COUGH, DYSPNOEA

DR.VEENA
2016 -2017
Learning outcomes
• At the end of this session, students should be able to:
• 1. List common causes of cough seen in PCM
• 2. Take a focused history in pts presenting with cough
• 3. Perform a focused clinical examination in pts presenting
with cough.
• 4. List investigations available in KK for cough
• 5. Correlate the symptoms and signs and come to a diagnosis
• 6. Briefly outline management of common conditions
• 7. List indication for referrals
Must know respiratory TOPICS
• CAP, ATYPICAL PNEUMONIAS, PUL TB
• BRONCHIAL ASTHMA
• COPD
• PNEUMTHORAX, PLEURAL EFFUSION
• CAUSES OF ACUTE/CHRONIC COUGH, ETIOLOGY IN CHILDREN,
ADULTS
• CA LUNG
• BRONCHIECTASIS
• CROUP, EPIGLOTTITIS
• CAUSES OF WHEEZE ADULTS/CHILDREN
Cough: diagnostic strategy
model
• Q. Probability diagnosis
• A. Upper respiratory infection
• Postnasal drip
• Smoking
• Acute bronchitis
• Chronic bronchitis
• Q. Serious disorders not to be missed
• A. Cardiovascular:
• • left ventricular failure
• Neoplasia:
• • lung cancer
• Severe infections:
• • tuberculosis
• • pneumonia
• influenza
Serious disorders not to be
missed
• • lung abscess
• HIV infection
• Asthma
• Cystic fibrosis
• Foreign body
• Pneumothorax
• Atypical pneumonias
Pitfalls often missed
• Atypical pneumonias
• Castro-oesophageal reflux (nocturnal)
• Smoking (children / adolescents)
• Bronchiectasis
• Whooping cough (pertussis)
• Interstitial lung disorders
• Sarcoidosis
Seven masquerades checklist
• Depression
• Diabetes
• Drugs ./
• Anaemia
• Thyroid disorder
• Spinal dysfunction
• UTI
• Q. Is the patient trying to tell me something?
• A. Anxiety and habit.
MEQ 1
• Jeremy, 57 years, is a store keeper who lives
• alone. He presents to your clinic ,with sharp left-sided chest
pain, shortness of breath and rigors -for 5 days with increasing
shortness of breath.
• He coughed copious amounts of yellow sputum last night.

• Past medical hx include: (IHD) with an acute myocardial

infarction hypertension and GERD.
• Jeremy was vaccinated against influenza 3 weeks ago.
• current medications are aspirin, ramipril, atorvastatin and
pantoprazole
MEQ-Q1
• On examination,
• . He has reduced breath sounds at the right
• lung base.
• His temperature is 38.2ºC (tympanic),
• His pulse rate is 84 beats per minute (regular), blood
• pressure is 130/70 mmHg, respiratory rate is 24
• breaths per minute and his oxygen saturation (Sa02)
• is 98% in room air.
• WHAT IS YOUR MOST LIKELY DIAGNOSIS?
• Community acquired pneumonia
Q2
• How would you assess the severity of community acquired
• pneumonia?
• Clinical assessment is the best
• make a decision on appropriate treatment and the need for
hospital admission
What clinical scoring tools are available to do this?

• Pneumonia Severity Index (PSI) (this uses information such as

the patient's age, comorbidities, vital signs and blood tests),

• CURB-65 (this uses information such as presence

• of confusion, urea level, respiratory rate, blood pressure and
• age >65 years),

• CRB-65 (this uses similar information to CURB with the

exception of urea),

• SMART-COP18
RED FLAGS FOR ADMISSION
• The presence of any one of the following key features
indicates a high likelihood of the patient having
• severe disease and requires inpatient care:
• • Clinical
• – respiratory rate greater than 30 breaths/min
• – systolic blood pressure less than 90 mmHg
• – oxygen saturation less than 92%
• – acute onset confusion
• • Investigations
• – arterial (or venous) pH less than 7.35
• – partial pressure of oxygen (PaO2) less than 60 mmHg
• – multilobar involvement on chest X-ray
MEQ Q3
• What scoring system is the most reliable?
• There is no evidence supporting one scoring system over
another.
• None can replace clinical assessment.
• Care must be taken when using scoring systems with younger
patients.
• Severely ill patients requiring ICU care do not need
• scoring systems.
• Patients classified in a higher risk group are those with
comorbidities and who are more likely to have an atypical
presentation
Q4
• What investigations would you request Kk?
• A CXR should be performed.
• Oxygen saturation and FBC, sputum gram stain and culture,
• HOSPITAL
• Arterial blood gases should be done on severely ill patients.
• ,urine antigen testing for pneumococcusand serological tests
can be performed for
• Legionella spp. or mycoplasma pneumoniae if
• epidemiological reasons exist. Haematology and
• electrolytes may also be appropriate
Q5
• What resources or guidelines could you use to guide your
initial management?
• The British Thoracic Society (BTS), American
• Thoracic Society and the Infectious Diseases
• Society also publish guidelines
• Hospitals will also have local protocols depending
• on local epidemiological conditions.
• NATIONAL ANTIBIOTIC GUIDELINES MALAYSIA 2014
Q6
• What advice would you give to a patient with CAP?
• A patient with CAP should be advised to rest
• and drink plenty of fluids.
• Oral analgesia, such as paracetamol or NSAIDS, can be used
for chest pain.
• Smoking cessation advice should also be offered to all patients
who smoke.
• Review a patient with CAP at 24–48 hours in order to detect
patients who are deteriorating despite treatment
Q7
• What are the organisms most likely to cause CAP ?
• Streptococcus pneumonia, Mycoplasma pneumoniae
Haemophilus influenza ,Chlamydophila pneumonia, Klebsiella
pneumonia (NAG 2014)

