RESPIRATORY REVISION

SECTION 1 COUGH

HISTORY
PC: COUGH
Exploratory qs: 10 weeks of cough, worsening
Productivity – green sputum
Quantity – ½ cup daily , worse in morning – subsides through day, persists
Changes to cough pattern – blood in sputum (ddx: lung ca, TB), developed in past 2 weeks – frank vs smear (visible in hanky or just smudges
in sputum)
Nature of cough
Assoc with other features – fever (responds to PCM, but not permanently) – what kind of fever?
Night sweats – to the extent she chages clthes frequently – also within 2 weeks
LOW – onset? Also within 2 weeks
LOA
Occupation – travels a lot to south indian subcont, longest stretch 3 months
Sick contact – non identified
Social
Fhx – maternal passing due to br ca – father – CVR dsx; siblings normal
Recent visits to GP for similar problems + use of medcaitons + ABX response
Hx of asthma + allergies
Past mhx: HBV
Smoking hx
Inhaler hx
Cardiac symptoms

Ddx: TB, pnm, ca, bronchiectasis

SUGGESTED MANAGEMENT
Note: physical exam must include breast given breast ca hx in fhx
Must enquire about chest pain (pnm – pleuritic chest pain; if consistent chest pain –lung ca; enq about noisy breathing, wheezing)
Contacts and living conditions for TB
Given HBV hx – HIV status to be inquired
Direct smear hx
If sputum not easily avail, use BAL or induction of sptum to guide initiation of tx for TB
Latent TB – apical and posterior segment, usually no midzonal or hilar shadow
Mantoux test [if pt sutum neg, do Mantoux – within 72 hours; if >21yo, and more than 15mm, most likely TB]
Eg if pt smear neg, asymtmtic, Mantoux +, do CXR- if CXR neg = watch and wait [? Latent TB]
If pat smear neg, asymtm, mant +, CXR done = + findings = try to get BAL/induce sputum to guide tx

SUGGESTED INVESTIGATIONS
CXR – patchy nodular shadow in hilar an dmiddle zones , no calcification seen, no outline of masses
Smear – positive
Sputum culture
FBC – WCC raised
CRP- raised
Infective screen and LFT for HBV given past hx
BAL

Isolation + start tx wo waiting for result of culture

DISCUSSION

SECTION 1 COUGH [patient] - cough, wheeze, SOB, chest pain, sputum, ET, hemoptysis
1. 48 YO INDIAN LADY WITH esrd REG hd, dm, htn, 4 h post dialysis exp cough 4 d and fever 1d
2. Yellow sputum, no blood, no URTI ss, no NS, no contacts with TB
 3. Fever with chills/rigors; higest temp at 38 in ED, subside with PCM;
4. LOW 15kg IN PAST YEAR
5. Similar last year – cougha dn fever post HD, tx for Pneumonia
6. NO sob, ANKLE SWELLING, CHEST Pain
7. PMHX – DM for 22 years, ACTRAPID 6 TDS, INSULATARD 10 ON [compliant]
8. HbA1C – mycoplasma, legionella heightened risk for immunocmp pat (such as DM, dialysis pat]
9. HIV stats and HBV given risk factors of dialysis
10. HPT on amlodipine 5 od
11. ESRF since 2012, ROF 500ml p day, dialysis 3 per week HD
12. Open heart sgx in 2015 for infective endocarditis [?valve replacement] + pulmonary embolectomy
13. Medication – allergic to penicillin (swelling + rash)
14. Fhx – nil
15. Social – no recent travel, non smoker
16. ROS – nil
17. EXPLORE SOB!
18. EXPLORE – CARDIAC HX GIVEN PHX OF IE/open heart sgx
19. INQUIRE BASELINE HEART FUNCTION

