respiratory and breathlessness Flashcards
what is characteristic of chest pain due to resp disease?
sharp, exacerbated by deep inspiration or coughing, commonly localised to one area of chest
pleuritic pain: associated with dyspnoea. may be due to pneumonia, pulmonary embolus or pneumothorax
what causes wheeze?
airflow limitation due to asthma, chronic airways disease, foreign body or tumour.
usually expiratory, inspiratory (stridor) suggest large obsturction
what previous conditions predispose to further episodes?
TB, pneumonia, DVT/PE, asthma and chronic bronchitis or emphysema
why is fhx important in resp disease?
TB can be spread to close contacts
CF and a1atd inherited
why are occupation and hobbies important in resp history?
dust and fumes-particularly asbestos
mouldy hay, humidifiers, air condiitoners->allergic alveolitis
animals and birds
what medications are relevant to resp disease?
steroids predispose reactivation of TB
resp side effects: ACEi cough, interstitial lung disease from methotrexate or cyclophosphamide, bronchospasm from BB or NSAID
cocaine can cause lung disease
IV drug users at risk of lung abscesses and drug-related pulmonary oedema
what are the causes of acute and chronic cough?
acute: infective
chronic: asthma copd, GOR, use of ACEi
what causes a productive vs dry cough?
productive: bronchiectasis (large vol), chronic bronchitis
dry: ACEi, GOR
what does the colour of sputum suggest?
purulent yellow/green: bronchiectasis, lobar pneumonia
dark and foul smeeling: lung abscess
yellow: asthma
pink frothy sputum: pulmonary oedema
what causes haemoptysis?
lung cancer until prove otherwise
TB, bronchiectasis, pulmonary infartion, trauma, generalised bleeding disorders, arteriovebous malformations
what causes a cough to be worse in the morning/evening/after food?
‘smokers cough’
asthma, HF
GOR
what are some trigger factors for a cough caused by allergy?
pollen, dust, cold air
what can cough, wheeze, pleuritic chest pain and sob be caused by?
asthma, copd, chest infections
why is travel important in the history of a cough?
TB more prevalent in Asia and Africa
pneumonia from abroad needs to be covered by abx that produce atypical organisms
why is the childhood history of resp disease important in cough?
pneumonia or whooping cough may lead to bronchiectasis
childhood asthma may represent
progressive cough and sputum from childhood could by cystic fibrosis
why is the onset of dyspnoea important?
sudden: inhaled foreign body, pneumothorax, PE, asthma
develops over a few hours: asthma, pneumonia, pulmonary oedema, extrinisc allergic alveolitis
over a few days: asthma, pleural effusion, pulmonary oedema
over months/years: copd, fibrosing alveolitis, non-resp e.g. anaemia
what causes chest pain and breathlessness?
MI, pneumothorax, PE
when might someone experience othopnoea (sob when lying flat)?
heart disease
what causes paroxysmal nocturnal dyspnoea?
if pulmonary oedema from LV failure, often with cough with frothy pink sputum
asthma
what causes tingling in fingers or light-headedness when sob?
decreased pco2 that occurs with hyperventilation
what is normal respiratpry rate/
<15 per min
increased in fever and severe lung disease
what signs in the hand and nails suggest resp disease/
clubbing: lung cancer, fibrosing alveolitis, lung abscess, bronchiectasis and empyema
wasting of muscles: lung cancer
peripheral cyanosis
red/warm/clammy=co2 retention
what type of tremor does co2 retention cause?
flapping
what signs in the eyes and face indicate resp disease?
horners syndrome=apical lung cancer
central cyanosis under tongue=hypoxaemia
what causes and increased JVP?
R heart failure, which may be secondary to cor pulmonale
what causes tracheal tug and deviation?
tracheal tug=severe obstruction
deviates towards the side in fibrosis or peumothorax
away in tension pneumothorax or pleural effusion
what does the shape of the chest indicate?
increased anteroposterior diameter (barrel) in emphysema
pectus carinatum from childhood asthma or rickets
what degree of chest expansion is pathological?
<5cm probably
<2cm definitely
what do changes in expansion suggest?
asymmetrical=pleural effusion, consolidation, pneumothorax, fibrosis
reduced bilaterally=chronic airways disease or fibrosing alveolitis
when is tactile vocal fremitus altered?
increased=consoliation
decreased=collapse, pleural effusion, pneumothorax
what causes percussion that isn’t resonant?
stony dull=pleural effusion
dull=fibrosis, consolidation, collapse
hyperresonant=emphysema, pneumothorax
what sounds can be detected in ausculataiton of the lungs?
vesicular=normal
broncial (loud blowing)=lung consolidation or pulmonary fibrosis
wheeze=narrowed
early inspiratory crackles=obstruction in central airways
late inspiratory crackles=fibrosing alveolitis, pneumonia, heart failure
pleural rub often associated with localised pain
when are the cervical and scalene lymph nodes enlarged
resp infection, malignant infiltration, sarcoidosis, HIV infection
what are the features of consolidation?
no mediastinal shift, chest wall expansion normal or decreased, percussion note normal or decreased, breath sounds increased (broncial), crackles, tactile vocal fremitus increased
what are the features of pleural effusion?