• Atypical pneumonia (is caused by organisms such as

mycoplasma pneumoniae, chlamydia pneumoniae
• and Legionella spp).
• In one study, over 30% of culture positive CAP had co-infection
with either a virus or atypical pathogen.
Mild CAP – No comorbid- out patient (pg 119)

• Preferred
• No recent antibiotic - Amoxycillin/Clavulanate 625mg PO q8h
for 5-7 day
• Alternative
• Ampicillin/Sulbactam 375mg PO q12h for 1 week OR
Doxycycline 100mg PO q24h for 1 week
• Penicillin Allergy: Moxifloxacin 400mg PO q24hr for 7-10 days
OR Levofloxacin 500mg PO q24hr for 1 week
• Reference : British Thoracic Society Guidelines, CAP in Ad
Q8
• Which antibiotic(s) would you prescribe for Jeremy and for how
long?
• Amoxycillin/Clavulanate 625mg PO q8h for 5-7 day

• Antibiotics should be given as soon as the diagnosis is confirmed.

• Macrolides have been proven to markedly reduce mortality in CAP

• and hospital acquired pneumonia. They are anti-inflammatory,
• cause less cell lysis and are active against mycoplasma and even
• some viruses
Q8
• Patients should be reviewed at 24–48 hours and if there is no
• improvement, combination therapy with amoxycillin plus either
• doxycycline or clarithromycin may be appropriate.
• Broad spectrum antibiotics and antibiotics not conforming with
• current guidelines risk Clostridium difficile associated diarrhoea and
• methicillin resistant Staphylococcus aureus (MRSA).

• It is recommended that antibiotic therapy should be continued

• for 5–7 days, and extended depending on response and clinical
• judgement.
• In Jeremy's case, it would be appropriate to continue amoxycillin
Q9
• Is immunisation useful in preventing CAP?

• Prevents hospitalisation for influenza and pneumonia.

• It also prevents deaths from influenza-related conditions
• among the elderly.
• Pneumococcal immunisation of at-risk
• individuals and children has reduced morbidity and mortality.
• However, there has been an increase in non-vaccine strains,
• recombinants and increased antibiotic resistance.
MEQ 2
• Jenny, 54 years of age, presents with 3 years of dry cough,
progressive breathlessness and reducing exercise tolerance.

• Q1. What further history will you explore?

