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Z Year3 Clinical Presentations > Shortness of Breath > Flashcards

Shortness of Breath Flashcards

1
Q

What are the 4 major reasons for SOB?

A
  1. Insufficient O2 into lungs
  2. Insufficient O2 in blood
  3. Insufficient O2 getting around the body
  4. Increased respiratory drive
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2
Q

Why might there be not enough oxygen in lungs?

A
  1. Obstructed airways
  2. Decreased lung volume
  3. Decreased volume of functioning lung
  4. Inability to inflate lungs
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3
Q

What conditions give obstructed airways?

A
  1. Asthma
  2. COPD
  3. Obstruction tumour
  4. Airway oedema in anaphylaxis
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4
Q

What are the intrathoracic causes of not enough O2 into lungs?

A
  1. pneumothroax

2. pleural effusion

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5
Q

What are the extrathoracic causes of not enough O2 into lungs?

A

kyphoscolisosis

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6
Q

What would cause decreased volume of functioning lung?

A
  1. bullous/cystic disease

2. scarred or fibrosed lung in intersitital lung disease

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7
Q

When would your lungs have an inability to inflate lungs due to increased work to do?

A
  1. Obesity

2. ILD

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8
Q

When would your lungs have an inability to inflate lungs due weak resp muscles?

A
  • GB

- Myasthenia gravis

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9
Q

When would your lungs have an inability to inflate lungs due to the, being already hyperinflated?

A

COPD

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10
Q

What would cause not enough O2 to get into blood?

A
  1. Damage alveolar membrane
  2. Fluid between alveolar wall and capillary
  3. Disrupted blood supply
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11
Q

What conditions would cause damage to alveolar membrane?

A
  • emphysema

- fibrosis (ILD)

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12
Q

What conditions would cause fluid between the alveolar wall and capillary?

A
  • oedema e.g. heart failure

- inflammatory e.g. pneumonia

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13
Q

What would cause disrupted blood supply?

A

PE

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14
Q

What would cause not enough O2 getting around the body?

A
  1. Reduced cardiac output
  2. Anaemia
  3. Shock
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15
Q

What would cause reduced cardiac output?

A
  1. heart failure
  2. aortic stenosis
  3. physical deconditioning
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16
Q

What would cause increased resp drive?

A
  1. hysterical hyperventilation

2. acidamia

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17
Q

What could be a cause of acidaemia?

A

diabetic ketoacidosis

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18
Q

What would you suspect if the SOB came on suddenly?

A
  1. PE
  2. Pneumothroax
  3. Foreign body
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19
Q

What SOB would present in months and years?

A
  1. lung cancer

2. pulmonary fibrosis

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20
Q

What conditions would have worse SOB when lying flat?

A

hear failure

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21
Q

What conditions would have worse SOB at certain times of year, place, early morning, exercise?

A

asthma

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22
Q

What condition of SOB is worse when stress?

A

psychogenic hyperventilation

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23
Q

What risk factors do you look for in SOB?

A
  1. smoking: 20 cig a day for a year = 1 pack year
  2. Pets
  3. Occupational history
  4. Medication
  5. Past MHx
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24
Q

Why do you check for occupational history?

A

pneumoconioses

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25
Q

Which drugs do you check for and why?

A

can cause hypersensitivity pneumonitis:

  • nitrodurantonin
  • amiodarone
  • methotrexate
  • bleomycin
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26
Q

What PMHx do you check and why?

A

SLE and RA can cause ILD and pleural effusions

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27
Q

What associated symptoms do you ask about with SOB?

A
  1. Cough
  2. Chest pain
  3. Muscular weakness or fatigue
  4. Tender limbs
  5. Weight loss
  6. Loss of blood
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28
Q

What questions do you ask about cough?

A
  • Productive?
  • Colour?
  • Blood?
  • When happen?
  • What sound?
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29
Q

What would a persistent, productive cough over last few days suggest?

A

pneumonia

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30
Q

What would persistent, productive cough most days of the past 3 months + spanning years?

A

chronic bronchitis

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31
Q

What would dry cough mainly during SOB or at night suggest?

A
  1. Asthma

2. Left ventirclar failure

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32
Q

What would blood stained sputum suggest?

A
  1. PE
  2. lung cancer
  3. cabitating pneumonia
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33
Q

What does croup sound like (children)?

A

barking seal

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34
Q

What produces a bovine cough?

A

recurrent laryngeal nerve pals

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35
Q

What would plueritic chest pain suggest with SOB?

A
  1. Pneumonia
  2. PE
  3. Pneumothorax
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36
Q

What would non-plueritic chest pain indicate with SOB?

A

CV pathology

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37
Q

What neuromusclar conditions do you think of with SOB and muscular weakness or fatigue?

