Respiratory - Cough Flashcards
A 21 year old man has a productive cough, wheeze and steatorrhea. On examination he is clubbed and cyanosed, and has bilateral coarse crackles. His blood glucose level is measure at 11mmol/l.
a) Lung cancer
b) Cystic fibrosis
c) Goodpasture’s disease
d) Pneumonia
e) Tuberculosis
b) Cystic fibrosis
Cough, wheeze
Digital clubbing and cyanosis
Bilateral coarse crackles
Pancreatic insufficiency
(Not cancer- yes he’s clubbed but other features don’t fit
Pneumonia – may currently have but overarching picture is something bigger)
A middle aged man comes into A+E with cough, haemoptysis and a fever. He says he doesn’t have a permanent home and you notice that his clothes look very loose on him.
a) Sarcoidosis
b) COPD
c) Lung cancer
d) Pneumonia
e) Tuberculosis
e) Tuberculosis
Productive cough +/- haemoptysis
Weight loss, Fevers
Contact with infected e.g. high risk groups
People without permanent residence at increased risk
(Fever – infection, systemic features less likely pneumonia
Haemoptysis and weight loss – could be cancer but again, homelessness (RF) and fever point towards infectious cause)
3) A 16 year old girl comes to the GP with an irritating cough. She says it bothers her at night and when she wakes up in the morning.
a) Asthma
b) Cystic fibrosis
c) Goodpasture’s disease
d) Pneumonia
e) Post-nasal drip
a) Asthma
Often young onset Recurrent, intermittent episodes of: Cough Wheeze SOB - Often worse at night
(No features CF
No infectious features)
What is CF?
autosomal recessive disease - mutation in CF transmembrane conductance regulator gene (CFTR) -> results in inability to secrete Cl and hydrate secretions.
Which organs/systems and how does CF affect most?
Lungs - recurrent infections -> bronchiectasis Pancreas- malabsorption, diabetes Liver - cirrhosis Biliary system - gallstones GI tract - obstruction Vas deferens - sterility \+ children - failure to thrive
(mucus blocks airways and pancreatic duct/ biliary tree)
What resp condition can commonly be a long-term complication of CF?
Bronchiectasis
What is bronchiectasis?
Bronchiectasis: abnormal and permanently dilated airways due to chronic infection of the bronchi and bronchioles -> permanent dilation of the airways. Related to CF ‘mucopurulent cough’
What are the features of CF?
Cough, wheeze
Cyanosis
Digital clubbing
Bilateral coarse crackles
+ children - failure to thrive
Diagnosis of CF?
NEONATAL SCREENING
Sweat test
Sputum culture, CXR, spirometry
Bloods:
Genetic screening
FBC/U&E/LFT/vitamins
Faecal elastase for pancreatic dysfunction
At what stage in life do patients with CF usually present?
Usually present very early in life – as most have pancreatic insufficiency -> malabsorption (steatorrhea)
Can present later if initially pancreatic sufficient -> then become insufficient
CF MGMT
MDT approach: Chest physio Mucolytics, Bronchodilators, Antibiotics Gene therapy Correction of vitamin deficiencies/pancreatic insufficiency (Creon) LUNG/LIVER TRANSPLANT
Aetiology of TB?
MYCOBACTERIUM TB
Contact with infected e.g. high risk groups, travel
Immune deficiency
NB: infection often latent (Latent: immune system contains infection/bacilli present in ‘ghon focus’ – calcified nodule, asymptomatic, not infectious – potential for reactivation )
Patophysiology of TB?
Immune response -> caseating granulomas
- Granuloma = Focal collection of inflammatory cells at sites of tissue infection
- Caseation = necrotic regions, ‘cheeselike’
(Can be extra-pulmonary:
LN, GI, bone and spine (pott’s disease), military, CNS, pericardial, skin and skeletal muscles, renal, thyroid, adrenals)
What groups are in high risk of getting TB?
High risk: migrated from high risk areas, homeless, overcrowding
Immune deficiency: HIV, steroids, immunosuppressant, etc
What are the clinical features of respiratory TB?