Answer
• Cough – duration, onset, trigger, agg/relieving factors,
associated symptoms, timing, dry/wet
• Sputum-colour, blood, odour, type
• SOB – SOCRATES
• Effort tolerance
• Wheezing
• Chest pain
• Snoring
• a/w – LOA,LOW, fever,
• Systems review- extra resp features
ANSWER
• PMHx, SHX, previous treatment.
• Hospitalization, injuries, immunization
• FHX
• Allergies
• Drugs – OTC, Alternative, illicit, doctor prescribed
• Social HX- occ, smoking, alcohol, diet, exercise, religion,
support, stress, finances, hobbies, access to health care,
family members.
• Concerns, idea, impact , belief
Further history
• Two years ago she was diagnosed with asthma and treated
with inhaled bronchodilators
• (which have been marginally effective). Jenny has worked in a
tile factory for 22 years; 15 years in the grinding department,
transferring to the chipping department 7 years ago.
• Q2. List 5 differential diagnosis
Differential diagnosis
• 1. Pul TB
• 2. Ca Lung
• 3. Cor Pulmonale, bronchiectasis
• 4. COAD
• 5. CCF
PE
• On examination she is tachypnoeic with a prolonged
expiratory phase. There are bilateral rhonchi and a few fine
crepitations at the left infrascapular region.
• Q3. What investigations will you conduct in KK?
ANSWER 3
• 1. FBC
• 2. ESR,
• 3. CXR
• 4. ECG
• 5. PEFR
• 6. Sputum c+s, afb
• 7. Mantoux test
FINAL DIAGNOSIS
• SILICOSIS
Q4
• Q4.How will you manage her?
• Refer to hospital
• Inform the family
• Shared care
MEQ 3
• Luke, aged 27 years, presents to your practice
• following a sudden onset of sharp left-sided
• pleuritic chest pain and shortness of breath 2 hours
• previously. He has no past medical history and
• has been well recently. You question him in detail regarding
his symptoms and past history and perform a clinical
examination
Q1
• What further information would you seek from Luke about his
current complaint?
• Do you smoke?
• • Do you have underlying lung disease – known bullae,
asthma,
• tuberculosis, cystic fibrosis?
• • Do you use drugs such as marijuana or cocaine?
• • Have you had a previous spontaneous pneumothorax?
Q2
• What findings on examination would be consistent with a diagnosis
of pneumothorax?
• reduced or absent breath sounds on the affected side
• • hyperresonance to percussion of the affected side.
• Less common findings include:
• • subcutaneous emphysema
• • unilateral chest enlargement
• • reduced excursion of the hemithorax with the respiratory cycle.
• Signs of a tension pneumothorax include distended neck veins,
• hypotension and cyanosis.
• Examination may be normal. A normal examination does not exclude
• pneumothorax.
Q3
• How are pneumothoraces classified?
• as spontaneous or traumatic.
• Spontaneous pneumothoraces are further divided into primary and
• secondary pneumothoraces.
• Primary spontaneous pneumothoraces affect patients who do not
• have clinically apparent underlying lung disease.
• Secondary spontaneous pneumothoraces occur in the setting of
• underlying pulmonary disease, most often chronic obstructive
• pulmonary disease, but also in conditions such as asthma, bullous
• lung disease, tuberculosis and cystic fibrosis.
Q4
• How would you investigate Luke?
• An erect inspiratory CXR
Q5
• Further information
• You arrange for Luke to have a CXR
Q5
• What does Luke’s CXR show?
• a left-sided pneumothorax
• the mediastinum has not been pushed to the
• right. There are no fractured ribs and no subcutaneous
emphysema.
• The lung fields are clear, suggesting no obvious underlying
lung pathology.
• There is a small amount of fluid in the pleural space
• (meniscus visible at the left costophrenic junction), suggesting
a small amount of haemorrhage associated with the pleural
injury that has produced the pneumothorax.
Q5
• A 2 cm pneumothorax distance seen on CXR corresponds to a
• 50% pneumothorax by volume
• Luke has a large primary spontaneous pneumothorax with a
loss of lung volume in the order of 50%.
Q6
• How would you manage Luke's pneumothorax?
• Large pneumothoraces in clinically stable patients should be
• aspirated?
• Larger intercostal catheters
Q7
• What would you tell Luke about his intended trip and scuba
diving?
• Luke should avoid air travel for 6 weeks following a CXR that
• confirms resolution of the pneumothorax.
• Commercial airlines advise a 6-week interval between the
diagnosis of a pneumothorax and flying.
• Scuba diving should be discouraged permanently unless a
definitive
• prevention strategy – All divers who wish to continue diving
should be referred to a thoracic surgeon for ongoing
management and advice,regardless of the type or size of the
pneumothorax.
SBA 1
• A 68-year-old man who has a 40 year smoking history comes
to the surgery complaining of haemoptysis - coughing up an e
cup full of pink/red frothy sputum on three occasions over the
past month.
• He has had a chronic cough over the past few months, and has
lost 5 kg in weight.
• On examination his BP is 155/90 mmHg, pulse is 80 and
regular. There is occasional wheeze on auscultation of his
chest consistent with COPD. Investigations including a chest x
ray are reported as normal, apart from a raised ESR of 70
2
• . A 44-year-old male long standing Hypertension presents with
worsening orthopnoea and ankle oedema in the past six
months. He is afebrile. There is no chest pain. A chest x ray
shows cardiomegaly with both enlarged left and right heart
borders, along with pulmonary oedema.
• What is the most likely cause of his underlying presentation ?
• A. Chronic kidney disease
• B. Type 2 DM
• C. Chronic liver disease
• D. Hypertension
• Answer D
SBA 3
• Mr. Jones presents to your office with a desire to quit
smoking. He would like to set a date to quit but first wants get
nicotine replacement or other therapy to help with his
attempt. You determine that he is in which of the “stages of
readiness” to quit smoking.
• a. Pre contemplation
• b. Contemplation
• c. Preparation
• d. Action
Answer
• . Pre-contemplation (not thinking about quitting)
• Contemplation (thinking about quitting but not ready to
quit)
• Preparation (getting ready to quit)
• Action (quitting)
• Maintenance (remaining a non-smoker)
Answer C
• The patient is ready to make a change by setting a specific
• quit date; at this stage nicotine replacement and
• further therapy should be offered to help the patient
• achieve this goal.
• A is incorrect because in the precontemplation stage
• the patient is not considering quitting, may not believe
• they are able to quit, and/or may not believe they are
• susceptible to severe illness due to their habit. At this
• stage, it is appropriate to ask the patient about their
• knowledge of the health consequences of smoking
• B is incorrect because at the contemplation stage the
• patient is merely considering cessation. They also recognize
• the dangers of smoking and may still be upset by
• previous failed attempts. At this stage, it is appropriate
• to encourage the patient to quit and provide educational
• Materials
• D is incorrect because the patient is not in the process
• of cessation. At this point, support and positive reinforcement
• are most appropriate, as well as discussing
• strategies if relapse were to occur. Maintenance is
• when a patient has successfully quit smoking and is
• continuing to live tobacco-free. Continuing support of
• this and aiding if relapse occurs are most appropriate
• at this stage.
SBA 4
• A 65-year-old male presents for follow-up on his CCF and
hypertension. His last echocardiogram revealed an ejection
fraction of 65% with diastolic dysfunction. He has been on
aspirin, carvedilol, lisinopril, furosemide and digoxin. He has
not been hospitalized in 3 years
• Clinical examination reveals clear lungs, regular heart rate and
rhythm with an S4 but no murmurs and no edema. He
• would like to discontinue some of his medications.
Which of the following medications should be discontinued
initially

