Respiratory History Flashcards
HPC
-key questions
What brings you in today
- SOCRATES
- frequency
- triggers, worse/better
- functional impacts in comparison to their normal
- volume of sputum, any blood?
ESTABLISH IF
- acute or chronic? -
- severity
Ok so it sounds like you have several things you’d like to discuss. I don’t think we’ll be able to discuss everything during this consultation, which problem is the most concerning to you at the moment? We can make a follow up appointment so we can address the other problems we couldn’t today.
Main respiratory symptoms to ask for
Cough
Sputum, haemoptysis
SOB and exercise tolerance
-on exertion, rest, lying down
Chest pain
-where, inspiration, expiration, SOCRATES
Stridor/wheeze
Hoarse voice
Systemic enquiry
Basic screen for signs => is this a severe/disseminated problem
Systemic - fever, weight changes, fatigue,
CV - chest pain, palpitations, leg swelling, how many pillows do you sleep with, fainting
GI - N+V, difficulties swallowing, abdo pain, changes in bowel habits
GU - changes in urinary frequency
Neuro - memory, confusion, seizures, vision, hearing, swallowing, dizzy, tingling or weakness, bowels and bladder
MSK - back pain, joint pain, rashes?
Past medical and drug history
-what else should you also ask about
Any other health problems?
-how are they managed? medications?
Any past surgeries, procedures or hospital visits?
Any other medications, OTC, contraceptives, herbal supplements, inhalers?
-HTN, DM, cholesterol,
Allergies and reactions
Have you been vaccinated against flu, pneumonia, COVID, TB?
Family history
Cancers or respiratory disease in family especially siblings, parents
-age and year of passing
Social history
- living
- substances
Home
- type of accommodation
- who they live with? carers? dependents?
- pets?
- level of independence - shopping, cooking, self care, cleaning?
Smoking - effects are dose dependent
-calculate pack years if possible
Alcohol
-units/week
-CAGE questionnaire to assess for dependence
Rec drugs
-withdrawal, opiate tolerance, BBV IVDU?
-HIV => increased risk of infections
Social history
- occupation
- travel
Occupation
- Navy, docks, construction => asbestos exposure => mesothelioma (poor prognosis)
- Birds, farmer => Hypersensitivity pneumonitis
Foreign travel
- infectious disease risk => TB
- long flight => PE, DVT
Key features to elicit
Age
Acute or chronic
Red flags or risk factors?
Severe/systemic or mild?
Investigations
Blood
- WCC, CRP - infection
- Hb - anemia (chronic disease? malignancy? internal bleed?)
Imaging
-CXR, CT
Diagnostic tests
- MC&S, cytology
- biopsy
Functional
- peak flow, spirometry
- lung function tests - ability to
- echocardiogram
Medical conditions relevant to respiratory disease
Asthma/COPD/a1antitrypsin deficiency
Lung cancer
Bronchiectasis
Pulmonary fibrosis
PE
TB
Neuromusclar cond - ALS
Congestive heart failure
CF
Medications with respiratory side effects
Bb + NSAIDs => BC
ACEi => dry cough
Estrogen containing medication => PE, DVT risk
Amiodarone, methotrexate => pleural effusions, ILD
Pulmonary fibrosis
- Risk factors
- core features
- investigations
- management
Risk factors
- Occupation - birds, farmer, coal worker
- Exposures - asbestos, radiation
- Drugs - nitrofurantoin, bleomycin, amiodarone, methotrexate
- AI - RA, AS, SLE,
Core features
SOB, dry cough
Reduced lung expansion, higher RR, inspiratory creps
Sign relating to cause
- IPF - idiopathic
- AS, RA, sarcoid, SLE
- radiation burns
Investigations
- Spirometry - restrictive
- Bloods - find cause (autoantibodies, TB)
- CXR - reticulonodular shadowing
- CT - honeycombing, ground glass opacity (grey patches)