Productive cough +/- haemoptysis
Weight loss, Fevers, Night sweats
TB investigations:
Chest X ray: consolidation +/- cavitation (usually upper zones), lymphadenopathy
Sputum: MC&S
Stain: Ziehl-Neelsen: Acid-fast bacilli
Culture: Lowenstein-jenson
LATENT TB: Tuberculin skin test, IFNY-y assays, elispot
HIV screening
(mc&s - microscopy, culture and sensitivities
CXR findings of TB:
consolidation +/- cavitation (usually upper zones), lymphadenopathy
Upper zones most oxygenated hence reside there
How would you manage a patient with TB?
6 month antibiotic course:
Rifampicyn 8+16 weeks Isoniazid 8+16 weeks Pyraminazide 8 weeks Ethambutol 8 weeks \+ Pyridoxine throughout: vit B6, prevents Isoniazid SEs.
What are the side effects of Isoniazid? What do you give to prevent them?
Increased blood levels of liver enzymes, peripheral neuropathy,
liver inflammation,
unclear if use during pregnancy is safe for the baby.
Pyridoxine, which is vitamin B6, may be given to reduce the risk of side effects (peripheral neuropathy in particular).
Side effects of Rifampicin?
Extra question, not sure if in Sofia
Liver toxicity — hepatitis, liver failure in severe cases
Respiratory — breathlessness
Cutaneous — flushing, pruritus, rash, hyperpigmentation, redness and watering of eyes
Abdominal — nausea, vomiting, abdominal cramps, diarrhea
Flu-like symptoms — chills, fever, headache, arthralgia, and malaise.
Rifampicin has good penetration into the brain, and this may directly explain some malaise and dysphoria in a minority of users.
Allergic reaction — rashes, itching, swelling of the tongue or throat, severe dizziness, and trouble breathing
What is asthma?
Chronic inflammatory condition of lung airways
Is asthma reversible?
Yes, it is (unlike COPD)
Asthma epidemiology?
Often young onset
Asthma classification?
Mild, moderate, acute severe, life threatening (to be covered in future session)
Causes of asthma?
Genetic: Atopy: asthma, eczema and hayfever (IgE mediated)
Environmental: Allergens: house dust-mite, pets, fungal spores…etc
Patophysiology of asthma?
Bronchial muscle contraction, mucosal inflammation, increased mucus -> airway narrowing
Characteristics:
Airflow limitation
Airway hyper-responsiveness
Inflammation of bronchi
Symptoms of asthma?
Recurrent, intermittent episodes of:
Cough
Wheeze
SOB
Often worse at night (or day if occupational)
Precipitated by: cold air, exercise, pollution, anxiety, drugs
(Occupational: flour, allergens from animals, wood dust, pharmaceutical
+ NSAIDS and Beta blockers)
Asthma signs on resp exam?
Tachypnoea Audible wheeze Hyperinflation Percussion: hyper-resonant Auscultation: polyphonic wheeze, diminished air entry
COPD vs Asthma: smoking?
COPD: nearly all
Asthma: possibly
COPD vs Asthma: symptoms <35yo?
COPD: Rare
Asthma: Often
COPD vs Asthma: chronic productive cough?
COPD: Common
Asthma: Uncommon
COPD vs Asthma: SOB?
COPD: Persistent and progressive
Asthma: Variable
COPD vs Asthma: night time waking with SOB or wheeze?
COPD: uncommon
Asthma: common
COPD vs Asthma: significant diurnal or day-to-day variability of symptoms?
COPD: uncommon
Asthma: common
Old patient with chronic cough + red flag features: weight loss, night sweats, fevers, heamoptysis?
Lung cancer
What is Goodpasture’s disease?
diffuse pulmonary haemorrhage and rapidly progressive glomerulonephritis.
Anti-GBM positive.
Signs of Goodpasture’s disease?
SOB, cough, haemoptysis, haematuria, oedema, HTN, systemically unwell
Three most common causes of chronic cough in a non-smoker?
- Asthma
- Post-nasal drip
- GORD
What is a post-nasal drip?
Occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the throat or back of the nose. It is caused by rhinitis, sinusitis, GORD, or by a disorder of swallowing (such as an esophageal motility disorder). It is frequently caused by an allergy, which may be seasonal or persistent throughout the year.
How does a post-nasal drip cause a cough?
excess mucus irritates cough receptors. Associated URT infection
Can GORD cause a cough?
Yes
How does GORD cause a cough?
Reflux irritates cough receptors. Especially at night
