WEEK 7 Flashcards
What is palliative care?
Improves the quality of life of pts & their families facing the problem(s) associted with life-threatening illness
- through the prevention & relief of suffering by means of early identification & impeccable assessment & treatment of pain & other problems (physical, psychosocial & spiritual)
What are the principles of delivering good end of life care? (HINT: there’s 6 points)
- Open lines of communication
- Anticipating care needs & encouraging discussion
- Effective multidisciplinary team input
- Symptom control - physical & psycho-spiritual
- Preparing for death - pt & family
- Providing support for relatives both before & after death
What are the areas for discussion during advance and anticipatory care planning? (HINT: there’s 7 areas)
- Wishes/preferences/fears about care
- Feelings/beliefs/values that may influence future choices
- Who should be involved in decision making?
- Emergency interventions e.g. CPR
- Preferred place of care
- Religious/spiritual/pther personal support
- May wish to make Advance & Anticipatory care plan/formalise wishes regarding care
What is the framework for assessing the validity of advance care decisions?
- Is it clearly applicable?
- When was it made?
- Did the patient have capacity when it was made?
- Was it an informed decision?
- Were there any undue influences when made?
- Has the decision been withdrawn?
- Are more recent actions / decisions inconsistent?
How important is good quality care in the last days or hours of life?
- Informative, timely & sensitive communication is an essential component of each individual person’s care
- Significant decisions about a person’s care, including `diagnosing dying, are made on the basis of multidisciplinary discussion
- Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed as far as is possible
- Consideration is given to the wellbeing of relatives or carers attending the person
role of a medical history in making a clinical diagnosis
- Forms a differential diagnosis & put health in context
- Identify risk factors for conditions
- Red Flags
- Direct further clinical examination
- Direct investigation & management
- Develop a rapport between pt & healthcare worker
how to take a detailed drug history
For each drug, in turn
- name of medicine?
- do you know what it is for?
- what is the dose/strength?
- what is the route
- number of tablets or puffs or dose units taken?
- type/form - device type?
- how often do you take this?
- any recent changes to dose/frequency?
What is a useful mneumonic for asking all the clarifying chest pain questions?
SOCRATES
- site
- onset
- character
- radiation
- associated symptoms
- timing
- exacerbators/relievers
- severity (1-10 rating scale)
What are specific respiratory questions asked?
- Chest Pain
- SOCRATES - Dyspnoea
- Cough
- how long had it, when occur
- anything make better or worse
- dry cough? cough anything up? - Sputum
- how often produced? How much? colour? blood? frothy or thick? smell? - Haemoptysis
- how much blood? any other colours? any breeding or bruising? taking blood thinners? - Wheeze
- Systemic upset
What are the respiratory causes of dyspnoea?
Airways - asthma, COPD, bronchiectasis, cystic fibrosis, larygeal tumour, foreign body, lung tumour Parenchyma - pneumonia, pulmonary fibrosis, sarcoidosis, TB Pulmonary Circulation - PE Pleural - pneumothorax, pleural effusion Chest Wall - kyphoscoliosis, ankylosing spondylitis Neuromuscular - myasthenia gravis, Guillain-Barre syndrome
What does an (i) acute cough (ii) chronic cough suggest?
(i) viral or bacterial infection pneumonia inhalation of foreign body irritants (ii) common = gastro-oesophageal reflux, asthma, COPD, smoking, post-nasal drip, occupational/other irritants, medication (ACEI)
What causes an (i) acute cough (ii) chronic cough?
(i) viral or bacterial infection
pneumonia
inhalation of foreign body
irritants
(ii) common = gastro-oesophageal reflux, asthma, COPD, smoking, post-nasal drip, occupational/other irritants, medication (ACEI)
less common = lung tumour, bronchiectasis, interstitial lung disease
What are the causes of central chest pain? (HINT: there’s 7)
tracheitis angina/MI aortic dissection massive PE oesphagitis lung tumour/metastases mediastinal tumour/mediastinitis
What are the causes of non-central (i) pleural (ii) chest wall pain?