• a. Carvedilol
• b. Lisinopril
• c. Digoxin
• d. Furosemide

• Answer C
• Beta blockers, such as
• carvedilol, are useful therapeutic agents in achieving
• these goals and thus are a cornerstone of therapy for diastolic
• heart failure.
SBA 4
• A 52-year-old man presents with a complaint of dyspnea,
• for 8 months. He smoked a pack of cigarettes
• daily for the past 30 years. His physical examination is
remarkable except for a prolonged expiratory phase and
diminished breath sounds bilaterally.
• In evaluating this patient, which of the following
• is the most likely cause for his chronic dyspnea?
• a. Pulmonary embolus
• b. Chronic obstructive pulmonary disease
• c. Diabetes mellitus
• d. Myocardial infarction
• Answer B
SBA 5
• A 20-year-old man with complains of a dry cough, which he
has had for the past month. He denies any fever, chills, or
night sweats. The cough started with a runny nose and
• low-grade fever. All the other symptoms resolved
• within a week but the cough has been persistent. His
• vital signs are stable, and the physical examination is
• unremarkable. The most likely diagnosis is:
• a. Sinusitis
• b. Post viral syndrome
• c. Psychogenic cough
• d. Asthma
• Answer B
• This patient had a viral illness prior to the onset of the
• cough. Postviral syndrome can cause cough for up to
• 8 weeks. It is unlikely that the patient has sinusitis without
• nasal congestion, headaches, or any other symptoms
• of sinusitis. Pneumonia is unlikely in the absence of fever
• dyspnea, or sputum production. Psychogenic cough is a
• possibility, but the viral prodrome and the short duration
• of symptoms make it unlikely. Asthma is a chronic condition
• characterized by repetitive episodes of cough associated
• with wheezing on physical examination
SBA
• Bridget brings in her previously well child Chloe, 16 months of
age, who suddenly developed mild respiratory distress while
playing. Examination reveals asymmetrical air entry and
distinct wheezes on the right.
• 4. The most important diagnosis to consider is:
• A. Bronchial asthma
• B. Bronchiolitis
• C. Tracheomalacia
• D. Foreign body aspiration.
• ANSWER D
BREATH SOUNDS
• http://solutions.3m.com/wps/portal/3M/en_EU/3M-
Littmann-EMEA/stethoscope/littmann-learning-
institute/heart-lung-sounds/lung-sounds/#wheeze-expiratory
• PLEASE KNOW THEM WELL!!!
Respiratory examination
• https://youtu.be/akr40RXu_H8
• MASTER IT!!
• REF: http://www.racgp.org.au/afp/2015/june/
• Tally O’connor’s examination of the respiratory system
MEQ
• Terri has brought her child Ally, aged 3 years, in to see you. Ally has
been coughing for 2 weeks and Terri is concerned because last night
‘Ally couldn’t stop coughing.’
• For 1 week prior to the onset of her cough, Ally had a clear runny
nose and was ‘off her food’. Ally has no siblings and attends
kindergarten on two mornings each week.
• On examination, Ally’s temperature is 37.2°C, her throat is not
inflamed, her eardrums appear normal, there is no
lymphadenopathy and her chest is clear.
• Q1.While sitting in your examination room, Ally has a prolonged
bout of coughing followed by gagging. What are your differential
diagnoses? List 4
ANSWER
• Pertussis, Respiratory syncytial virus ,adenovirus and croup.
• prolonged bout of coughing followed by gagging, pertussis.
• Infection with the Bordetella pertussis bacterium causes an
acute respiratory illness characterised by a catarrhal phase,
which is
• followed by a paroxysmal cough with or without the
characteristic
• ‘whoop’ or post-tussive vomiting.
MEQ
• Q2. What investigation(s) would you request to confirm your
working
• diagnosis?
• Q3. What treatment would you give Ally? What would you advise
Terri about excluding Ally from other people?
Answer.
• 2. PCR and culture for pertussis, (and respiratory viruses) on a
nasopharyngeal swab and serology for pertussis.
Answer 3
• 3. Ally has clinical features of pertussis and should be treated
with one of the antibiotics .
• Once symptoms are established antibiotics have little impact
on the progression of the illness in the individual.
• However, for public health purposes the aim of antibiotic
treatment is to reduce the patient’s infectious period to
others.
• Antibiotics should be commenced within 3 weeks of the onset
of cough.
Answer 3
• Exclusion from school
• 1.excluded from kindergarten until she has received 5 days
• of antibiotic. In general, all cases with an association with
childcare, day care, preschools, excluded from those settings
for 21 days after the onset of illness,
• or until they have received 5 days of a 7 day course of
appropriate antibiotics.
• 2 .Notification to the local public health unit or health
department and advice sought on prophylaxis for contacts.
MEQ
• Further information
• Ally’s nasopharyngeal swab result comes back pertussis PCR
• positive. You note that Ally is up to date with her childhood
• vaccinations. Terry is angry that her child has developed
• pertussis despite being fully vaccinated and wants to know how
• this was possible.

• Question 4
• What would you say to Terri?
• 84–89% effective in preventing pertussis infection
• protection from the vaccine does wane over time and booster doses are
• necessary
• vaccination is very effective in preventing death or serious illness from
pertussis in young children.
• Commend Terri for having Ally fully vaccinated and reassure her
• that it is highly unlikely that Ally will develop severe disease.
MEQ
Question 5
• In general, what contacts of a case of pertussis should receive
• chemoprophylaxis?

• In general, chemoprophylaxis is limited to a narrow range of contacts

• who have been exposed to an infectious case of pertussis in the
previous
• 3 weeks
• The definitions of eligible contacts (other than household contacts) for
pertussis chemoprophylaxis are complex and best discussed
• with the local public health unit, which will follow up contacts.