A
  • GB
  • myasthenia gravis
  • LE syndrome
  • polymyositis
  • MND
38
Q

What would tender limbs with SOB suggest?

A

PE from DVT - swollen, red, tender warm shiny looking limb

39
Q

What would weight loss, loss of appetite and night sweat suggest with SOB?

A

highly metabolic, systemic inflammatory process going on (often cancer)

40
Q

Why do you ask about loss of blood with SOB?

A

anaemia can exacerbate shortness of breath so ask heavy menstraul bleeding, fresh rectal bleeding, and melaene

41
Q

What SOB conditions present in seconds to minutes?

A
  1. Bronchospasm (acute asthma or COPD)
  2. Anaphylaxis
  3. Laryngeal oedema (secondary to burns or chemical irritation)
  4. PE
  5. Pneumothorax
  6. Flash pulmonary oedema
  7. Hysterical hyperventilation
  8. Inhaled foreign body
  9. Tension pneuomothorax
  10. Acute epiglottitis/supraglottitis
42
Q

What SOB conditions present in hours to days?

A
  1. Pneumonia
  2. Heart Failure
  3. Pleural effusion
  4. Post-operative atelectasis
  5. Chronic pulmonary emboli
  6. Altitude sickness
  7. GB syndrome
  8. Myasthenia gravis
  9. ARDS
  10. Lung collapse
43
Q

What SOB conditions present in weeks to months?

A
  1. COPD
  2. Chronic asthma
  3. Heart failure
  4. Pulmonary fibrosis
  5. Anaemia
  6. Bronchiectasis
  7. Physcial deconditioning
  8. Obesity
  9. Pulmonary hypertension
  10. Mesothelioma
  11. Pulmonary TB
  12. Kyphoscoliosis
  13. Ankylosing spondylitis
  14. MND
44
Q

What does COPD encompass?

A

chronic bronchitis and emphysema

45
Q

What would history of chronic bronchitis be like?

A

productive cough of most days of 3 months for 2 consecutive years) and permanent, largely irreversible SOB

46
Q

What are risk factors for COPD?

A
  1. Smoking (usually more than 20 pack years)
  2. Occupational exposure to lung irritants e.g. coal miners, tunnel workers
  3. Alpha 1 antitrypsin deficency (liver failurem) family hisotry
47
Q

What are the signs on examination of COPD?

A
  1. Hyperexpanded chest
  2. Breathing through pursed lips
  3. Reduced air entry/chest expansion
  4. Prolonged expiratory phrase
  5. Hyper-resonant percussion note
48
Q

What is the history of asthma like?

A
  1. wheeze, breathlessness
  2. chest tightness and/or cough
  3. often worse at night.early morning
  4. during exercise or when exposed to allergens or cold
49
Q

What associated atopic conditions are there with asthma?

A

eczema, hayfever, allergies, nasal polyps

50
Q

What drugs can exacerbate the symptoms of asthma?

A
  • NSAIDs
  • Beta blockers
  • Aspirin
51
Q

What is heard on auscultation of the lungs in asthma

A

wheeeeeze

52
Q

What would the history be like for someone with ILD?

A
  1. exposure to asbestos, silica or coal (pneumoconioses causing ILD)
  2. exposure to drugs (e.g. methotrexate, amiodarone)
53
Q

What are the signs of ILD on exmaination?

A
  1. Clubbing (in usual interstitial pneumonitis)
  2. Reduced air entry/chest expansion
  3. Late inspiratory fine crackles (heard at bases or apices)
54
Q

What would the history of someone with heart failure be like?

A
  1. shortness of breath on exertion
  2. orthopnoea (breathless when lying flat)
  3. paroxysmal nocturnal dyspnoea (waking up short of breath)
  4. swollen ankles (if right and left heart failure)
55
Q

What are the risk factors for heart failure?

A
  1. Ischaemic heart disease (smoking, DM, hypertension, hypercholesteroleamia, south asian descent, strong family history)
  2. Other atherosclerotic disease (e.g. stroke, TIA, limb claudication)
  3. Hypertension (can cause heart failure in the absence of isachaemic heart disease)
  4. Valvular disease (e.g. aortic stenosis)
  5. Cardiomyopathy
56
Q

What are the signs found on examination for someone with heart failure?

A
  1. Displaced apex beat
  2. 3rd and 4th heart sounds
  3. crackles in both lung bases
  4. Raised JVP
  5. Hepatomegaly
  6. Peripheral oedema (ankles, sacrum)
57
Q

What is the history of someone with anaemia like?

A
  1. bleeding (e.g. menorrhagia, melaena)
  2. SOB on exertion
  3. fatigue
58
Q

What signs would you find for someone with anaemia?

A
  1. Signs of peripheral or central cyanosis
  2. Koilonychia
  3. glositism anuglar stomstitis
  4. Check for conjunctival pallor (unreliable)
59
Q

What would the history of someone with bronchiectasis be like?

