oedema (heart failure)
Non-inflammatory Narrowing / Obstruction: Lung cancer, Pulmonary embolism, Inhaled foreign body
What are common pathogens which cause pneumonia?
S.pneumoniae
H.influenzae
Mycoplasma
What are symptoms of pneumonia?
Fever
Cough
Dyspnoea (acute / sub-acute)
Purulent sputum
What are pathological features of asthma?
Reversible airway obstruction
Bronchial muscle contraction
Mucosal swelling / inflammation
Increased mucus production
What are symptoms and features that would make you suspect asthma?
Childhood
Usually episodic, diurnal variation
Wheeze, dyspnoea
Non-productive nocturnal cough
What are features of COPD?
Progressive disorder of airway obstruction
Little / no reversibility or diurnal variation
Chronic bronchitis - clinical
Emphysema - histological
SMOKERS, Chronic cough, dyspnoea, wheeze and sputum, Age >35yrs
What is bronchiectasis?
Chronic infection of airways
Destroys muscular tissue so held dilated by lung parenchyma
Filled with purulent sputum
What are some causes of bronchiectasis?
Congenital: cystic fibrosis
Post-infection: measles, pertussis, TB
Airway obstruction: tumours
Immunosuppression
How can heart failure be a cause of SOB?
Impaired left ventricular function –blood backs up in pulmonary
circulation so Pulmonary Oedema
What are causes of heart failure?
Ischaemic heart disease
Cardiomyopathy
Myocarditis
What are non cardiac causes of fluid overload which could result in pulmonary oedema?
Excessive IV fluids
Renal failure
What questions in the history would you want to ask about someone’s cough?
When did it first start? Is it present all the time? Does it wake you up at night? Worse at any time of day? Does anything trigger it? Work? Exercise? Medication? Do you cough anything up? What colour? Any blood?
What questions in the history would you want to ask about someone’s SOB?
When did it first start? How quickly has it come on?
Is it present all the time? Is it only present when you exert yourself?
Before this started, how far could you walk on flat before getting breathless? And now?
Is it worse in certain positions? How many pillows do you use?
Does anything else trigger it?
What associated symptoms would you want to ask about in a patient who you suspect has asthma?
Acute onset
Rashes
Itchy skin
Watering eyes
What associated symptoms would you want to ask about in a patient who you suspect has bronchiectasis?
Fever
Progressive illness (or acute-on-chronic)
Weight loss
What past medical history questions are important in a patient who you suspect has bronchiectasis?
Chest infections? Especially as a child
Cystic fibrosis?
Previous TB?
What past medical history questions are important in a patient you suspect has heart failure?
Heart attacks?
Angina?
Kidney disease?
Which drugs might be particularly relevant to ask about in a patient presenting with SOB?
Steroids?
Immunosuppressants?
On home nebulisers or oxygen?
Multiple allergies / atopy?
What social history questions are important in a patient presenting with SOB?
Occupation? Change of job? Moved house? New pet? New hobby? SMOKING!! Pack years? Occupation? Time spent living abroad? TB contacts? Alcohol?
What family history questions are important in a patient presenting with SOB?
Asthma? Eczema? Hay fever? Bronchitis? Emphysema? Especially at an early age Cystic fibrosis? TB? Heart disease?
What end of the bed signs might you look for in a patient with SOB?
Breathlessness Resp rate Accessory muscle use Sputum pots Inhalers / nebulisers Oxygen masks/tubing Cachexia
What examination findings might you see in a patient with SOB?
Peripheral cyanosis Clubbing Tar staining CO2 retention flap Central cyanosis Pitting oedema
What are respiratory causes for clubbing?
A – abscess B – bronchiectasis (incl CF) C – cancer (bronchial + mesothelioma) D – decreased oxygen (hypoxia) E – empyema F – fibrosing alveolitis
What is cor pulmonale? What are symptoms of this?
Right sided heart failure due to long term pulmonary hypertension or chronic low oxygen conditions - COPD, CF
Symptoms: SOB during activity, tachycardia, palpitations, chest pain, syncope, cyanosis, raised JVP
What are the descriptors for abnormal percussion of a lung?
Pleural Effusion: stony dull
Consolidation: dull
Collapse: dull
Pneumothorax: hyper resonant
Which conditions may increase or decrease vocal resonance?
Consolidation: increased vocal resonance
Effusion and pneumothorax: decreased vocal resonance
What are bronchial breath sounds?
Tubular, hollow sounds heard over large airways
Louder and higher pitched than vesicular breath sounds
What are crackles? If they are head in early or late phases of breathing what does that signify?
Early inspiratory and expiratory: chronic bronchitis
Late inspiratory: pneumonia, CHF, atelectasis
What is a pleural rub?
Creaking or grating sound like standing on snow
Produced by two inflamed surfaces sliding on one another - pleurisy
What is pleurisy?
Inflammation of the pleurae which impairs their lubricating function and causes pain when breathing
What additional investigations might you want to do after an examination of a patient with SOB?
Peak flow
Sputum Pot
Oxygen saturation
ABG
How might a patient describe pleuritic chest pain?
Usually lateral Sudden Sharp, stabbing On deep inhalation Severe
What are the 5 Ps which might cause pleuritic chest pain?
Pneumonia Pulmonary embolus (PE) Pneumothorax Pericarditis Pneumomediastinum
What are causes for haemoptysis?
Pneumonia, upper respiratory tract infection Pulmonary embolism Coagulopathy Coughing Malingering Vasculitis Bronchial carcinoma
What questions in the history would you want to ask about a patients pleuritic chest pain?
Where is it?
When did it start? Over how long? What were you doing?
How would you describe it?
Does it go anywhere else?
Is it there all the time or does it come and go?
Does anything make it worse? Breathing? Position?
Where is it on a scale of 1-10?
What questions in the history would you want to ask about a patients haemoptysis?
What exactly happens? Are you really coughing blood?
When did it first start?
How often does it happen? Per day?
Fresh blood or clot?
How much is there? Streak? Teaspoon? More?
What additional symptoms would you want to ask a patient about who presents with pleuritic chest pain?
Leg pain? Leg swelling? Fever? Purulent sputum? Unintentional weight loss? Longstanding cough?
What aspects of a patients past medical history would you want to ask about if they present with pleuritic chest pain?
Previous DVT/PE? Recent immobility? Recent surgery? Recent travel? Pregnancy? History of cancer? Immunocompromise?
Which specific drugs would you want to ask about in a patient presenting with pleuritic chest pain?
Oral contraceptive?
Steroids?
Immunosuppressants?
What family history would you want to ask about in a patient presenting with pleuritic chest pain?
DVT?
PE?
History of lung cancer?
What social history would you want to ask about in a patient presenting with pleuritic chest pain?
Level of activity? Occupation? Home environment? Occupation? Smoking? Pack years?
What signs would you look for from the end of the bed in a patient with pleuritic chest pain?
In pain Shallow, rapid breaths Sputum pots Oxygen Inhalers Chest expansion
What examination signs might you look for in a patient with pleuritic chest pain?
Peripheries cold Oxygen saturations Peripheral cyanosis Clubbing Tar staining Conjunctival pallor Fever Calf swelling/ tenderness
What is the mechanism that leads to clubbing in lung conditions?
VEGF induces vascular hyperplasia, oedema, and fibroblast or osteoblast proliferation at a peripheral level in the nails
In primary pulmonary conditions such as lung cancer, this is the operative mechanism
What are the stages of clubbing?
Nail bed fluctuation Loss of nail bed angle Increase curvature of nail fold Thickened distal phalanx/ Drumstick appearance Hypertrophic osteoarthropathy