Makindo Medical Notes

Related Subjects: | Assessing Breathlessness

Core Symptoms

• Breathlessness, reduced exercise tolerance
• Chest pain, orthopnoea, cough, wheeze
• Sputum production, haemoptysis, fever, weight loss
• History of smoking, allergies/atopy, exposure to asbestos, dust, and animals
• Impact on social activities and ability to manage activities of daily living (ADLs)

Introduction

• Respiratory and cardiac symptoms often overlap; patients may present with conditions affecting both systems.
• Gather a detailed history, including quantitative aspects such as sputum or haemoptysis amounts, walking distance, cigarettes smoked, and weight loss.
• Establish a clear timeline for symptoms, clarifying vague descriptions (e.g., "a little while") by asking specific time frames (e.g., "days, weeks, months, years").
• Investigate smoking, animal exposure, and occupational history as they are key factors in respiratory disease.
• Assess how symptoms affect daily life: ability to climb stairs, manage housework, personal care needs, and use of aids.

Breathlessness

• Onset: Sudden or gradual, episodic or persistent, improving, worsening, or stable.
• Quantify limitations (e.g., able to walk 500m, now only 20m); inquire about exercise tolerance and ability to climb stairs.
• Consider past medical history and context when assessing the rate of onset.

Timing of Breathlessness

• Rapid onset (within minutes):
  • Asthma: Often in younger patients, nocturnal cough, wheeze, and history of atopy.
  • Left ventricular failure (LVF): Known cardiac impairment, previous MI, or other causes.
  • Pulmonary embolism (PE): Risk factors include post-op status, immobility, pregnancy, or prior VTE.
  • Respiratory obstruction (e.g., foreign body): Common in children.
  • Anaphylaxis or laryngeal edema: Ingestion of allergens or corrosives.
  • Pneumothorax or panic attacks/anxiety (often in young individuals).
• Rapid onset over several hours:
  • Acute asthma attack or COPD exacerbation (typically in smokers, middle-aged).
  • Pulmonary oedema (improves on sitting up), pneumonia with fever and sputum.
  • ARDS (post-op, sepsis, trauma), pulmonary embolism, pleural effusion (smoker, asbestos exposure), allergic alveolitis, metabolic acidosis (e.g., DKA).
• Gradual onset over weeks: Progressive massive fibrosis, Hamman-Rich syndrome, congestive cardiac failure.
• Gradual onset over months/years: COPD (smokers, middle-aged), idiopathic pulmonary fibrosis,
• Gradual onset over months/years:
  • COPD (common in smokers, middle-aged).
  • Idiopathic pulmonary fibrosis, Sarcoidosis.
  • Bronchiectasis, cystic fibrosis.
  • Congestive cardiac failure, lymphangitis carcinomatosis.
  • Hypoventilation due to neuromuscular disease.
• Episodic Breathlessness:
  • Asthma, left ventricular failure (LVF), angina equivalent.
  • Pulmonary embolism, hypersensitivity pneumonitis.
  • Hyperventilation, panic attacks.

Cough

Cough is commonly due to infection but a persistent cough (>6 weeks) should raise concern for malignancy, particularly in smokers. At minimum, a chest X-ray (CXR) is advised, and further investigation should be pursued if cough persists and malignancy remains a differential.

Causes of Cough

• Tracheitis (painful cough), bronchitis.
• Asthma (often nocturnal), pneumonia (fever, rusty or green sputum).
• Bronchiectasis (copious, foul-smelling sputum), post-nasal drip (often worse at night and with hay fever).
• Bovine cough: Recurrent laryngeal nerve damage, often due to lung tumors.
• ACE inhibitors (bradykinin-mediated).

Nocturnal Cough

• Asthma (worse at night), post-nasal drip, gastro-oesophageal reflux.
• Pulmonary oedema.

Common investigations include CXR, serial peak expiratory flow rate (PEFR) measurements, spirometry, high-resolution CT (HRCT) of the chest, bronchoscopy, and ENT examination if indicated.

Stridor

• Stridor is an inspiratory noise indicating upper airway obstruction.
• Causes of Stridor:
  • Acute epiglottitis in children (a pediatric emergency).
  • Laryngospasm or oedema (anaphylaxis, local burn).
  • Laryngeal obstruction (foreign body or tumor).
  • Diphtheria, croup in infants.

Wheeze

• Wheeze is an expiratory noise typically seen with bronchoconstriction.
• Causes of Wheeze:
  • Asthma, COPD, pulmonary oedema.

Haemoptysis

• Causes of Haemoptysis:
  • Infections: Pneumonia, bronchitis (often with fever and rigors).
  • Pulmonary embolism (new onset breathlessness).
  • Lung cancer (especially in smokers with lung masses).
  • Tuberculosis (fever, weight loss, immunocompromised patients).
  • Pulmonary oedema (oedema visible on CXR).

Sputum Production

• Types of Sputum:
  • Purulent (green/yellow): Commonly seen in infections, containing neutrophil myeloperoxidase.
  • Bloody: Associated with pneumonia, PE, or cancer.
  • Rusty: Often indicative of pneumococcal pneumonia.
  • Mucoid, copious, thick, and tenacious: Seen in bronchiectasis and cystic fibrosis.

Causes of Sputum Production

• Chest infections: Pneumonia, bronchitis, tracheitis.
• Chronic bronchitis, bronchiectasis.
• Lung tumors.

Fever (Temperature > 38°C)

• Causes of Fever:
  • Infections such as pneumonia or tuberculosis.
  • Lymphoma or other malignancies.
  • Connective tissue disease.
  • Extrinsic allergic alveolitis.

Unexpected Weight Loss (Chest Causes)

• Malignancy, tuberculosis.
• Idiopathic pulmonary fibrosis, COPD.

Smoking History

• A significant smoking history directs attention towards COPD and lung cancer.
• Assess for clubbing, recent weight loss, or a mass on CXR.
• Calculate pack years (packs per day multiplied by years of smoking).

Occupational History and Animal Exposure

• Inquire about all past jobs, as even brief exposure (e.g., lagging pipes 50 years ago) could relate to asbestos exposure and mesothelioma.
• Ask about pets and exposure to organic and other allergens at home or work.
• Investigate potential asbestos exposure, passive smoking (e.g., bar workers).

Chest Pain

• Possible Causes of Chest Pain:
  • Pulmonary embolism or infarction (usually pleuritic).
  • Localized infection (pneumonia with pleurisy), pneumothorax.
  • Tumors (e.g., mesothelioma, rib metastases causing localized pain).
  • Rib fractures from trauma or malignant lesions.
  • Acute coronary syndrome (should be ruled out if symptoms are suggestive).
  • Oesophagitis, pericarditis.

Miscellaneous Considerations

• Sexual or IV drug history (if considering HIV-related pneumonia such as PCP).
• Recent travel history (e.g., hotel stay for Legionnaire's disease).
• Travel to endemic areas for certain diseases (e.g., TB, Coccidioidomycosis from California, anthrax from hides or bioterrorism).