IB Lec 07

Resp Medicine

Prof. W K Lam

Learning Objectives

Learn the common symptoms of resp diseases
Principles of P/E of the RS
Common tests in Ix of resp diseases

SYSTEMIC SYMPTOMS

General symptoms may occur in assoc. with a resp disease

Fever: infection
Chills and rigours: infection
Weight loss: chronic, malignant diseases
Appetite: chronic, malignant diseases (eg. HK - TB)
Malaise: general lack of energy
Leg swelling
Facial swelling: SVC obstruction
Sleepiness: obstructive sleep apnoea

MAJOR PULMONARY SYMPTOMS

Cough
Sputum production
Haemoptysis: blood in sputum
Chest pain
Dyspnoea
Noise - wheeze, snoring

These may also be important in other system diseases

Eg. Chest pain: related to heart disease

Eg. Dyspnoea + SOB: heart disease, anaemia

FOR ALL SYMPTOMS ASSESS

Onset: acute, chronic, how long has it been present?
Severity: mild, moderate, severe
Timing of occurrence: mainly in morning, night?
Associated factors: runny nose, fever, wt loss?
Other assoc. symptoms

PAST HISTORY

Past TB, asthma, bronchiectasis
Once you have TB, likely that disease will be reactivated
Operations of trauma involving chest
Drug allergy: esp. when cough, haemoptysis
Old CXR's: compare with present X-rays

FAMILY & SOCIAL Hx

Smoking history - cancer, COPD, pulmonary disease: these are directly related to cigarette smoking ; very few Pt's with COPD who are not smokers; there are non-smokers with carcinoma (HK: 70% women are non-smokers; 20-30% men are non-smokers)
Drug Hx, drug addiction
Travel Hx: different organism cause different pneumonia
Allergy: animals, food
Family Hx of TB, asthma: asthma: hereditary
Occupation - silicosis, asbestosis, occupational asthma

DYSPNOEA

Acute, subacute, chronic
Progressive
Intensity - at rest, exertion (degree of SOB)
Orthopnoea: unable to lie flat (typical of LV heart failure)
Timing: related to exercise
Associated features - eg. Wheeze, chest pain
Assoc. with chest pain when you exercise: angina pectoris
Playing with pets assoc. with wheezing: asthma

COUGH

Acute or chronic: indicates different diseases

Productive or non-productive:

- Productive: cough with sputum

Non-productive: dry cough

- Eg. Acute productive cough - pneumonia

- Eg. Dry cough: asthma

- Eg. Chronic productive cough (mth-yr): chronic bronchitis, bronchiectasis

Type and quality of sputum

- Type: bloody, white, mucoid

- Bloody: infection, malignant disease (inc. TB)

- A lot of whitish mucoid sputum: chronic bronchitis

- Chronic cough with yellow sputum: bronchiectasis

Time relations - eg. At night (asthma)

Provoking factors: eg. Cold air, exercise, playing with animals ® asthma

Associated features - wheeze, fever

- Fever: infection

- Wheeze: asthma

ASTHMA: wheeze, SOB, nocturnal cough

SPUTUM

Acute or chronic

Acute: infection

Chronic: CB, bronchiectasis

Colour

Mucoid: CB

Mucopurulent: CB complicated with infection

Purulent

Rusty: a little of blood; pneumococcal pneumonia

Blood streaks: more severe infection; TB; malignant disease

Blood: frank blood; TB, bronchiectasis; malignant disease; pulmonary infarction

Pink: pulmonary oedema (heart failure)

Amount

Large amt: CB, bronchiectasis

Character - viscous, frothy

Pink frothy: LV heart failure

Provoking factors - eg. Posture

Only on lying down: LV heart failure

Assoc. features

HAEMOPTYSIS

1^st episode or recurrent

First episode: malignancy?

Recurrent with lots of yellow sputum over many years: bronchiectasis

If recurrent - duration of Hx of haemoptysis

Amount - massive haemoptysis may be life-threatening due to suffocation
Pt's BP, pulse (manage Pt before taking further Hx)
Character

Blood streaks mixed with sputum: bronchiectasis, 1st time: TB, malignancy, chest infection

Frank blood

Blood with large amt of purulent sputum

Rusty: pneumococcal pneumonia

Frequency

Daily

Monthly

Any known resp condition

Many Pt with bronchiectasis know they already have it

Differentiate from blood from post-nasal drip or GIT - esp. for first time haemoptysis

Teeth bleeding

Nose bleeding / gum

Differentiate between vomiting and coughing blood

Assoc. features - eg. Wt loss, age, smoking Hx, cervical LN, past Hx of TB

Afternoon fever: TB

Know order of differential diagnosis as well as definite diagnosis

CHEST PAIN

Acute, subacute, chronic
Intensity: mild. moderate, severe
Site and radiation
Chest pain due to lung disease: radiation may not be as helpful as in angina
Character
Aggravated by breathing: related to pleura
Brought on by exertion: angina

