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Cardiovascular
Respiratory System a) Myocardial ischaemia
b) Chronic heart failure
Cough 2. Respiratory
Causes of cough a) COPD
According to site affected b) Bronchial asthma
 Pharynx c) Bronchiocarcinoma
a) Nasal drip d) Interstitial lung disease (sarcoidosis)
 Larynx e) Large pleural effusions
a) Laryngitis 3. Other causes of Dyspnoea
b) Laryngeal tumor (painful cough + a) Obesity
voice alteration) b) Severe anaemia
c) Whooping cough
 Trachea Chest Pain
a) Tracheitis (retrosternal pain) 1. Cardiac causes
 Bronchus (With wheeze – air escapes from a) Angina
narrow cavity) b) Pericarditis
a) Bronchitis c) Myocardial infarction
b) COPD d) Mitral valve prolapsed
c) Asthma 2. Non cardiac causes
d) Carcinoma a) Esophagus
 Lung parenchyma i) Esophagitis
a) Tuberculosis (productive cough with ii) Esophageal spasm
hemoptysis) b) Respiratory causes
b) Pneumonia (dry to productive cough) i) Pneumonia
c) Pulmonary edema (pink frothy ii) Tuberculosis
sputum) iii) Bronchogenic carcinoma
 Side effects of drugs iv) Pneumothorax
a) ACE inhibitors (dry cough) v) Pulmonary embolism
c) Aorta
Causes of Acute Dyspnoea i) Aortic aneurysm  abnormal
(no S/s, sudden onset) dilatation
 Cardiovascular : Acute pulmonary edema ii) Aortic dissection  Damage to
(accumulation of fluid in lungs due to left inner lining of aorta causes
ventricular failure) intravasation of blood
 Respiratory d) Muscle tear
a) Acute exacerbation of asthma e) Rib fracture or costochondritis
b) Acute exacerbation of COPD f) Neurological causes
c) Pneumothorax i) Prolapsed intervertebral disc
d) Pulmonary embolism ii) Herpes zoster syndrome
e) Inhalation of foreign body
f) ARDS Causes
 Others 1. Bronchial
a) Metabolic acidosis a. Bronchial adenoma
b) Uremia b. Bronchial Carcinoma
c) Renal failure c. Bronchiectasis
d) Salicylate poisoning d. Acute bronchitis
e) Cytogenic causes like panic attacks or e. Foreign body
anxiety 2. Parenchymal
a. Tuberculosis
Causes of Chronic dyspnoea b. Supportive pneumonia

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 c. Lung abscess lungs to be isolated and ventilated
d. Trauma separately)
3. Lung vascular disease  Emergency bronchoscopy
a. Pulmonary  Torrential bleeding  Rigid
infarction/embolism bronchoscope
b. Good Pasture’s syndrome  Cold saline lavage  Fibro-optic
(hemoptysis + hematuria) bronchoscope
4. Cardiovascular  Surgery indicated only when lobe
a. Acute left ventricular failure resection is required (rare)
b. Aortic aneurysm  Stop anticoagulants
5. Blood disorders  In case of non-stop bleeding:
a. Haemophilia  Iron
b. Leukaemia  Vitamin K
c. Anticoagulant therapy  Blood transfusion
patients (Warfarin)

Investigations Pulmonary embolism:

