respiratory and breathlessness

Question 1

what is characteristic of chest pain due to resp disease?

Answer 1

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

Question 2

what causes wheeze?

Answer 2

airflow limitation due to asthma, chronic airways disease, foreign body or tumour.
usually expiratory, inspiratory (stridor) suggest large obsturction

Question 3

what previous conditions predispose to further episodes?

Answer 3

TB, pneumonia, DVT/PE, asthma and chronic bronchitis or emphysema

Question 4

why is fhx important in resp disease?

Answer 4

TB can be spread to close contacts

CF and a1atd inherited

Question 5

why are occupation and hobbies important in resp history?

Answer 5

dust and fumes-particularly asbestos
mouldy hay, humidifiers, air condiitoners->allergic alveolitis
animals and birds

Question 6

what medications are relevant to resp disease?

Answer 6

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

Question 7

what are the causes of acute and chronic cough?

Answer 7

acute: infective
chronic: asthma copd, GOR, use of ACEi

Question 8

what causes a productive vs dry cough?

Answer 8

productive: bronchiectasis (large vol), chronic bronchitis
dry: ACEi, GOR

Question 9

what does the colour of sputum suggest?

Answer 9

purulent yellow/green: bronchiectasis, lobar pneumonia
dark and foul smeeling: lung abscess
yellow: asthma
pink frothy sputum: pulmonary oedema

Question 10

what causes haemoptysis?

Answer 10

lung cancer until prove otherwise

TB, bronchiectasis, pulmonary infartion, trauma, generalised bleeding disorders, arteriovebous malformations

Question 11

what causes a cough to be worse in the morning/evening/after food?

Answer 11

‘smokers cough’
asthma, HF
GOR

Question 12

what are some trigger factors for a cough caused by allergy?

Answer 12

pollen, dust, cold air

Question 13

what can cough, wheeze, pleuritic chest pain and sob be caused by?

Answer 13

asthma, copd, chest infections

Question 14

why is travel important in the history of a cough?

Answer 14

TB more prevalent in Asia and Africa

pneumonia from abroad needs to be covered by abx that produce atypical organisms

Question 15

why is the childhood history of resp disease important in cough?

Answer 15

pneumonia or whooping cough may lead to bronchiectasis
childhood asthma may represent
progressive cough and sputum from childhood could by cystic fibrosis

Question 16

why is the onset of dyspnoea important?

Answer 16

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

Question 17

what causes chest pain and breathlessness?

Answer 17

MI, pneumothorax, PE

Question 18

when might someone experience othopnoea (sob when lying flat)?

Answer 18

heart disease

Question 19

what causes paroxysmal nocturnal dyspnoea?

Answer 19

if pulmonary oedema from LV failure, often with cough with frothy pink sputum
asthma

Question 20

what causes tingling in fingers or light-headedness when sob?

Answer 20

decreased pco2 that occurs with hyperventilation

Question 21

what is normal respiratpry rate/

Answer 21

<15 per min

increased in fever and severe lung disease

Question 22

what signs in the hand and nails suggest resp disease/

Answer 22

clubbing: lung cancer, fibrosing alveolitis, lung abscess, bronchiectasis and empyema
wasting of muscles: lung cancer
peripheral cyanosis
red/warm/clammy=co2 retention

Question 23

what type of tremor does co2 retention cause?

Answer 23

flapping

Question 24

what signs in the eyes and face indicate resp disease?

Answer 24

horners syndrome=apical lung cancer

central cyanosis under tongue=hypoxaemia

Question 25

what causes and increased JVP?

Answer 25

R heart failure, which may be secondary to cor pulmonale

Question 26

what causes tracheal tug and deviation?

Answer 26

tracheal tug=severe obstruction deviates towards the side in fibrosis or peumothorax away in tension pneumothorax or pleural effusion

Question 27

what does the shape of the chest indicate?

Answer 27

increased anteroposterior diameter (barrel) in emphysema | pectus carinatum from childhood asthma or rickets

Question 28

what degree of chest expansion is pathological?

Answer 28

<5cm probably | <2cm definitely

Question 29

what do changes in expansion suggest?