P/E

Inspection
Palpation
Percussion
Auscultation

1. General examination

2. RS

GENERAL EXAMINATION

Cyanosis/ Plethora/ Pallor
General appearance: noise, distress, obesity / cachexia (TB, malignant), hoarse voice (ca lung, 3-4w, inv. of recurrent laryngeal n by tumour)
Clubbing
Lymphadenopathy
Ankle oedema: chronic lung disease (years), lots of lung fibrosis harder for heart to pump blood into lung, right heart failure causing ankle oedema (raised JVP, liver engorged) - cor pulmonale (RH failure due to lung disease)
Unilateral limb swelling
Superior vena caval obstruction syndrome

COMMON TESTS IN Ix of RESP DISEASE

Blood tests

Blood counts: WBC, differential count, eosinophilia
Serology: virus infections, cold agglutinins, collagen vascular disease, allergy (type III), alpha1-antitrypsin

Radiology

DIAG: CXR - white line that curves laterally upwards - typical of pleural effusion
DIAG: heart shifted to right side, collapse of right lower lobe (mediastinal shift, due to loss of volume on right side)

Sputum examination

Gross appearance
Amount
Microscope: Wright's stain (WBC), Gram's stain (bacteria), ZN stain (mycobact. TB), Cytology x malignant cells
Culture: aerobic, anaerobic, AFB, fungi

DIAG: Gram stain: diplococci - pneumococcal pneumonia
DIAG: stain = ZN stain, organisms = AFB - therefore TB Dx
DIAG: squamous cell carcinoma in sputum

Pleural fluid examination

DIAG: instrument for obtaining pleural fluid tapping and pleural biopsy
Therefore for pleural effusion, take pleural fluid as well as pleural biopsy

Lung function tests

Peak flow rate
Spirometry (FEV1, FVC) Etc.
DIAG: VC, TV, RV, FRC, TLC
If FRC is known, RV and TLC can be calculated
DIAG: spirometry (expiratory vol. vs. time)
DIAG: PFR (easy to measure with peak flow meter; therefore commonly used)
DIAG: vitalograph
DIAG: TLC and RV measured with more complicated machines (eg. Body box, computers)

Arterial blood gases

Bronchoscopy

Eg. Flexible fibre bronchoscope
Bronchoscope inserted into lung, flexible, can look at upper lobe, there are forceps and brushes at the end

Oxygen saturation of Hb (SaO2)

SaO2 = O2 combined with Hb / O2 capacity x 100%
SaO2 with PaO2 13 kPa = 97%
You can only measure partial pressure of oxygen with arterial blood
Oxygen saturation (related to partial pressure of oxygen): measured with pulse oximeter (non-invasive; continuous, real-time, pulse rate)

Other special tests

Exercise tests: bicycle (ergometer), treadmill (speed, incline)
Bronchial challenge tests
Prick skin tests
Sleep studies

SPIROMETRY

FEV1 - forced expiratory vol. in 1 sec
FVC - force vital capacity
PEFR - peak expiratory flow rate
FEV1/FVC%
Normal > 75%
Restrictive lung diseases > 75% (both FEV1 + FVC low)
Obstructive lung diseases < 75%

PICTURES

DIAG: finger clubbing, purulent sputum

Important causes of finger clubbing:

CVS: usually congenital cyanotic heart disease; IE

RS: fibrosing alveolitis, ca lung, any lung condition assoc. with pus

Abscess

Empyema - pus in pleural cavity, [note: emphysema (fai hei jung/ - COPD)

Pus in aw - bronchiectasis]

GIT disease: cirrhosis of liver

DIAG: central cyanosis (blue tongue), oedematous - "blue-bloater" = chronic bronchitis
DIAG: chronic asthma, pigeon chest (chest wall bulging out)
DIAG: growth from chest wall, lymphadenopathy

Ca lung with involvement of cervical LN

DIAG: dilated superficial veins on chest wall

Blood cannot return to heart through proper channels (H&N to heart usually through SVC; if SVC blocked, blood returns through collaterals in superficial BV in chest wall and neck) - most common cause of obstruction is tumour - therefore, ca of lung with SVC obstruction

Lines on chest (grid): radiotherapy markings

DIAG: same Pt

Oedematous upper limb: difficulty for blood to return via SVC - therefore blood pooled in upper limb and H&N region

DIAG: ca lung

Ptosis of left eye

Look at pupil: constricted? Horner's syndrome (look up details)