• Further information Ally and Terri shared a household with David and Faith and
their new baby while infectious with pertussis. David and Faith had received
adult pertussis vaccination from their GP shortly after their baby was born.
• Question 6
• Should David and Faith receive chemoprophylaxis?
Answer 6
• Yes.
• While David and Faith are most likely to be protected by their
recent vaccinations, the setting and potential for them to
acquire infection from Ally and transmit it to their
unimmunised new-born would warrant
• chemoprophylaxis to ‘all family members when there is an
unvaccinated infant in the household’
SBA
• You are seeing a 44-year-old non smoker for an acute cough.
The cough has been present for 4 days. He had a low-grade
fever for the first 2 days, but that has resolved. He reports that
the cough is worse at night, has become productive of yellow
sputum, but there is no hemoptysis or shortness of breath.
What is the most likely cause of the cough?
• a. Pneumonia
• b. Sinusitis with postnasal drip
• c. Pertussis
• d. Viral upper respiratory infection
• e. Tuberculosis
• Answer D
SBA
• A 33-year-old nonsmoking man presents to you for evaluation of his
• chronic cough. He says the cough has been present for about 8 weeks. Initially,
• he went to an urgent care where he received antitussives and a bronchodilator.
• Those did not help, and he returned 1 week later and was given
• a course of azithromycin. His cough has continued to persist. His symptoms
• are worse when he lies down for sleep, and are associated with a sore
• throat and a “sour” taste in the back of his mouth. He has also noticed that
• when he drinks caffeine or alcohol, the cough seems to worsen. What is the
• most likely diagnosis?
• a. Gastroesophageal reflux
• b. Asthma
• c. Side effect from a medicaiton
• d. Chronic bronchitis
• e. Pertussis
• Answer A
ANSWER A
• The most common causes of a chronic cough are
• asthma, postnasal drainage, smoking, and gastroesophageal
• reflux disease.
• Given that he did not respond to a bronchodilator,
• asthma is an unlikely diagnosis.
• Pertussis would have likely responded to azithromycin, and is
therefore not likely to be the correct answer in this
• case.
• His associated symptoms of sore throat and sour taste in his mouth,
• combined with symptoms that are worse when lying down make
GERD the most likely diagnosis.
• Medication side effects should be considered, with
• the ACE inhibitors most likely to cause a cough
SBA
• You are treating a 52-year-old woman with a 40-pack/year history of
• smoking. She reports a productive cough that has been present for
the last 3–4 months, beginning in the fall. She remembers having
the same symptoms last year in the fall, and attributed it to a “cold
that she just couldn’t kick.”
• She does not have fevers, reports mild dyspnea when walking up
• stairs, and denies hempotysis. What is the most likely diagnosis?
• a. Irritation of airways from cigarette smoke
• b. COPD
• c. Postnasal drainage due to seasonal allergies
• d. Lung cancer
• e. Asthma
• ANSWER B
• Number of pack-years = (number of cigarettes smoked per day/20)
× number of years smoked. (1 pack has 20 cigarettes)
SBA
• Four weeks ago, you treated a 22-year-old woman for acute
bronchitis.
• Although she feels much better, the cough has persisted. She
has used bronchodilators, antihistamines, and antitussives.
What is the best course of treatment at this time?
• a. A 10-day course of amoxicillin
• b. A 5-day course of azithromycin
• c. Steroid nasal spray
• d. NSAIDs
• e. An oral steroid taper
• ANSWER E
Answer E
• The Centers for Disease Control published guidelines for
treating acute bronchitis. The guidelines state the antibiotics
are not indicated for uncomplicated acute bronchitis,
regardless of the duration of the cough.
• Antibiotics should be reserved for patients with significant
chronic obstructive pulmonary disease (COPD), CHF, those
who are very ill appearing or the elderly.
• This patient likely has hyper-responsive airways, sometimes
called a post bronchitic cough. In this case, the best treatment
would be an inhaled steroid or oral steroid taper. Anti-
inflammatory medications and nasal
• steroids are not effective.
SBA
• You are seeing an 18-year-old man who has had a cough for 2
weeks.
• It started like a typical “cold,” but has persisted. Over the last 3
days, the cough has come in “spasms” and he barely has time
to catch his breath during the coughing episodes.
Nasopharyngeal swab confirms the diagnosis of
• pertussis. Which of the following treatments is
recommended?
• a. A 10-day course of amoxicillin
• b. A 10-day course of amoxicillin/clavulanate
• c. A 10-day course of erythromycin
• d. A 5-day course of azithromycin
• e. Supportive therapy without antibiotics, but in isolation
ANSWER D
• Antibiotics do not alter the
• course of pertussis unless initiated early in the illness.
However, antibiotics
• do prevent transmission and decrease the need for respiratory
isolation
• from 4 weeks to 1 week, and are therefore recommended.
The first-line
• antibiotic choice is either erythromycin for 14 days, or
azithromycin for
• 5 days. Amoxicillin and amoxicillin/clavulanate are not
effective.
EMQ -SHORT OF BREATH
• A pleural effusion
• B pulmonary oedema
• C right-sided rib fracture
• D pneumothorax
• E bronchogenic carcinoma
• F pneumonia
• G fibrosing alveolitis
• H extrinsic allergic alveolitis
• I anaemia
• J pulmonary embolus
• K acute respiratory distress
• syndrome
• L cystic fibrosis
EMQ
• For each clinical scenario below, give the most likely cause for the clinical
• findings. Each option may be used only once.