Answer 29

asymmetrical=pleural effusion, consolidation, pneumothorax, fibrosis reduced bilaterally=chronic airways disease or fibrosing alveolitis

Question 30

when is tactile vocal fremitus altered?

Answer 30

increased=consoliation | decreased=collapse, pleural effusion, pneumothorax

Question 31

what causes percussion that isn't resonant?

Answer 31

stony dull=pleural effusion dull=fibrosis, consolidation, collapse hyperresonant=emphysema, pneumothorax

Question 32

what sounds can be detected in ausculataiton of the lungs?

Answer 32

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

Question 33

when are the cervical and scalene lymph nodes enlarged

Answer 33

resp infection, malignant infiltration, sarcoidosis, HIV infection

Question 34

what are the features of consolidation?

Answer 34

no mediastinal shift, chest wall expansion normal or decreased, percussion note normal or decreased, breath sounds increased (broncial), crackles, tactile vocal fremitus increased

Question 35

what are the features of pleural effusion?

Answer 35

no or away mediastinal shift, decreased expansion, stony percussion note, decreased breath soudnds, occassional rub, decreased tactile vocal fremitus

Question 36

what are the features of lobar collapse?

Answer 36

mediastinal shift towards, decreased expansion, decreased percussion note, decreased breath sounds, no added sounds, decresed tactiile vocal fremitus

Question 37

what are the features of a pneumothorax?

Answer 37

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

Question 38

what are the features of pleural thickening?

Answer 38

no mediastinal shift, decreased chest wall expansion, decreased percussion note, decreased breath sounds, decreased tactile vocal fremitus

Question 39

what are the key symptoms associated with breathlessness?

Answer 39

chest pain, stridor, wheeze, cough, sputum production, haemoptysis

Question 40

give the differnetials for breathlessness.

Answer 40

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

Question 41

what are the features of heart failure?

Answer 41

progressive sob new/worsening peripheral oedema associated orthopnoea/pnd

Question 42

what are the features of anaphylaxis

Answer 42

impending airway obstruction, hives, angioedema, possible known allergen

Question 43

what are the features of a PE?

Answer 43

rf, associated pleuritic chest pain, calf swelling, +/-haemoptysis, peripheral oedema

Question 44

how does pneumonia present?

Answer 44

gradual, progressibe, +/-pleuritic chest pain, associated fever and productive cough

Question 45

how does pneumothorax present?

Answer 45

tall, thin, pleuritic chest pain, sudden onset

Question 46

what are the featurs of copd?

Answer 46

smoker, frequent chest infections, wheeze, chronic productive cough

Question 47

how does asthma present?

Answer 47

younger patients, hight time cough, associated atopy, triggers

Question 48

how does lung cancer present?

Answer 48

smoker, wt loss, chronic cough>3wks, +/-haemoptysis, bone pain

Question 49

how does ascites present?

Answer 49

breathing worse when lying flat, large abdomen

Question 50

what ix are done for breathlessness?

Answer 50

bloods: FBC, U+E, clotting, TFTs, cultures | peak flow, cxr, ecg, spirometry, ctpa, hrct

Question 51

what is the curb 65 score for?

Answer 51

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

Question 52

what is important in the hx of breathlessness

Answer 52

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?

Question 53

what is important in the hx for a cough?

Answer 53

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?

Question 54

what is important in the hx for sputum

Answer 54

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)

Question 55

what is important in the hx of haemoptysis

Answer 55

``` 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? ```

Question 56

which resp conditions are important in the family hx

Answer 56

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

Question 57

what social hx is important for resp conditions?

Answer 57

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

Question 58

what drug hx is important in resp conditions

Answer 58

Inhalers, steroids, antibiotics, ACE inhibitors (may cause cough), amiodarone (pulmonary fibrosis), beta-blockers (may worsen airways obstruction), NSAIDS, oxygen therapy

Question 59

what resp problems cause a fine tremor?

Answer 59

beta-agonists e.g. | salbutamol

Question 60

what resp problems cause asterixis?

Answer 60

respiratory failure

Question 61

what causes wasting of the intrinsic hand muscles?

Answer 61

(T1 | nerve invasion by an apical lung cancer

Question 62

what is pulsus paradoxus

Answer 62

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.