Ddx:
Acute exacerbation of asthma
Acute exacerbation of COPD
Pneumonia
Acute bronchitis
Bronchiectasis
Lung carcinoma
CCF
PE
Respiratory sx:
I. Cough:
- when did it start?
- Any particular time of the day you would cough?
- is it a dry cough or did you cough up any phlegm?
II. Sputum:
- how much sputum would you cough up?
- Whats the colour of sputum?
- Any change in the colour?
- Any particular time of the day you would cough up more
sputum?
III. Haemoptysis:
- did you cough up any blood?
- How much blood would you cough up?
- Whats the colour of the blood?
Cardiovascular symptoms:
I. Any chest pain? (SRTCOPDSARA) Did you get chest pain when
breathing in?
II. Orthopnea? How many pillows do you sleep at night? (>2)
III. PND?
IV. Any swelling in the legs?
V. Any pain at the back of your legs?
VI. Any heart racing? (Palpitations)
VII. Any dizziness?
VIII. Any faintness? Did you lose your consciousness?
IX. Any headache?
X. Any n/v?
XI. Any sweating?
Risk Factors:
1. Smoking:
- Do you smoke?
- How long have you been smoking?
- How much do you smoke every day?
- (have you smoked before?)
- (when did you give up?)
- (how much did you smoke before you gave up?)
2. Drinking:
- Do you drink?
- What do you drink?
- How often do you drink?
- How many units do you drink weekly?
3. History of asthma/copd
- Have you ever been diagnosed with asthma/copd?
- When were you diagnosed?
- Are you taking any inhalers? Which inhalers? Whats the dose?
Any change in the dose? How often do you use your inhalers?
Did it help? Do you use the correct technique for the inhaler?
- Do you use any oxygen at home?
- Do you do any chest physiotherapy? What do you do? How
often do you do chest physio?
- Do you use any peak-flow meter at home? Whats your average
reading?
- Any admission to hospital for COPD/Asthma? When was the
last time?
- How long did you stay in the hospital?
- Did they give you oxygen? Did it help?
- Did you get any nebulizer? Did it help?
- Any recurrent chest infections? How often do you get chest
infections in a year?
- Do you have to be admitted into hospital for chest infections?
- How long were you on the antibiotic course?
- Do you get influenza vaccination every year?
Social History:
Investigations:
Pneumonia 1. ABG 1. O2
2. ECG 2. Antimicrobial therapy, initially empiric,
3. Bloods FBC, u&e,LFTs, blood thereafter as per culture sensitivities
culture 3. Saline nebulisers +/- bronchodilator
4. Sputum culture, ZN, TB culture nebulisers if concomitant obstructive
5. Viral serology airways disease
6. Mycoplasma serology 4. +/- oral prednisolone/iv hydrocortisone
7. Legionella urinary antigen if COPD/Asthma component
8. CXR 5. Anti-pyretics
9. CT thorax 6. +/- IVF
10. Bronchoscopy, bronchial 7. Oxygen therapy as appropriate
washing/BAL 8. Chest physiotherapy/ACBT
11. Dx/Tx pleural aspiration under 9. Non-invasive ventilation-CPAP/BiPAP if
US-guidance Type 1/Type 2 respiratory failure,
respectively
Curb-65 (diagnosis): admit if score 2 or 10. Therapeutic pleural aspiration/pleural
more. drain for parapneumonic effusions
- Confusion 11. NIV unit/HDU/ICU management as
- Urea > 7mmol/L required
- RR>30
- SBP <90, DBP
<60mmHg
- Age >65
Lung cancer 1. FBC, U&E, LFTs, Ca/Albumin, LDH, Management depends on:
ESR, CRP - Histology
2. ABG - Staging
3. Sputum Cytology - ECOF performance
4. CXR - Comorbidities
5. PFTs- spirometry, reversibility, - MDT discussion
lung volumes, DLCO
6. CT Thorax/Liver/Adrenals 1. Limited Stage SCLC
7. a. Chemotherapy plus Thoracic
8. PET/CT Radiotherapy
i. Platinum-based chemotherapy +
- Assesses metabolic activity etoposide
of primary lesion +/- b. Prophylactic cranial irradiation
clarifies/identifies sites of 2. Extensive Stage SCLC
metastatic disease a. Palliative Chemotherapy
9. Bronchoscopy i. Can increase survival from 2
months to 10 months
10. Bronchial washings, bronchial b. Whole Brain Radiotherapy for brain
brushings, bronchoalveolar metastases
lavage, endobronchial biopsy c. Palliative Care
11. Endobronchial Ultrasound and
Trans-Bronchial Needle 3. Stage I, II or III treatment modalities
Aspiration of mass/lymph node include
(EBUS-TBNA) o Surgery
- Stages mediastinal disease o Chemotherapy (platinum-doublet) +/-
bevacizumab (VEGF-inhibitor)
12. Pleural ultrasound o +/- Pemetrexed (Alimta ) only if non-
13. Pleural aspiration under squamous subtype
ultrasound guidance o Radiotherapy/Stereotactic RT
14. CT-/US-guided biopsy of a o Tyrosine-Kinase Inhibitors if EGFR
peripheral mutation-positive
Erlotinib, gefitinib
lung/liver/adrenal/neck lesion o ALK tyrosine kinase inhibitor if ALK
15. Endoscopic Ultrasound (EUS) fusion oncogene positive
16. Liver Ultrasound crizotinib
17. Radioisotope Bone Scan 4. Stage IV (Advanced)
18. CT Brain/MRI Brain o Palliative Chemotherapy
o Bisphosphonates iv for bone metastases
Inhibits osteoclasts
o Metastatectomy-brain, adrenal
Questions:
1. What are the side effects of long-term steroids?
- Thin skin
- Muscle wasting
- Easy bruising
- Poor wound healing
- DM
- Infection
- Low mood, depression, psychosis
- Acne, cushingoid facial
- Central obesity
- Hypertension
- GI ulcers/PUD
- Osteoporosis