A

productive cough and recurrent chest infections or a history of cystic fibrosis

60
Q

What conditions of SOB can be excluded on inspection?

A
  • Obesity
  • Kyphoscoliosis
  • Ankylosing spondylitis
61
Q

What blood tests do you run?

A
  1. FBC
  2. Blood cholesterol, glucose, HbA1c
  3. Thyroid function tests
  4. U+Es
  5. Brain Natriuretuc peptide (BNP)
62
Q

Why do you carry out FBC?

A

look for anaemia

63
Q

Why do you measure blood cholesterol, glucose and HbA1c?

A
  • Know risk factors for IHD

- HbA1c to see diabetes control over last 60 days

64
Q

Why do you measure U+Es?

A

before start diuretics for excess fluid check baseline electrolytes and renal function

65
Q

What is BNP?

A

hormone released by ventricular cells during heart failure

66
Q

Why do you measure BNP?

A
  • modest rises may be seen in other causes of heart strain e.g. PE, cor pulmonlae in severe lung disease and other disease e.g. renal failure
  • low specificty
67
Q

Why would you do a chest radiograph?

A

look for signs of:

  • pneumonia
  • heart failure
  • pulmonary fibrosis
  • pleural effusion
  • bronchiestasis
68
Q

Why do you do an ECG?

A

abnormal in patients with heart failure

69
Q

What is an important cause of heart failure?

A

necrosis to areas of heart caused by MI and diabetics have silent MI

70
Q

What features on an ECG would suggest previous full thickness MI?

A
  • pathological Q waves

- bundle branch block

71
Q

What other tests do you do for SOB?

A
  1. PEFR

2. Spirometry

72
Q

Why do you do PEFR?

A

stratify the severity of an asthma attack in chronic asthma

73
Q

Why do you use spirometry?

A

used to distinguish between obstructive and restrictive lung disease

74
Q

What are examples of obstructive airway disease?

A
  1. asthma
  2. COPD
  3. bronchieactasis
75
Q

What are examples of restrictive airway disease?

A

pulmonary fibrosis

76
Q

What happens in OAD?

A

bronchi are narrowed by mucus such that less air can be forcefully exhaled during a single second

77
Q

What are the FEV values in OAD?

A
  • FEV1<70%

- FVC >70% as total lung capacity not reduced (unless severe COPD)

78
Q

What is RAD?

A

the total lung volume is reduced but amount of air that can be exhaled in the first second remains the same

79
Q

What are FEV levels in RAD?

A

FVC <70%

FEV1 >70%

80
Q

What are the signs of left ventricular failure?

A
  1. Bibasal crackles suggestive of pulmonary oedmea
  2. displaced apex beat
  3. chest radiograph showing bilateral pulmonary oedema
81
Q

What are the signs of right ventricular failure?

A
  1. Peripheral oedema

2. Raised JVP

82
Q

Is heart failure a diganosis?

A

no a syndrome!

83
Q

What are the causes of heart failure?

A
  1. Hypertension
  2. Valvular disease
  3. Alcohol-induced cardiomyopathy
  4. Ischaemic heart disease (most common)
84
Q

What are secondline investigations?

A

ECG. coronary angiography

85
Q

How would you treat acute pulmonary oedema symptomatically?

A
  1. Sit upright
  2. Give oxygen
  3. Reduce cardiac preload with vasodilators such as nitrates and durossemide
  4. Consdier haemofiltration or CPAP
86
Q

How would you treat chronic pulmonary oedema due to left ventricular failure symptomatically?

A

Loop diuretic (flurosemide) combined with a potassium sparing diuretic aldosterone receptor antagonist (e.g. spironolactone, eplerenone)

87
Q

What does reduced cardiac output stimulate?

A
  • renin-angiotensin system

- sympathetic (beta adrenergic receptors)

88
Q

How do you reduce the oxygen demand on the heart?

A

Beta Blocker which slows the heart beat, start small dose and increase slowly - NOT in LV

89
Q

How do you inhibit the RA system?

A
  1. ACE inihibtors
  2. Or ARBs
  3. Aldosterone antagonists such as spironolactone can be used in those with left ventircular ejection fraction <35%
90
Q

How do you stop progression of atherosclerosis?

A
  1. Statins (reduce cholesterol level)
  2. Aspirin (reduce risk of thrombosis)
  3. Medication for DM
91
Q

How do you treat advanced heart failure?

A
  1. Digoxin
  2. Cardiac resynchronization therapy
  3. ICDs
  4. Mechanical assit devices
  5. Heart transplant
92
Q

What lifestyle changes do you suggest for someone with pulmonary oedema?

A
  • Stop smoking
  • Low salt diet
  • Minimising alcohol
  • Regular exercise

Z Year3 Clinical Presentations (37 decks)

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