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Y3 Oxford Cases > Shortness of Breath > Flashcards

Shortness of Breath Flashcards

1
Q

In broad terms, what pathological processes can cause shortness breath

A

Insufficient oxygen entering the lungs
Insufficient oxygen entering the blood from the lungs
Insufficient oxygen being delivered to the body
Increased respiratory drive

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2
Q

What may cause insufficient oxygen from entering the lungs

A

Obstruction (asthma, COPD, tumour, anaphylaxis)
Reduced lung volume (pneumothorax, effusion, kyphoscoliosis)
Reduced functioning lung volume (bullous, cystic disease, ILD)
Inability to inflate (obesity. ILD, GBS, MG, COPD)

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3
Q

What may cause insufficient oxygen from entering the blood from the lungs

A

Damage to the alveolar membrane (emphysema, fibrosis in ILD)
Fluid between the alveolar walls and capillaries (oedema, inflammation)
Disrupted blood supply - PE

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4
Q

What may cause insufficient oxygen from being delivered to the body

A

Reduced cardiac output - HF, aortic stenosis
Anaemia
Shock

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5
Q

What may cause an increased respiratory drive

A

Hysterical hyperventilation, psych disorders, anxiety

Acidaemia (metabolic) - DKA

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6
Q

What questions should be asked about SOB itself

A

Timing and Onset - acute is more mechanical or vascular, chronic more lung cancer, fibrosis
Alleviating or exacerbating factors e.g. lying flat (HF), certain times of year or on exercise (asthma), Anxiety and stress (psychogenic)

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7
Q

What questions should be asked about risk factors for SOB

A

Smoking
Pets
Occupation - in particular coal, silica, asbestos
Medication - nitrofurantoin, amiodarone, methotrexate, bleomycin -> EAA
Past medical history - autoimmune conditions e.g. RA< SLE

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8
Q

What associated symptoms should be asked about with SOB presentation

A 
Cough 
Chest pain
Muscular weakness or fatigue
Tender limbs
Constitutional symptoms
Loss of blood
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9
Q

What does a cough with SOB suggest

A

Suggests resp pathology
Persistent, productive cough over days - pneumonia
Persistent productive cough over months = bronchitis
Dry cough with SOB episodes - asthma or LVF
Bloodstained sputum - LVF, PE, cancer, cavitating lesion

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10
Q

What does chest pain with SOB suggest

A

Pleuritic - PE, pneumothorax

NOn pleuritic - cardio

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11
Q

What does muscular weakness of fatigue with SOB suggest

A 
GBS
Myasthenia gravis
Lambert Eaton Syndrome 
Polymyositis
MND
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12
Q

What does tender limbs with SOB suggest

A

PE, esp if lower limbs (DVT)

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13
Q

What does loss of blood with SOB suggest

A

Anaemia will exacerbate SOB, ask about menstrual bleeding, haematochezia and melaena

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14
Q

What are the differentials for SOB that develops in seconds to minutes

A 
Bronchospasm (asthma or COPD exacerbation)
Anaphylaxis
Laryngeal oedema
PE
pneumothorax (+ tension)
hyperventilation
Inhaled foreign body 
Epiglottitis
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15
Q

What are the differentials for SOB that develops in hours to days

A 
pneumonia 
Heart failure
pleural effusion
post-op atelectasis
chronic pulmonary emboli
GBS/MG
ARDS
Lung collapse
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16
Q

What are the differentials for SOB that develops in weeks to months

A 
COPD
Asthma
HF
Pulmonary fibrosis
Anaemia
Bronchiectasis
Obesity/physical deconditioning
Pulmonary HTN
Mesothelioma
TB
MND
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17
Q

What are the main features of COPD that may distinguish it from other causes of SOB

A

Hx of chronic bronchitis and permanent irreversible SOB

Presence of risk factors - smoking (>20PY), occupational exposure, alpha-antitrypsin deficiency

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18
Q

What are the signs of COPD

A 
Hyperexpanded chest
Breathing through pursed lips
Reduced expansion
Prolonged expiratory phase
Hyper-resonant precussion note
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19
Q