PHYSICAL EXAMINATION
1. Cachexia due to increased calorific requirement rate in ESRD, 2 AV uninfected fistulas on right forearm @45 degrees, speak in full
sentecnes, no bedside equip, alert
2. No cough or wheeze noted
3. ET normal
4. Note: patient was examined
5. Vital signs – BP 171/84, bpm 77, RR 20, spo 97, 37C, not tachypneic at interview
6. On admission, BP 200/120 + tachypneic
7. No club/stain/flaps/stigmata of Horners, no raised JVP, no tracheal deviation, no lymphadenopathy, no central cyanosis
8. Chest – midline scar, chest moves symmetrically with respiration
9. Palpation – reduced chest expansion no rib tenderness to rule out frx rib/ prolonged coughing causing rib tenderness/ SE of chronic
dialysis leading to hypocalcemia
10. Percussion – dullness at right middle zone
11. Auscultation – bronchial sounds throughout, reduced AE bilat, late exp coarse cracks worse on right, increased voca resonance
[bronchial sounds = fluid in alveoli/consolidation] – possible patchy lung consolidation
12. No signs of RHF including displaced apex, JVP raised
13. Ddx:
a) Pneumonia – dullin right middle lobe, reduced chest expansion ? consolidation in both lungs ; increased vocal resonance bilat
@ middle and lower zones, prev hx of pnm
b) Pul Oe - ?FLUID OVERLOAD, ESRD pt
c) Tb – LOW but no NS, hemoptysis
d) LUNG CA – LOW
e) PUL EM – unlikely, does not present with fever but still important due to risk factors
14. IX
a) FBC, RP – Hb normal, high WCC, rest norm, creat 340 (sig high despite 4 days post HD), phosphate and mag decreased esp
in ESRD
b) LFT – TRO SYSTEMIC SEPSIS, ? LEGIONELLA, also to allow profiling before starting drug tx [raised ALP – obs in bilary tree =
?cholestatic picture – however her bilirubin is normal/ ?metastatic liver dsx/ chronic bone disease]
c) COAG
d) UE
e) ABG – lower oxygen, CO2 up (which type of respiratory failure do you think she will have?] – done only when oxy sat
deteriorated [given it was still 97, not done]
f) Smears / gram stain
g) ESR
h) CRP
i) GRAM STAIN - POSTIVE
j) SPUTUM AND BLOOD CULTURES
k) ECG – ST dep lead 1,2 AVF, ?LVH [what are the ECG criteria?] – LVH perhaps due to long standing HTN (commonest cause
of LVH)
l) GLUCOSE
m) CXR –loss of vol on right leads to tracheal deviation [30-35m]
n) Urinary antigen- legionella and pneumococcus
15. Management
a) Oxygen on standby
 b) CURB65 – pat scored 1 (urea 8.5, RR 26, alert, 48 yrs, BP 170 sys) – qs: is urea still a relevant predictor in CURB65 for ESRD
patients vs normal renal fc patients
c) Empirical abx – broad spec ie co-amoxiclav ruled out due to penicillin allergy (10% risk with cephalos)
d) fluorQ + macrolide (axithro for 3 days)
e) sepsis screen – 3/3
f) antipyretics
g) IV flud
h) Chest physio
i) Oxygen tx
j) If req NIV CPAP,BIPAP], therapeutic pleural aspration, HDU/ICU if necc

Note: when concerning weight, diff bn wet and dry weight – when was weight measurement done?

COUGH LECTURE
1. Due to stim of receptors – inflamm, mechaicla, chemical, thermal – a protecttiv emechanism hence in kids advised NOT to suppress
cough (expectorants favoured rather than antitussives]
2. Remember to ask for ACEI
3. Ddx of cough
a) Infection – URTI, pneumonia, TB (risk factors for TB in patient: recurrent dialysis, repeated visit to hospital massive LOW 15kg
and poor controlled DM and – should send for direct smear)
b) Reactive airwar disease - bronchial mucosa reacts to allergens and pollutants
c) GERD
d) Air pollution
e) Foreign body esp in small kids
f) ACEI
g) Others – CF, bronchiectasia, ILD, sarcoidosis, benign and malignance lung ca, mediastinal masses [hilar LN in sarcoidosis]
h) CARDIOCASVULAR DISEASE
4. Cough – actue, subacute, chronic, paroxysmal
5. Acute – common cold
6. Post viral
7. Chronic – postnasal, asthma, GERD, chronic bronchitis, bronchiectasis, LHF, bronchogenic ca, sacrcoidosis
8. PROXYSMAL = OLD
9. Associated findings:
a) Inspiratory stridor = ?upper airway problems – barking vs brassy (lung ca due to paralysis of vocal cord muscles) vs hoarse
b) Bronchial disorders = wheezy 9whistling, signhing) = ? reactive airway disease, GERD, asthma, OLD
10. Sputum production – sputum vs phlegm (phlegm is secretion expelled from lungs and trabro tree
11. Sputum is expelled from nose, mouth, sinuses, pharynx, trabro tree
12. Sputum from trabro 100ml /day – collect and inspect over 24 h for accurate analysis
13. Sputum description = color, consistency, quantity, time of day produced, odor, blood
14. Sputum – mucoid, tinged, mucopurulent, copious , ?odour (must smell) – MUST ENQUIRE SMELL
15. Hemoptysis – streak vs frank (rusty = streptococcal)
16. Cough complications – MUST ASK IN HX
a) Chronic = more than 8 weeks
b) Fatigue
c) Insomnia
d) Abdominal and pelvic hernia
e) Rib fractures
f) Disruption of surgical wounds
g) Npenumothorad and penumomediastinum
h) Cough syncope
i) Subconjunctival hemorrhage/ red eye syndrome
j) Esophageal rupture
k) Urinary incontinence an dprolapsed uterus
17. Diagnostic approach = specific vs non specific = must enquire about associated symptoms
18. Fever for parasite and TB = low grade fever/ evening fever [20-23m]
19. Pneumonia is diagnosed by consolidative changes in CXR with adventitious changes in lung sounds