Term
What is haematemesis?
Describe it? |
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Definition
Blood brought up from the GI tract.
Usually acidic with a coffee ground appearance. |
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Term
What is haemoptysis?
Describe it? |
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Definition
Blood brought up from the lungs below the larynx.
Usually acidic and either bright or dark red. |
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Term
| What investigations should be carried out with the presentation of haemoptysis? |
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Definition
Always CXR.
Consider:
Bloods- FBC, clotting screen, ABG.
Sputum sample
Chest clinic referral? |
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Term
| What are the differential causes for blood streaked sputum and clot production? |
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Definition
| Bronchitis, pneumonia, TB, bronchiectasis, Lung CA, heart failure, PE and anticoagulation. |
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Term
| What are the differential causes for massive haemoptysis? |
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Definition
| Bronchiectasis, Lung CA, TB and aspergilloma. |
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Term
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Definition
| Abnormal and permanent dilation of the proximal bronchioles due to inflammation. |
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Term
| What physiological changes would you expect with a diagnosis of bronchiectasis? |
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Definition
Destruction of elastic and muscular wall content.
Mucous plug formation. |
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Term
| What may result from the mucous plug formation in bronchiectasis? |
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Definition
| Infection due to lack of clearance and cyst formation in advanced disease. |
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Term
| What are the 4 potential causes of bronchiectasis? |
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Definition
Genetic/congenital- cystic fibrosis, Kartagener’s Syndrome, α-1-antitrypsin deficiency.
Post-infective- Childhood infection e.g pneumonia
Immunodeficiency- e.g HIV leading to recurrent infections.
Gastric aspiration. |
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Term
| What symptoms would lead you to a differential diagnosis of bronchiectasis? |
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Definition
| Recurrent exacerbations of a persistent productive cough with purulent sputum and sometimes haemoptysis. |
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Term
| What signs would lead you to a differential diagnosis of bronchiectasis? |
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Definition
| Wheeze and crcakles on examination of the lungs, dyspnoea and clubbing. |
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Term
| What investigations would you carry out for bronchiectasis? |
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Definition
Sputum Culture - Most common organisms are Strep P, Haem Inf, Pseudomonas Aer
CXR - May show Ring/Tubular Opacities, Tramlines, Fluid Levels (in cystic bronchiectasis)
CT/MRI - May show bronchial dilation, bronchial wall thickening
‘Cygnet Ring’ Sign - Large, dilated bronchioles next to arterioles which they should be the same size as
Spirometry - May show obstructive or restrictive pattern |
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Term
| What non-medical management should be considered for bronchiectasis? |
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Definition
| Education, Lifestyle modification (smoking and diet) and physiotherapy to aid mucous clearance. |
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Term
| What medical management should be considered for bronchiectasis? |
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Definition
| Bronchodilators, mucolytics, O2 therapy, and antibiotics for acute exacerbations. |
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Term
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Definition
| Autosomal recessive disorder resulting in the defective production of cystic fibrosis transmembrane conductance regulator protein (CFTR protein). |
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Term
| What pathology does defective CFTR result in with cystic fibrosis? |
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Definition
| Defective CFTR = ↓diffusion of Cl- out of cells = ↓Na+ leaves cell = ↓Osmosis of Water out of cell, due to ↑[ion]= thick mucous. |
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Term
| Thick mucous in cystic fibrosis results in what? |
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Definition
| Chronic respiratory infection, pancreatic duct blockage, billary cirrhosis, thick intestinal secretion and infertility in men. |
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Term
| What screening is in place for cystic fibrosis? |
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Definition
| Guthrie heel prick test, genetic and sweat test confirms diagnosis. |
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Term
| What are the respiratory clinical features of cystic fibrosis? |
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Definition
| Bronchiectasis, recurrent infection and pneumonia. |
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Term
| What are the GI clinical features of cystic fibrosis? |
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Definition
Meconium Ileus (10-20%) - Vomiting, abdo distension, failure to feed in first few days.
