Respiratory Flashcards
Specific questions to ask when a patient presents with a cough.
Sputum Colour Nature of Sputum Onset of cough Duration of cough Periodicity Age of patient Smoking history
What does sputum colour indicate in a cough?
Clear / White (Mucoid) - no infection present.
Yellow / Green / Brown - infection present, generally viral not requiring immediate referral.
Haemoptysis - rust coloured in pneumonia, pink in LV failure or dark red in carcinoma.
Includes bright red blood - usually a one-off due to force of coughing. Not serious and doesn’t require immediate referral.
What does the nature of the sputum indicate in a cough?
Thick & Frothy - LV failure.
Thick & Mucoid / Yellow - asthma.
Offensive foul-smelling sputum - bronchiectasis or lung abscess.
What does the onset of the cough indicate?
A cough that is worse in the morning may suggest upper airways cough syndrome, bronchiectasis or chronic bronchitis.
What does the duration of the cough indicate?
Upper respiratory tract infection (URTI) cough can linger for more than 3 weeks and is termed ‘postviral
cough’.
Coughs lasting longer than 3 weeks should be viewed with caution.
The most likely diagnoses of cough are as follows:
- At 3 days’ duration will be a URTI.
- At 3 weeks’ duration will be acute or chronic bronchitis.
- At 3 months’ duration conditions such as chronic bronchitis, tuberculosis and carcinoma become more likely.
What does periodicity of cough indicate?
Adult patients with recurrent cough might have chronic bronchitis, especially if they smoke.
Care should be exercised in children who present with recurrent cough and have a family history of eczema, asthma or hay fever. This might suggest asthma and referral would be required for further investigation.
What does the age of patient with a cough indicate?
Children will most likely be suffering from a URTI but asthma and croup should be considered.
With increasing age conditions such as bronchitis, pneumonia and carcinoma become more prevalent.
What does smoking history of a patient with a cough indicate?
Patients who smoke are more prone to chronic and recurrent cough. Over time this might develop in to chronic bronchitis and COPD.
What are the symptoms of croup?
Symptoms occur in the late evening and night. The cough can be severe and violent, and is described as having a barking (seal-like) quality. In between coughing episodes the child may be breathless and struggle to breathe properly. Typically, symptoms improve during the day and often recur again the following night, with the majority of children seeing symptoms resolve in 48 hours.
In what age group is croup most likely to be prevalent?
Infants between 3months-6years. Incidence is highest between 1-2years and is more common in boys.
What medicines may be related to a cough or wheeze?
ACE inhibitors - not dose related and may occur at any time during treatment.
NSAIDs
Beta-blockers
Cough referral symptoms.
Cough lasting >3 weeks SOB / breathlessness / wheeze Chest pain Pain on inspiration Hemoptysis Regularly recurring cough Debilitating symptoms Persistent nocturnal cough in children Purulent sputum lasting after 7-10 days (risk of secondary bacterial infection from initial viral infection) Any cough that does not improve with treatment
Treatment options for productive coughs.
Expectorants:
Guaifenesin: >6 years.
6-12 years = 100mg QDS >12 years = 200mg QDS
Antihistamines:
Diphenhydramine: >6 years. Generally in combination products.
Treatment options for non-productive coughs.
Suppressants: Codeine: >18 years - limit use due to risk of abuse. 5ml QDS Pholcodine: >6 years. 5-10ml TDS/QDS Dextromethorphan: >12 years. 10ml QDS
Antihistamines:
Diphenhydramine: >6 years. Generally in combination products.
Demulcents:
Simple Linctus: >1 month. No associated side-effects.
5-10ml TDS/QDS
Specific questions to ask when a patient presents with a cold.
Onset of symptoms.
Nature of symptoms.
Aggravating factors.
What does the onset of the cold symptoms indicate?
Peak incidence of flu is in the winter months; the common cold occurs any time throughout the year.
Flu symptoms tend to have a more abrupt onset than the common cold – a matter of hours rather than 1 or 2 days.
In summer months, must be differentiated from hay fever.
What does the nature of the cold symptoms indicate?
Marked myalgia, chills and malaise are more prominent in flu than the common cold. Loss of appetite is also common with flu.
What do the aggravating factors of the cold symptoms indicate?
Headache/pain that is worsened by sneezing, coughing and bending over suggests sinus complications.
If ear pain is present, especially in children, middle ear involvement is likely.
What are the symptoms of sinusitis?
At least 2 of the following: - Blockage / congestion - Discharge / UACS - Facial pain / pressure - Reduction / loss of smell Pain starts localised and becomes bilateral and more severe. May be exacerbated by bending forwards or moving the head side-to-side or when sneezing.
What are the symptoms of flu?
- Shivering
- Chills
- Malaise
- Marked aching of limbs
- Insomnia
- Non-productive cough (cough in the common cold is usually – - Loss of appetite
Flu is more debilitating but symptoms tend to improve within 5 days.
Cold referral symptoms.
- Acute sinus involvement that fails to respond to OTC decongestant therapy
- Middle ear pain that fails to respond to analgesia
- Patients with symptoms indicative of flu
- Vulnerable patient groups such as the very elderly
Treatment options for a cold.
Anthistamines:
Diphenhydramine: >6 years
Systemic sympathomimetics:
Phenylepherine: >12 years
Pseudoephedrine: >6 years
Topical sympathomimetics:
Oxymetazoline: >12 years
Xylometazoline: >6 years
Topical products should be limited to 7 days use to prevent rebound congestions.
Products often come as combinations.
Saline nasal drops may be used in babies to relieve congestion.
Important drug interactions for sympathomimetics used in colds.
MAOIs
Moclobemide
Control of HTN and diabetes shouldn’t be affected in the short-term but caution should be taken.
Non-pharmacological advice for patients with a cold.
- Limiting viral spread: Use disposable tissues, wash hands regularly, don’t share towels, avoid touching your nose.
- Many products use paracetamol in combination. Advise to not use any other products containing paracetamol.
Specific questions to ask when a patient presents with a sore throat.
Age of the patient.
Tender cervical glands.
Tonsillar exudate present.
Ulceration.
What does the age of patient with a sore throat indicate?
Although viruses are the most common cause of sore throat, there are epidemiological variances with age:
- Under 3 years old, Streptococcus is uncommon
- Streptococcal infections are more prevalent in people under the age of 30, particularly those of school age (5–10 years) and young adults (15–25 years old).
Viral causes are the most common cause of sore throat in adults
Glandular fever is most prevalent in adolescents.
What does tender cervical glands in a sore throat indicate?
Patients suffering from glandular fever and streptococcal sore
throat often have markedly swollen glands. This is less so in viral sore throat.
What does tonsillar exudate in a sore throat indicate?
Marked tonsillar exudate is more suggestive of a bacterial cause than a viral cause.
What does ulceration in a sore throat indicate?
Herpetiform and herpes simplex ulcers can also cause soreness in the mouth, especially in the posterior part of the mouth.
Sore throat referral symptoms.
Duration >2 weeks Marked tonsillar exudate, accompanied with a high temperature and swollen glands Suspected ADR (agranulocytosis) Dysphagia Associated skin rash
Treatment options for a sore throat.
- Topical anaesthetics:
Lidocaine: >12 years.
Benzocaine: >3 years (lozenge) >6 years (spray) - Topical antibacterials: Chlorhexidine & benzalkonium containing products.
- Topical anti-inflammtories:
Benzydamine: >12 years (rinse) >6 years (spray)
Flurbiprofen: >12 years. - Simple analgesia: Paracetamol & NSAIDs.