• 1 A 21-year-old man has a productive cough, wheeze and steatorrhoea. On

examination he is clubbed and cyanosed, and has bilateral coarse crackles.
• ANSWER L CYSTIC FIBROSIS

• 2 A 63-year-old man presents to A&E with weight loss, cough, haemoptysis and
• shortness of breath. On examination he is anaemic, clubbed and apyrexial.
• ANSWER E BRONCHOGENIC CA

• 3 A 65-year-old man presents with shortness of breath and cough productive of

• pink frothy sputum. On examination he is cyanosed and tachycardic, and has
• bibasal end-inspiratory crackles. His jugular venous pressure (JVP) is elevated.
• .ANSWER B APO
EMQ
• 4 A 70-year-old woman presents with fever, rigors, shortness
of breath and right-sided pleuritic chest pain. On examination
the right side of the chest shows reduced expansion, dull
percussion and increased tactile vocal fremitus.
• ANSWER F PNEUMONIA

• 5 A 30-year-old farmer presents with repeated episodes of

fever, rigors, dry cough and shortness of breath with onset
several hours after starting work. On examination
• he is pyrexial with coarse end-expiratory crackles. His chest
radiograph shows mid-zone mottling
• ANSWER H EXTRINSIC ALLERGIC ALVEOLITIS
ANSWERS
• 1. L
• 2. E
• 3. B
• 4. F
• 5. H
• 1.Cystic fibrosis is an autosomal recessive condition associated with a
• mutation in the CFTR (cystic fibrosis transmembrane conductance
• regulator) gene on chromosome 7.
• Patients are susceptible to recurrent respiratory infection and the development
• of bronchiectasis. Acute exacerbations are often caused by
• Pseudomonas spp. which may be highly resistant to antibiotics. Haemoptysis
• is common and may indicate the presence of aspergilloma. Pancreatic
insufficiency
• usually develops resulting in malabsorption and steatorrhoea.
• Growth and puberty are delayed in most patients. Males are usually
• infertile as a result of the failure of the vas deferens and epididymis to
• develop. High sweat sodium and chloride concentrations (60 mmol/l)
• are highly suggestive of the disease.
ANSWERS
• 2.Respiratory causes of clubbing:
• carcinoma of the bronchus,
• mesothelioma,
• bronchiectasis,
• abscess,
• empyema,
• cryptogenic fibrosing alveolitis
• cystic fibrosis
• 3.This is the presentation of acute pulmonary oedema secondary to
left ventricular failure. Pulmonary oedema occurs because left-sided
filling pressures are elevated, causing high pulmonary capillary
pressures. This results in transudation of fluid from the plasma into
the alveoli, impairing gas exchange and reducing pulmonary
compliance. Sputum is often pink due to leakage of RBCs into the
alveoli due to ruptured pulmonary capillaries.
ANSWER
• 4. Reduced expansion, dullness to percussion and increased
tactile vocal fremitus,, suggest consolidation.
• Bronchial breathing is also a feature of consolidation and
results from transmission of airway sounds through the
consolidated lung to the periphery.
• Consolidation refers to the replacement of alveolar air by
• fluid, cells, tissue or other material. The most common cause
is pneumonia
ANSWER
• 5.This is a classic presentation of extrinsic allergic alveolitis
(EAA), which is a hypersensitivity reaction to inhaled antigens.
• In farmers, the antigen often responsible is thermophilIc
actinomycetes in mouldy hay or Aspergillus clavatus on
germinating barley.
• Lung function tests reveal a reversible restrictive defect. The
cause of the reaction may be determined by finding serum-
precipitating antibodies. In chronic EAA a honeycomb lung can
sometimes be seen on the chest radiograph.
• Acute cases may be treated with corticosteroids but allergen
• avoidance is the key preventive measure
EMQ. CAUSES OF PNEUMONIA
• A Legionella pneumophila
• B Aspergillus fumigatus
• C Pneumocystis carinii
• D Streptococcus pneumoniae
• E cytomegalovirus (CMV) infection
• F Chlamydia psittaci
• G Coxiella burnettii
• H Mycoplasma pneumoniae
• I Escherichia coli
• J Chlamydia pneumoniae
• K Moraxella catarrhalis
• L varicella zoster
• M Staphylococcus aureus
• N Pseudomonas sp.
EMQ
• 1 An 80-year-old man presents with bilateral cavitating
bronchopneumonia after an influenza infection.
• ANSWER M STAPH AUREUS

• 2 A 24-year-old student presents with severe headache, fever,

dry cough and arthralgia. He has recently bought several
parrots and was previously fit and well.
• ANSWER F CHLAMYDIA PSITACCI

• 3 A 40-year-old man with HIV presents with fever, dry cough,

weight loss and exertional dyspnoea
• ANSWER C PCP
EMQ
• 4 A 75-year-old man presents with headache, dry cough,
anaemia and a skin rash. Blood tests detect cold agglutinins.
• ANSWER H MYCOPLASMA PNEUMONIAE

• 5 A 25-year-old air-conditioning technician, who suffered from

flu-like symptoms a week ago, has developed a dry cough. His
chest radiograph shows multilobar shadowing. Blood tests
show hyponatremia and lymphopenia. Urinalysis reveals
• Haematuria
• ANSWER A LEGIONELLA
SBA
• Which one of the following pulmonary function tests is the MOST
useful in a case of severe bronchial asthma in KK?
• (A) Peak expiratory flow rate (PEFR)
• (B) Forced expiratory volume in 1 s (FEV1)
• (C) Forced vital capacity (FVC)
• (D) Total lung capacity
• (E) Arterial blood gas
• ANSWER A
• Of the listed tests, PEFR is the most helpful at the
• bedside in an ED. Both PEFR and FEV1 are useful in assessing the
severity of an asthma attack and the adequacy of the response to
treatment. However, FEV1 is difficult to perform
• at the bedside in an acutely ill patient, and FVC is poorly tolerated
because of the need to forcefully exhale the entire vital capacity.
SBA
• Which of the following is the MOST common effect
• of pregnancy on an asthma patient?
• (A) An improvement in respiratory function
• (B) An exacerbation of asthma symptoms
• (C) A decrease in asthma symptoms
• (D) A worsening in overall respiratory function
• (E) An increase in maternal complications and
• perinatal mortality
• ANSWER E The effect of pregnancy on asthma is unpredictable.
• Respiratory status and asthmatic symptoms can worsen, improve, or remain
unchanged. However, maternal complications are slightly increased, and
perinatal mortality nearly doubles. Premature births are also more common in
asthma patients
SBA
• Which one of the following indicates severe asthma?
• (A) Pulsus paradoxus >10 mm Hg
• (B) Pulsus paradoxus < 10 mm Hg
• (C) Pulsus paradoxus > 20 mm Hg
• (D) Pulsus paradoxus > 10mm Hg
• (E) Pulsus paradoxus < 30 mm Hg
• ANSWER C
• Pulsus paradoxus is an accentuation of the decrease in systolic blood pressure
that normally occurs during inspiration. A drop in blood pressure of greater than
20 mm Hg (i.e., pulsus paradoxus > 20 mm Hg) indicates excessive negative
intrathoracic pressure and correlates with severe asthma.