Pancreatic Insufficiency -Steatorrhoea- Malabsorption & Failure To Thrive. |
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Term
| How is cystic fibrosis diagnosed? |
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Definition
Sweat test shows elevated CL-.
Sweating stimulated using pilocarpine and sweat is collected in capillary tube/filter paper. |
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Term
| How is cystic fibrosis managed? |
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Definition
Chest physiotherapy-to clear secretions.
Prophylactic antibiotics.
Nebulised saline
Enzyme replacement
High calorie diet |
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Term
| What are the risk factors for PE? |
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Definition
| Post-Surgery, Malignancy, Renal (Nephrotic S., Dialysis), RHF, Pregancy (oestrogen), history of venous thrombotic event. |
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Term
| What chest signs/symptoms would you expect to see in a PE? |
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Definition
Sudden onset
Pleuritic pain
Dyspnoea
Haemoptysis
Hypoxia |
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Term
| What peripheral signs/symptoms would you look for in a suspected PE? |
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Definition
| DVT signs - swollen, painful leg. |
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Term
| What criteria are necessary for a diagnosis of acute PE? |
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Definition
• hypoxaemia
• Tachypnoea
• Cyanosis
• Recent surgery
• Catastrophic drop in CO
• Collapse/ hypotension |
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Term
| What criteria are necessary for a diagnosis of subacute PE? |
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Definition
• progressive occlusion hence SOB
• Tachypnoea |
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Term
| What criteria are necessary for a diagnosis of chronic thromboemboli PE? |
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Definition
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Term
| What is the gold standard for diagnosis of PE? |
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Definition
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Term
| Other than pulmonary angiogram what investigations may be useful towards the diagnosis of PE? |
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Definition
Observations - ↑HR, ↑RR, ↑Temp, ↓Sats (↓BP if severe)
Examination - ↑JVP, Gallop Rhythm/P2 heart sound, Pleural Rub, Signs of DVT
Bloods - FBC (Look at Hb, Platelets), Clotting Screen
CXR - To exclude other causes, may be normal – non-specific ?Small effusion ?Peripheral wedge ?Elevated diaphragm ?Paucity of vessels
Troponin I
D-dimer - Better used to exclude PE/DVT
If necessary: ECG
ABGs - ↓PaO2 & ↑PaCO2 (CO2 is also important |
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Term
| What signs might you find on an ECG in PE? |
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Definition
Sinus Tachycardia
Right Ventricular Strain - Rt Axis Deviation, Tall R waves & T wave inversion in right sided leads i.e. V1-V3, 2, & AVF
New RBBB
S1Q3T3 - S Wave in 1, Q wave & inverted T wave in 3 |
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Term
| With the wells 2 level score, what score would make a PE likely or unlikey? |
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Definition
o <= 4 Points - PE Unlikely
o >4 Points - PE Likely |
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Term
| If wells score shows PE unlikely, what should be your next step? |
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Definition
| Do D-Dimer - Can exclude PE if low Wells’ score & low clinical suspicion |
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Term
| If wells score shows PE likely, what should be your next step? |
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Definition
Immediate CTPA - Or give anticoagulation until CTPA can be carried out
V/Q Scan can be used if CTPA CI’d (e.g. contrast allergy, pregnancy), but less good in chronic resp. disease |
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Term
| What anti-coagulation should be given in PE? |
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Definition
LMWH or Fondaparinux.
Warfarin- at Target INR of 2-3 for at least 3 months (Longer if unprovoked)
CI’d in Pregnancy - Use LMWH
-Consider IVC Filter if anticoagulation CI’d |
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Term
| What should be investigated in unprovoked PE? |
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Definition
| Malignancy and thrombophillia. |
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Term
| What are the complications of PE? |
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Definition
| Pulmonary hypertension and right heart failure. |
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