Management
- Conservative - smoking cessation, pulmonary rehab, long term O2
- Acute - CS
- Maintenance - antifibrotics in IPF (nintedanib, pirfenidone
- Curative - lung transplants
COPD
- risk factors
- core features
- investigations
- management
Risk factors
- smoking
- FHx
Core features
SOB, worse on exertion, white sputum, cough, wheeze
Expiratory wheeze, CO2 retention
Investigations
- Spirometry - obstructive, no BD reversibility
- assess severity
- CXR - hyperinflation, flat diaphragms
Management
Conservative - smoking cessation, pulmonary rehab, vaccines
-1st line - SABA/SAMA
-2nd line - SABA + ICS or SABA + LABA
-3rd line - SABA ICS LABA or SABA LAMA LABA
Asthma
- risk factors
- core features
- investigations
- management
Risk factors
- FHx
- atopic triad
Core features
-Triggered by allergen, viral infection => SOB, tight chest, wheeze, cough
Investigations
- Spirometry - obstructive, BD reversability
- FeNO, eosinophilia - objective inflammation
Management
Conservative - identify and avoid triggers
-1st line - SABA + ICS
-2nd line - SABA + ICS + LRTA
-3rd line - SABA + ICS + LABA
Bronchiectasis
- risk factors
- core features
- investigations
- management
Risk factors
-chronic lung problem (CF, recurrent infections, malignancy)
Core features
Productive chronic cough
Coarse inspiratory crepitations, clubbing
Investigations
- CXR - tramtracks
- CT - signet ring
- sputum culture - causative infectious organism
Management Address cause Conservative -Prophylactic ABx -BD -Chest physio -Vaccines
Acute lung conditions you must look out for
PE
PT
Asthma/COPD exacerbation
MI
Lung cancer
- risk factors
- core features
- investigations
- management
Risk factors
- SMOKING
- FHx
- past radiation exposure
Cancer guidelines
2ww referral
-CXR suggests cancer
-40+ haemoptysis
2week CXR - 40+
Smoker + 1 unexplained feature
Never smoked + 2 unexplained feature
-cough/SOB/chest pain
-fatigue/weight loss/anorexia
Investigations
Definitive - biopsy (FNA, US guided bronchoscopy)
Staging - CAP PET
Management
Surgical
Chemo/radtiotherapy before/after
Bronchiolitis, croup
- core features
- investigations
- management
Bronchiolitis
Core features
U2
Flulike - dry cough, SOB
Wheeze, fine inspiratory crackles
~~~
Clinical diagnosis
Supportive - rest, fluids, simple analgesia
Croup
Core features
U3
Flulike - stridor, barking cough
Clinical diagnosis
Management - dexmeth
TB
- risk factors
- core features
- investigations
- management
Risk factors
- IC, unvaccinated, IVDU, alcohol
- recent exposure
Core features
Only infectious if symptomatic
-weight loss, fever, night sweats, fatigue, anorexia
Diagnosis
Active - sputum culture for acid fast bacillli
CXR - upper lobe cavitation, bilar hilar LN
Management
Pyrazinamide, ethambutol - 2months
Isoniazid, rifampicin - 6months
Sarcoidosis
- risk factors
- core features
- diagnosis
- managemeent
Risk factors
-young adults
Core features
Bilateral hilar LN + erythema nodosum + SOB/cough
Diagnosis
Lung biopsy - non caseating granuloma
Management
Acute - CS, simple analgesia
Sore throats -laryngitis -pharyngitis vs strep throat - how to differentiate -glandular fever Management
Laryngitis - croaky voice, irritating cough
Viral Pharyngitis - cough, no LN, no fever, no purulent tonsils, adult
Strep pharyngitis - no cough, LN, fever, purulent tonsils, child => penicilin
-Peritonsillar abscess - difficulty speaking, breathing, swallowing, opening mouth
Glandular fever - fever and chills, LN, extreme fatigue
-avoid contact sports - reduce risk of hepatosplenic rupture
Management
Supportive - fluids, simple analgesia, rest