• left ventricular afterload and venous return to the right heart are increased,
causing a transient reduction in cardiac output and systolic blood pressure
SBA
• Which of the following is NOT characteristic of pneumococcal
• pneumonia?
• (A) Acute onset, tachycardia, and tachypnea
• (B) Recurrent rigors
• (C) Pleuritic chest pain
• (D) Thick, rusty sputum
• (E) Malaise, flank or back pain, and vomiting
• ANSWER B
• Pneumococcal pneumonia is the most common community-
• acquired pneumonia, with peak incidence in the winter and spring. It is
characterized by acute onset, with associated symptoms that include
fever, tachycardia, tachypnea, pleuritic chest pain, malaise, back or flank
pain, and vomiting.
• Cough is a common symptom and usually productive of rusty, thick
sputum.
• A single rigor lastingminutes is common, but recurrent rigors suggest
another diagnosis
SBA
• Treatment for atypical pneumonia includes all of the
• following EXCEPT
• (A) erythromycin
• (B) azithromycin
• (C) tetracycline
• (D) penicillin
• (E) bronchodilators, expectorants,
• cough suppressants
• ANSWER D
• Erythromycin is the drug of choice for atypical pneumonias,
• including Mycoplasma and chlamydial infection.
• Newer-generation macrolides, doxycycline, and tetracycline are also
effective.
• Because these organisms lack a cell wall, penicillin and cephalosporins
are ineffective.
• Treatment with bronchodilators, expectorants, and cough suppressants
provides symptomatic
SBA
• What is the MOST common chest x-ray finding
• seen in patients with Mycoplasma pneumonia?
• (A) Acute interstitial, patchy infiltrates
• (B) Lung abscess
• (C) Large pleural effusions
• (D) Mediastinal lymphadenopathy
• (E) Cavitary lesions
• ANSWER A
• peribronchial and perivascular interstitial infiltrates - reticular densities most
common ~ 49% (can be patchy with a segmental or non segmental distribution)
• airspace consolidation ~ 38%
• reticulonodular opacification ~ 8%
• nodular or mass-like opacification ~ 5%.
ANSWER
• Bilateral peribronchial perivascular interstitial infiltrations in
central and middle lung zones have also been described.
Lower lobes are more commonly involved.