(i) pneumonia/bronchiectasis/TB lung tumour/metastases/mesothelioma PE pneumothorax (ii) muscular/rib injury costochondritis lung tumour/bony metastases/mesothelioma shingles
What are the conditions associated with dyspnoea that onsets in minutes? (HINT: there’s 5 conditions)
PE Pneumothorax Acute LVF Acute asthma Inhaled foreign body
What are the conditions associated with dyspnoea that onsets in hours to days? (HINT: there’s 3 conditions)
Pneumonia
Asthma
Exacerbation of COPD
What are the conditions associated with dyspnoea that onsets in weeks to months? (HINT: 3 conditions)
Anaemia
Pleural effusion
Respiratory neuromuscular disorders
What are the conditions associated with dyspnoea that onsets in months to years? (HINT: 3 conditions)
COPD
Pulmonary fibrosis
Pulmonary TB
What is the appearance & cause of serous sputum?
Clear, watery, frothy, pink
- acute pulmonary oedema
What is the appearance & cause of mucoid sputum?
Clear, grey, white, viscid
- COPD/asthma
What is the appearance & cause of purulent sputum?
Yellow, green, brown
- infection
What is the appearance & cause of rusty sputum?
Rusty red
- pneumococcal pneumonia
What is 2 examples of malignant haemoptysis?
bronchial carcinoma
metastatic lung disease
Name 3 examples of infective haemoptysis?
acute infection
bronchiectasis
TB
Name 2 examples of vascular haemoptysis?
Pulmonary infarction
Pulmonary embolus
Name 2 examples of cardiac haemoptysis?
mitral valve disease
acute LVF
Name 2 examples of vasculitis haemoptysis.
Wegener’s granulomatosis
What are 3 other examples of haemoptysis that don’t come under any specific sub-category.
trauma
anticoagulation (warfarin)
clotting disorder
What are 4 reasons for unintentional non-concordance with regards to drug taking?
- Physical dexterity
- Reduced vision
- Cognitive impairment
- Poor understanding
What is the difference between a blue & brown inhaler?
BLUE “reliever”
- salbutamol
BROWN “preventer”
- beclomethasone
What structures form the (i) conducting (ii) respiratory tract?
(i) nasal cavity nasopharynx oropharynx larynx trachea main bronchi lobar bronchi segmental & terminal bronchioles (ii) respiratory bronchioles alveolar ducts alveoli
What is the structure & function of the trachea?
10-11cm long & 12 mm’s wide internally
Palpable above suprasternal notch
starts C6 ends T4/5
C-shaped rings of hyaline cartilage supporting a fibro-elastic & muscular air-transport tube
What is the NVS of the trachea? What are the relations of the trachea?
Arteries = inf. thyroid & bronchial Veins = inf. thyroid Lymph = pre & para tracheal Nerves = vagi, recurrent laryngeal, sympathetic trunks
LRLN lies in groove between trachea & oesophagus
R. vagus, azygous & R. brachiocephalic vein lie to the right, L. common carotid lies to left.
How does the epithelium of the bronchial tree change as they branch into the lungs?
terminal bronchioles = smallest part of conducting portion.
Beyond, passage becomes increasingly involved in gaseous exchange
Respiratory bronchioles have a few alveoli coming off walls & no goblet cells w. cuboidal epithelial cells
- give rise to several alveolar ducts which branch into alveolar sacs & finally alveoli
What is the structure & function of the right & left lung?
R = 3 lobes L = 2 lobes
1/2 cone shaped
Anterior, posterior & inferior borders
Costal, diaphragmatic & mediastinal surfaces
Oblique (T4 spine - 6th rib) & horizontal (rib4/5) fissures
L. lung smaller than R
What are the relations of the (i) right (ii) left lung?
(i) RA, SVC, azygous vein (posteriorly)
(ii) Aorta, LV forming cardiac notch
Phrenic nerves pass ant. to lung roots & vagus pass posterior
main bronchus posterior (1L, 2R)
PA anterior & superior (1L, 2R)
Pulmonary veins anterior & inferior
What is the blood supply of the lungs?
PA arise from PT just below sternal angle. Carry de-oxy blood at low pressure to lungs
R. PA longer than left & passes anterior to bifurcation of trachea & R. primary bronchus. Lies posterior to asc Ao & SVC
L. PA shorter & anterior to desc Ao
PV carry blood back to LA
Bronchial arteries supply lung tissue
List the different ways tumours can affect the lungs.