What are the main features of chronic asthma that may distinguish it from other causes of SOB

A

Hx of wheeze, SOB, chest tightness, cough (often worse at night/early morning/during exercise/exposure to allergens or cold)
Associated atopic conditions or FHx e.g. eczema, hayfever, nasal polyps, allergies
Exacerbation by NSAIDs or beta blockers
Wheeze on auscultation

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20
Q

What are the main features of interstitial lung disease that may distinguish it from other causes of SOB

A

Hx of exposure to asbestos, silica, coal (pneumoconiosis) or exposure to drugs (methotrexate, amiodarone)

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21
Q

What are the signs of ILD on examination

A

Clubbing
Reduced chest expansion
Late inspiratory fine crackles (base OR apices)

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22
Q

What are the main features of heart failure that may distinguish it from other causes of SOB

A

SOB on exertion, orthopnoea, PND, swollen ankles
Risk factors: IHD ( smoking, DM, cholesterol, HTN, south east asian, FHx), stroke, TIAs, limb claudication, HTN, valvular disease, cardiomyopathy

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23
Q

What are the features of heart failure on examination

A

Ascites, hepatosplenomegaly, peripheral oedema, raised JVP

Bi-basal crackles that do not move on coughing (pulmonary oedema)

Displaced apex beat
Third or fourth heart sounds

24
Q

What are the main features of anaemia that may distinguish it from other causes of SOB

A 
Hx bleeding (menorrhagia, melaena), fatigue, SOB on exertion
Signs of cyanosis, koilonychia, glossitis, angular stomatitis
25
Q

What are the main features of bronchiectasis that may distinguish it from other causes of SOB

A

Hx of productive cough and recurrent chest infection
Hx cystic fibrosis
Bi basal crackles that move on coughing

26
Q

What blood investigations should be arranged for suspected congestive heart failure

A

FBC (anaemia)
Cholesterol, glucose and HbA1c (risk factors)
TFTs (potential cause)
U+Es (before starting diuretics)
Brain Natriuretic peptide (BNP) - hormone released by ventricular cells in HF

27
Q

What imaging should be arranged for suspected congestive heart failure

A

CXR (signs of HF, pneumonia, effusion, bronchiectasis, fibrosis)
ECG (BBB, pathological Q waves from previous MI)
Echo (ventricular function + confirm low CO and HF)
Coronary angiography (? coronary artery disease)

28
Q

What other tests could be arranged for SOB, excluding bloods and imaging

A

PEF - Asthma

Spirometry - obstructive vs restrictive

29
Q

What drugs should be prescribed for heart failure

A

Symptomatic relief: pulmonary oedema - sit up, oxygen, morphine, nitrate/furosemide.
Long-term: furosemide +/e spironolactone
Path: beta-blocker and ACEi/ARB
Cause: statin, aspirin, DM control

30
Q

What may cause SOB post-op

A 
Atelectasis
Pneumonia
Pulmonary oedema
PE
Anaemia
Pneumothorax
31
Q

What is atelectasis

A

Pain prevents patients from breathing adequately and excoriating any mucus in their lungs.
The mucus eventually plugs the bronchioles, preventing air entry, and areas of the lung collapse

32
Q

How does post-op atelectasis present

A

Mucous: Rattling cough
Collapsed lung: Reduced chest expansion
Crackles
Dull percussion

33
Q

What is the management for post-op atelectasis

A

Physiotherapy + mobilisation
Analgesia
Oxygen
Incentive spirometry

34
Q

What is the management for asthma

A

Avoidance of triggers
Bronchodilation with beta agonists, theophyllines, antimuscarinics
Reduction of immune response: corticosteroids, leukotriene receptor antagonists

35
Q

What is the management for COPD

A 
Smoking cessation
Inhaled corticosteroids
Pulmonary rehabilitation
Vaccination
NIV for exacerbations 
Long term oxygen
36
Q