no or away mediastinal shift, decreased expansion, stony percussion note, decreased breath soudnds, occassional rub, decreased tactile vocal fremitus
what are the features of lobar collapse?
mediastinal shift towards, decreased expansion, decreased percussion note, decreased breath sounds, no added sounds, decresed tactiile vocal fremitus
what are the features of a pneumothorax?
none in simple but away mediastinal shift in tension pneumothorax, normal or decreased expansion, increased percussion note, decreased breath sounds, occasional click, decreased tactile vocal fremitus
what are the features of pleural thickening?
no mediastinal shift, decreased chest wall expansion, decreased percussion note, decreased breath sounds, decreased tactile vocal fremitus
what are the key symptoms associated with breathlessness?
chest pain, stridor, wheeze, cough, sputum production, haemoptysis
give the differnetials for breathlessness.
cardiac: heart failure, arrhythmia, acs, angina
GI: ascites
resp: anaphylaxis, pe, pneumothorax, pneumonia, copd, asthma, ild, bronciectasis, lung cancer, occupational lung disease
msk: chest wall trauma, rib fractures
other: anaemia, obesity, anxiety, smoking, neurological
what are the features of heart failure?
progressive sob
new/worsening peripheral oedema
associated orthopnoea/pnd
what are the features of anaphylaxis
impending airway obstruction, hives, angioedema, possible known allergen
what are the features of a PE?
rf, associated pleuritic chest pain, calf swelling, +/-haemoptysis, peripheral oedema
how does pneumonia present?
gradual, progressibe, +/-pleuritic chest pain, associated fever and productive cough
how does pneumothorax present?
tall, thin, pleuritic chest pain, sudden onset
what are the featurs of copd?
smoker, frequent chest infections, wheeze, chronic productive cough
how does asthma present?
younger patients, hight time cough, associated atopy, triggers
how does lung cancer present?
smoker, wt loss, chronic cough>3wks, +/-haemoptysis, bone pain
how does ascites present?
breathing worse when lying flat, large abdomen
what ix are done for breathlessness?
bloods: FBC, U+E, clotting, TFTs, cultures
peak flow, cxr, ecg, spirometry, ctpa, hrct
what is the curb 65 score for?
severity of community acquired pneumonia. 0-1=low risk, home tx, 2=hospital supervised tx, >3=severe, consider admission to intensive care
confusion, uremia (>7), resp rate (>30), blood pressure (systolic<90, diastolic<60), age>65
what is important in the hx of breathlessness
How is the patient normally? (Is this acute / chronic / acute on chronic?)
• Onset, timing, duration, variability, diurnal variation
• Exacerbating factors e.g. allergic triggers, exertion, cold air
• Relieving factors e.g. rest, medication
• Associated symptoms e.g. cough, sputum, haemoptysis, pain, wheeze, night sweats,
weight loss, oedema
• Severity e.g. at rest? Only on exertion? Limiting ADLs?
what is important in the hx for a cough?
Onset, timing, duration (less than 2 months = acute, more than 2 months = chronic),
variation (e.g. recent change in a chronic cough), diurnal variation.
• Productive / unproductive?
what is important in the hx for sputum
Onset, timing, duration, variation, diurnal variation
• Colour (e.g. rusty sputum suggests pneumococcal pneumonia; frothy pink may
indicate pulmonary oedema). Any haemoptysis?
• Consistency (viscous (fluid), mucous, purulent, frothy)
• Quantity (teaspoon, cupful etc.)
• Odour (fetid suggests bronchiectasis or a lung abscess)
what is important in the hx of haemoptysis
Origin (differentiate haemoptysis from haematemesis, was it coughed up?) • Onset, timing, duration, variation • Quantity • Colour (fresh blood or dark altered blood) • Consistency (liquid, clots, mixed with sputum) • Sputum • Chest pain • Recent trauma to chest or elsewhere? • Recent / current DVT? • Weight loss, fever, night sweats? • Breathlessness? • Bleeding or bruising elsewhere?
which resp conditions are important in the family hx
Infections may be transmitted between family members
• There is a genetic predisposition to allergic conditions (e.g. asthma)
• Alpha1-antitrypsin deficiency is a genetic cause of emphysema
what social hx is important for resp conditions?
Occupation (industrial hazards e.g. dusts, asbestos)
• Smoking (pack years e.g. 10/day for 30 years = half a pack x 30 = 15 pack years)
• Pets (can transmit infection or cause hypersensitivity reactions)
• Overseas travel
• Living conditions e.g. damp
• Alcohol
• Exercise, activities of daily living, independence
what drug hx is important in resp conditions
Inhalers, steroids, antibiotics, ACE inhibitors (may cause cough), amiodarone (pulmonary
fibrosis), beta-blockers (may worsen airways obstruction), NSAIDS, oxygen therapy
what resp problems cause a fine tremor?
beta-agonists e.g.
salbutamol
what resp problems cause asterixis?
respiratory failure
what causes wasting of the intrinsic hand muscles?
(T1
nerve invasion by an apical lung cancer
what is pulsus paradoxus
exaggeration of the normal decrease in
blood pressure during inspiration). The ‘paradox’ is that you can detect beats on
auscultation of the heart during inspiration that cannot be palpated at the radial artery
due to a fall in blood pressure. Pulsus paradoxus is seen in severe obstructive airways
disease and cardiac tamponade.