On both sides:
1. Tumour may impinge upon phrenic nerve to cause paralysis of the diaphragm on the affected side
2. Tumour may impinge upon the sympathetic trunk & embarrass sympathetic supply to the head causing Horner’s Syndrome, which is a drooping eyelid with a constricted pupil & a dry but flushed face on the affected side
On the left side only:
- tumour (or affected lymph nodes) may impinge upon the recurrent laryngeal nerve to cause hoarseness of the voice
What does the (i) single R. bronchial artery (ii) 2 L. bronchial arteries arise from?
(i) 3rd posterior intercostal artery
(ii) aorta directly
When might the trachea deviate from the midline?
By a tension pneumothorax
What are the various bronchopulmonary segments of the right lung? (HINT: there’s 10 segments)
UPPER LOBE - apical, anterior & posterior MIDDLE LOBE - medial, lateral LOWER LOBE - apical, anterior, posterior, medial, lateral
What are the various bronchopulmonary segments of the left lung? (HINT: theres 8-10 segments)
UPPER LOBE - apical, anterior & posterior LINGULA - superior & inferior LOWER LOBE - apical, anterior, medial, lateral, posterior
Describe the features of bronchopulmonary segments.
Pyramid with its base on the surface of the lung & apex pointing to the hilum
- they are separated from each other by connective tissue
- disease may be confined within a segment, but can be removed surgically
Identify the structures in the hilum of the lung.
Main bronchus is posterior (1L, 2R)
PPA is anterior AND superior (1L, 2R)
2 pulmonary veins are anterior & inferior
Lymphatics and hilar lymoh nodes, nerves, bronchial vessels
What is the pulmonary ligament?
a fold of pleura (like a coat sleeve) that allows hilar movement during respiration and vessel expansion
What anastomoses occurs in the lungs?
Bronchial arteries may anastomose with PAs in the walls of the bronchioles,=> some blood supplied by the bronchial arteries drains into the pulmonary veins
- Bronchial veins themselves drain into the azygos system
What is the lymphatic drainage of the lungs?
deep lymphatic plexus running alongside the arteries and the dividing bronchial tree; plus a superficial or sub-pleural plexus of lymphatics. They converge on pulmonary nodes which merge & drain to bronchopulmonary nodes, which then merge with and drain to paratracheal nodes and R. and L. bronchiomediastinal lymph trunks
- R. usually joins R. lymphatic trunk & L joins thoracic duct
What is the nerve supply of the lungs & pleura?
Supplied by pulmonary plexuses that lie anterior & posterior to the main bronchi at root of lung
- PS fibres from vagus synapse in plexuses: postganglionic fibres are bronchocontrictor, vasodilator & secretomotor
- S synapse in sympathetic ganglio, post ganglionic are bronchodilator, vasoconstrictor
- pain fibres travel with symp
VISCERAL pleura - no general sensory supply
PARIETAL pleura = sensory fibres from intercostal and phrenic nerves (referred pain)
What is involved in the close inspection & palpation of the respiratory exam?
Examine hands - inspect, palpate for warmth & venodilation, flapping tremor & fine tremor, palpate radial pulse (rate & rhythm)
Count respiratory rate
Inspect face, eyes, mouth & pharynx
What are the respiratory causes of clubbing?
Bronchial carcinoma Mesothelioma Chronic suppurative lung disease - bronchiecstasis, lung abscess, empyema Pulmonary fibrosis Cystic fibrosis
What is Horner’s syndrome? What are the clinical features of Horner’s syndrome?
Damage to cervical sympathetic nerves
Clinical features:
- unilateral miosis, partial ptosis, loss of sweating on same side (facial anhidrosis)
What are the 2 types of hand tremor? What do they result from?
FINE TREMOR - excessive use of beta agonists FLAPPING TREMOR - severe ventilatory failure with CO2 retention - hold hands outstretched - wrists cocked-back - look for a jerky, flapping tremor - associated confusion
When doing a close inspection of chest/neck of respiratory system, what are you looking for?
Scars - cardiac surgery, thoracotomy, chest drain scars
Pattern of breathing
Shape of chest - symmetry, deformity, increase in A-P diameter
Prominent veins on chest wall - SVC obstruction
JVP
What is involved in the palpation of the chest & neck in a respiratory exam?
Lymph nodes
Subcutaneous ('surgical') emphysema
- crackling sensation
- air in subcutaneous tissues
- may be diffuse chest, neck & face swelling
Mediastinal position
- tracheal position
- cardiac apex
Chest expansion
- anterior and posterior
- ask pt to breath deeply and thumbs should move apart equally