What is the management plan for a patient with TII resp failure

A

Controlled oxygen therapy
NIV if needed
Treat underlying cause

37
Q

What is the classical presentation of pneumocystis jiroveci pneumonia

A

Young patient from Africa
Dry cough, SOB,
Low sats and desaturation on exercise
Diffuse interstitial shadowing on CXR

38
Q

What investigations are done for suspected pneumocystis jiroveci pneumonia

A

Microscopy + silver staining
Culture on sputum and BAL
HIV testing
TB testing (Microscopy with Ziehl-Neelson)

39
Q

What presentation might suggest interstitial lung disease

A 
Chronic progressive SOB, worse one exertion. 
BG of a cause 
Fine crackles all over the lungs
Spirometry suggests restrictive disease
Absence of other obvious diagnoses
40
Q

What conditions may cause ILD

A

Congenital - neurofibromatosis, Gaucher
Inflammatory - RA, ankylosing spondylitis, sarcoidosis
Chemical irritation - asbestos, silica, coal, chlorine
Drugs - methotrexate, amiodarone
radiation

41
Q

How is ILD confirmed

A

HRCT lung - linear reticular opacities and ground0glass appearance

42
Q

What is diagnostic of Hodgkin’s lymphoma

A

Presence of binucleated lymphocytes (Reed-Sternberg cells) on lymph node biopsy

43
Q

What are the type of medications used for COPD and asthma

A 
Short acting bronchodilators
Inhaled steroids
Long acting bronchodilators
Oxygen
Others
44
Q

Give examples of short acting bronchodilators used for COPD and asthma

A

Salbutamol/ventolin, blue, beta2 agonist
Ipratropium/atrovent, white green, antimuscarinic
Combination/combivent, white and orange

45
Q

Give examples of inhaled steroids used for COPD and asthma

A

Beclometasone, Budesonide - brown

fluticasone - orange

46
Q

Give examples of long acting bronchodilators used for COPD and asthma

A

Salmeterol - formoterol - LABA

Tiotropium - LAMA

47
Q

Give examples of other drugs used for COPD and asthma

A

Oral steroids
Xanthine derivatives e.g. theopylline
Leukotriene antaongists - montelukast
Phosphodiesterase inhibitos - roflumilast

48
Q

What is the difference between bronchitis and pneumonia

A

Both LRTI
Bronchitis is disease of the airways, pneumonia disease of the alveoli
Bronchitis - inflammation -> mucous production and obstruction -> cough
Pneumonia -> pus accumulates in alveoli

49
Q

What are the causes of type I and II resp. failure

A

Type I: asthma, COPD, pneumonia, pulmonary fibrosis, pulmonary oedema

Type II: Opiates, central neuro damage (stroke, trauma), COPD, deformity, obesity, MND

50
Q

What are the causes of crepitations on examinations

A

Pulmonary oedema
Interstitial lung disease
Bronchiectasis
Pneumonia

51
Q

What do the following presentations match (with crepitations):
Displaced apex beat, raised JVP, ankle oedema, orthopnoea, IHD Hx

Reduced expansion, clubbing, does not vary with cough

Chronic productive cough, wheeze, crepitations vary with cough, clubbing

Acute productive cough, fever, chest pain, bronchial breathing, dull percussion

A

Displaced apex beat, raised JVP, ankle oedema, orthopnoea, IHD Hx - pulmonary oedema

Reduced expansion, clubbing, does not vary with cough - interstitial lung disease

Chronic productive cough, wheeze, crepitations vary with cough, clubbing - bronchiectasis

Acute productive cough, fever, chest pain, bronchial breathing, dull percussion - pneumonia

52
Q

What is the management for a post-op patient with pulmonary oedema

A

Sit patient up
Furosemide
Oxygen
Nitrates

53
Q

What is the management for a post-op patient with a PE

A

LMWH
Start warfarin
TED stockings

54
Q

What is the management for a post-op patient with atelectasis

A

Analgesia
Oxygen
Chest physio

55
Q

What is the management for a post-op patient with pneumonia

A

Antibiotics
Oxygen
IV fluids

Y3 Oxford Cases (29 decks)

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