Respiratory - clinical exam Flashcards
Cystic fibrosis clinical findings
“child with CF, please examine for complications”
Poor growth - check growth charts
Vitals- tachypnoea, cyanosis rare
Nutrition: Reduced muscle bulk/fat stores OR cushinoid body habitus (say “reasonable muscle bulk and fat stores”
Pubertal delay
COUGH (?wet ?check sputum colour, rust= ABPA)
Clubbing
Koilonichia, pallor of palmar creases (anemia)
Palmar erythema (liver disease)
CGM/fingerpricks/lipohypertrophy (diabetes)
Splaying of wrists (vit D def)
Scratch marks (cholestasis)
Eyes- conjunctival pallor, scleral icterus
Nose- polyps
Face- sinusitis
Mouth - angular chelitis, central cyanosis
Cervical lymphadenopathy if resp infection
Hyperinflated chest, symmetrical chest expansion, midline trachea (unless pneumothorax)
Increased work of breathing
Tracheal deviation
RV heave (cor pulmunale)- say “no clinical evidence of pulmunary hypertension, including no loud P2 and no parasternal heave”
Bilat crackles, wheeze (think ABPA)
Apex beat on right in Kartageners syndrome (major differential)
Consolidation (dullness) on percussion
May have scar of lung transplant,or mec ileus
Abdominal scars/devices (eg gastrosomy, central line)
Portal HTN- caput medusae, spider nevi, splenomegaly)
Hepatomegaly
Faecal loading (constipation/DIOS)
Legs- same as hands
Gait: peripheral neuropathy (vit E def), cerebellar ataxia ( vit E def), proximal muscle weakness (corticosteroids)
Splayed wrists (vit D deficiency)
Say would also look at tanner staging
Ask for these investigation findings if suspecting CF in short case
Spirometry
CXR
BSL
Bloods:
LFTs/USS/elastography if suspecting liver disease
FBE (anemia, thrombocytopenia if portal HTN)
OGTT
Coags (liver disease)
Vitamin A,E,K,D levels
Scope for varices/gastro referral if concerns liver disease
DEXA scan for bone density
CF long case - dont forget to ask
Diagnosis
- how/when diagnosed?
- family history/carrier status
- ?mec ileus ?early resp illnesses
Lung disease
- which bacteria have been cultured (colonisation, clearance)
- staph, pseudomonas, cepacia, burholderia, non TB mycobacteria
- what medications? any prophylactic or just in case antibiotics? tune ups in hospital?
- tell me about exacrbations? how many admissions/how often needs admissions
- Best and worst FEV1
- complications: pneumothoraxes, sinusitis, nasaal polyps
- girls: cough incontience
GIT complications
- pancreatic insufficiency - creon, how do you go with calculating/taking it at school/daycare?
- stooling: frequency, steattorhoea, flatulance, bloating , loose or offensive stools ?abdominal pain
- liver disease
- rectal prolapse
- pancreatitis
- DIOS
- ?ABPA
CF related diabetes
- when diagnosed (HbA1C, OGTT)
- insulin, dose? CGM
- how often checks BSLs
- what are the usual levels
- any hypoglycemic episodes
Growth/nutrition
- centile
- gastrostomy; cares, any limitations (eg no swimming), body image
- what is diet like (high calorie)- what eat at school?
Steroids
- ABPD
- complications from this
- sick day plan
- DEXA scans
Physio- how long for and how many times per day
- PEP mask
- percussions
- physical activity
- compliance/what is the most difficult
Mental health of patient and family, IMPACT
How do school help out with disease
Compliance issues
Transition (any adolescent)
Procedural anxiety
IV access
Future planning
Ask mum - future pregnancies/genetics
Puberty
Vaccines- particularly annual fluvax and extra pneumococcal
What do you think the future holds
NDIS
HEADSS- impact on school attendance and socialisation ?
SMOKING- patient or family
Common long case management issues in CF
1) Recovery from current illness (if admitted )
-FEV1 pre and post (any bronchodilator responsive component)
- review colonisation including recent culture
- review ABPA culture/ IgE
- review recent chest imaging
- opportunistic PT and dietician review
- any other screening to do opportunistically
2) surveillance complications of CF
- DEXA
- nutritional deficiencies/ growth
- HbA1C/OGTT >10 years
- monitor puberty closely
- liver disease +/- portal hypertension: liver enzymes, tests of liver function, abdominal USS (+/- elastography)
3) if on steroids- monitoring for steroid A/E
- sick day plan for home and school to bring to hsoptial if on long term steroids due to adrenal supression
- monitoring growth
- HTN, lipids, DM monitoring
- Bones: DEXA, ?calcium and vit D supps, physical activity, opthal review for cataracts/glucoma
4) Poor compliance
- need to know WHY poor compliance/barriers and address these specifically
5) Transition to adult healthcare
- increasing responsibility eg for taking meds, cleaning nebuliser
- see patient on their own initially for part of appt, then full appt
- own medicare card
- reproduction/contraception, smoking, drugs
6) Reinforcing psychosocial supports
- GP
- CF australia
- FB groups
7) Body image
8)fears/hopes for the future
ALWAYS MENTION IMPACTS OF THE DISEASE
Diagnosis ABPA in CF
Clinical:
-Increased wheezing/chestiness particularly if failing to respond to antibiotics and inhaled anti-inflammatory or bronchodilator medications
-Thick sputum with brown or black bronchial casts
-Indolent deterioration and weight loss
Investigations:
Major criteria
-CXR pulmonary infiltrates > 1cm diameter and segmental collapse
-High serum IgE - especially an abrupt recent rise (usually described as fourfold increase) and/or above 500 IU/ml
-High specific aspergillus IgE RAST. Normal value <0.35IU/ml may rise 10-100x in ABPA
-Positive IgG aspergillus precipitins
-Eosinophilia (>0.4 x 109/l) on FBE
Treatment ABPA
Oral prednisiolone (2-4 weeks) + itraconazole (continue 1-2 months after stopping steroids)
What is ABPA
Potential cause of lung damage and has a prevalence of about 10% in Cystic Fibrosis (CF) clinics.
The presence of Aspergillus prompts vigorous antibody (IgE and IgG) and cell-mediated immune responses to Aspergillus antigens.
Over time, the immune reactions, combined with direct toxic effects of the fungus, lead to airway damage with dilatation and progression to bronchiectasis and fibrosis.
Side effects Trikafta requiring monitoring
Abnormal LFTs (3 monthly in first year then annually)
Cataracts