• Other reported plain film findings include bilateral lesions,

pleural effusion (uncommon - in approximately 25% of cases)
and hilar lymphadenopathy
SBA
• Which of the following BEST characterizes the typical
• chest x-ray findings seen in PCP infection?
• (A) Normal chest x-ray
• (B) Diffuse bilateral interstitial infiltrates
• (C) Hilar lymphadenopathy
• (D) Pneumothorax
• (E) Pleural effusions
• ANSWER B
• The chest radiograph is abnormal in up to 90 percent
• .The classic chest x-ray pattern is diffuse bilateral interstitial infiltrates
PCP can also present as asymmetrical infiltrates, with a cavitary or cystic
appearance.
• Unilateral or bilateral pneumothoraces, bronchopleural fistulas, hilar
lymphadenopathy, and pleural effusions can also be seen but are less
common.
• A normal chest x-ray, as seen in 10 to 20 percent DOES NOT RULE OUT
PCP
SBA
• Which of the following is the BEST view to request
• when assessing for the presence of pneumothorax on
• chest x-ray?
• (A) Supine anteroposterior
• (B) Upright posteroanterior (PA)
• (C) Inspiratory PA
• (D) Lateral decubitus with the patient lying on the
• unaffected side
• (E) Expiratory PA
• ANSWER c
SBA 155
• A 33-year-old healthy non smoker man presents to you for of
his chronic 8 weeks. Initially, he received antitussives and a
bronchodilator. he returned 1 week later and was given a
course of azithromycin.. His symptoms are worse when he lies
down for sleep, and are associated with a sore throat. He has
also noticed that when he drinks caffeine or alcohol, the
cough seems to worsen. Which of the following is the most
likely diagnosis?
• a. GERD
• b. Asthma
• c. Side effect from a medication
• d. Chronic bronchitis
• Answer a
Answer
• The answer is a.
• The most common causes of a
• chronic cough are asthma, postnasal drainage, smoking, and GERD. Given
• that he did not respond to a bronchodilator, asthma is an unlikely diagnosis.
• Pertussis would have likely responded to azithromycin, and is therefore not
• likely to be the correct answer in this case. His sore throat, combined with
• symptoms that are worse when lying down, or with ingestion of caffeine or
• alcohol make GERD the most likely diagnosis. Medication side effects should
• be considered, with the ACE inhibitors most likely to cause a cough. The
• patient described is not on this class of medication. If the cough were acute,
• the differential diagnosis would include asthma exacerbation, acute bronchitis,
• aspiration, exposure to irritants (cigarette smoke, pollutants), allergic
• rhinitis, uncomplicated pneumonia, sinusitis with postnasal drip, and viral
• upper respiratory infection.
SBA 158
• You are seeing an 18-year-old man who has had a cough for 2
weeks.
• It started like a typical “cold,” but has persisted. Over the last 3
days, the cough has come in “spasms” and he barely has time
to catch his breath during the coughing episodes.
Nasopharyngeal swab confirms the diagnosis of pertussis.
Which of the following treatments is recommended?
• a. A 10-day course of amoxicillin
• b. A 10-day course of amoxicillin/clavulanate
• c. A 7-day course of erythromycin
• d. A 5-day course of azithromycin
• e. A supportive therapy without antibiotics, but in isolation
Answer
• The answer is d.
• Antibiotics do not alter the course of pertussis unless initiated
early in the illness.
• However, antibiotics do prevent transmission and decrease
the need for respiratory isolation from 4 weeks to 1 week and
are therefore recommended.
• The first-line antibiotic choice is either erythromycin for 14
days, or azithromycin for 5 days. Amoxicillin and
amoxicillin/clavulanate are not effective
Bronchiolitis
• Bronchiolitis is the most common disease of the lower
respiratory tract during the first year of life.
• under 2 years of age and most commonly in the first year of
life, peaking between 3 and 6 months.
• presents with cough with increased work of breathing, and it
often affects a child's ability to feed
• confused with a common cold, though the presence of lower
respiratory tract signs (wheeze and/or crackles on
auscultation) in an infant in mid-winter would be consistent
with this clinical diagnosis
• Self limiting or severe disease
Risk factors
• several individual and environmental risk factors
• congenital heart disease,
• neuromuscular disorders,
• immunodeficiency
• chronic lung disease.
Diagnosis
• if the child has a coryzal prodrome lasting 1 to 3 days,
followed by:
• persistent cough and
• either tachypnoea or chest recession (or both) and
• either wheeze or crackles on chest auscultation (or both)
• young infants with this disease (in particular those under 6
weeks of age) may present with apnoea without other clinical
signs.

• symptoms usually peak between 3 and 5 days, and that cough

resolves in 90% of infants within 3 weeks.
Differential diagnosis
• Consider a diagnosis of pneumonia if the child has:
• high fever (over 39°C) and/or
• persistently focal crackles.
• viral-induced wheeze or early-onset asthma
• persistent wheeze without crackles or
• recurrent episodic wheeze or
• a personal or family history of atopy
• Uncommon below 1 year
Management
• depends on the severity of the illness.
• In most cases ,can be managed at home by parents or carers.
• associated with an increased risk of chronic respiratory
conditions, including asthma, but it is not known if it causes
these conditions.
Urgent referral
• refer children with bronchiolitis for emergency hospital care
• apnoea (observed or reported)

• child looks seriously unwell to a healthcare professional

• severe respiratory distress, for example grunting, marked

chest recession, or a respiratory rate of over 70
breaths/minute

• central cyanosis

• persistent oxygen saturation of less than 92% when breathing

air.
Indication for admission
• apnoea (observed or reported)

• persistent oxygen saturation of less than 92% when breathing

air

• inadequate oral fluid intake (50–75% of usual volume, taking

account of risk factors [see recommendation 1.3.3] and using
clinical judgement)

• persisting severe respiratory distress, for example grunting,

marked chest recession, or a respiratory rate of over 70
breaths/minute.
Management
• Do not routinely perform a chest X-ray in children with bronchiolitis,
because changes on X-ray may mimic pneumonia and should not be
used to determine the need for antibiotics.

• Do not use any of the following to treat bronchiolitis in children:

• antibiotics
• hypertonic saline
• adrenaline (nebulised)
• salbutamol
• montelukast
• ipratropium bromide
• systemic or inhaled corticosteroids
• a combination of systemic corticosteroids and nebulised adrenaline.
Management
• Give oxygen supplementation to children with bronchiolitis if
their oxygen saturation is persistently less than 92%.
• Give fluids by nasogastric or orogastric tube in children with
bronchiolitis if they cannot take enough fluid by mouth.

• Do not perform chest physiotherapy on children with

bronchiolitis who do not have relevant comorbidities (for
example spinal muscular atrophy, severe tracheomalacia).
• Do not routinely perform upper airway suctioning in children
with bronchiolitis.
• Do not routinely carry out blood gas testing in children with
bronchiolitis.
Information for parents
• how to recognise developing 'red flag' symptoms:
• worsening work of breathing (for example grunting, nasal
flaring, marked chest recession)
• fluid intake is 50–75% of normal or no wet nappy for 12 hours
• apnoea or cyanosis
• exhaustion (for example, not responding normally to social
cues, wakes only with prolonged stimulation
• not smoke in the child's home
Red Flags
• worsening work of breathing (for example grunting, nasal
flaring, marked chest recession) RR over 60 breaths/minute.

• fluid intake is 50–75% of normal or no wet nappy for 12 hours

• apnoea or cyanosis

• exhaustion (for example, not responding normally to social

cues, wakes only with prolonged stimulation).
References
• Bronchiolitis – NICE 2015
• PBB –http://www.racgp.org.au/afp/2015/june/
• MEQ 1,2 – RESPIRATORY CHECK SEPT 2012
THANK YOU