1. Blood examination Occlusion of pulmonary artery or its branches
2. Chest X Ray by an emboli
a. Pneumonia – consolidation
b. Tuberculosis – Consolidation, Pulmonary infarction:
cavity, shadowing Ischaemic necrosis of lung tissue from embolic
3. Sputum examination occlusion of smaller pulmonary arteries
a. Microscopy
b. Culture and sensitivity Types of pulmonary embolism
c. Cytological exam 1) Acute massive pulmonary embolism
4. Urine examination for Goodpasture’s whereby the embolus lodges in the main
syndrome pulmonary artery
5. CT scan 2) Pulmonary infarction from embolus lodging
6. Bronchoscopy in smaller pulmonary arteries
7. Biopsy 3) Reccurent silent pulmonary embolism
8. Isotope lung scan – when suspecting resulting in chronic pulmonary hypertension
pulmonary embolism but Xray chest is and chronic right heart failure
clear
Risk factors
Treatment 1) Surgery
 If minor:  Major abdominal/pelvic surgery
 Investigate and treat underlying cause  Hip/knee surgery
 If severe: 2) Obstetric causes
 Upright position  Pregnancy causing amniotic fluid
 Setup IV lines, collect blood for embolism
routine blood tests 3) Cardio-respiratory diseases
 Start IV fluids (NS), oxygen therapy  COPD
 If BP falls and pulse rate is high:  CHF
 Transfuse blood immediately 4) Lower limb pathology
 If BP merely falls:  Fracture of femur
 IV fluids  Varicose veins
 Mild sedatives for anxiety 5) Malignancy
 Endotracheal intubation if
hemodynamically unstable (Double lumen Clinical Presentation
endotracheal tube which allows the 2 1) Acute massive pulmonary embolism

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Symptoms 2) Pulmonary embolism as most likely
 Crushing, central chest pain diagnosis [Score +3]
 Severe dyspnoea 3) Heart rate >100 [Score +1.5]
 Prolapse 4) Immobilization for 4 weeks [Score +1.5]
Signs 5) Previous pulmonary embolism/DVT [Score
 Tachycardia +1.5]
 Hypotension 6) Haemoptysis [Score +1]
 Increased JVP (Jugulovenous pressure) 7) Malignancy [Score +1]
with prominent ‘a’ waves Score Probability
 Loud pulmonary component (p2) of >6 High
the second cardiac sound 2-6 Intermediate
 Right ventricular gallop rhythm <2 Low
 Severe cyanosis
 Wide splitting of second cardiac sound Complications
indicating pulmonary hypertension 1) Respiratory
 Right ventricular failure a) Wasted ventilation (decreased
perfusion with adequate air) - Part of
2) Acute small/medium pulmonary embolism lung ventilated, but not perfused
Symptoms b) Loss of surfactant  leading to
 Pleuritic chestpain (increased pain on alveolar prolapsed and atelectasis
inspiration) c) Arterial hypoxaemia
 Dyspnoea 2) Haemodynamic
 Haemoptysis a) Acute pulmonary hypertension
Signs b) Acute right ventricular failure
 Pleural rub (sound during inspiration) c) Shock
 Tachycardia
 Crackles Investigations
 Effusion (maybe blood stained) 1) Chest X-ray
 Low grade fever maybe present a) Acute massive pulmonary embolism
b) Increased radioluscence in a lung zone
3) Chronic pulmonary embolism due to diminished or absent blood
Symptoms flow
 Exertional dyspnoea c) May also find pulmonary opacities
Signs which are linear or disc shaped
 In early cases  Minimal / absent d) May find difference in diameter of
signs pulmonary artery and their main
 In later cases  Right ventricular branches on either side
heave and loud p2 e) May find pleural effusion
 In terminal cases  Signs of right f) Cardiomegaly
sided heart failure 2) Arterial blood gas (immediate test)
a) Hypoxaemia
Well’s scoring system b) Hypocapnia
It is used to determine the probability of c) Metabolic acidosis
pulmonary embolism. 3) ECG
1) Symptoms of DVT [Score +3] a) In acute massive pulmonary
a. Redness embolism, there is typical S1Q3T3
b. Hardness pattern
c. Swelling i) Presence of S wave in lead I
d. Some mild grade fever (usually in ii) Presence of Q wave in lead III
colder regions) iii) Presence of T wave in lead III

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 b) In other cases, there is sinus  Patients suffer massive haemorrhage
tachycardia during anticoagulation
c) In chronic cases, there is right  Usually surgery is done in patients
ventricular hypertrophy and right having recurrent pulmonary embolism
ventricular strain pattern despite anticoagulation
4) D-dimer
a) Degradation product released when
fibrin undergoes endogenous
fibrinolysis
b) This is NOT specific as it also rises in
cases like pneumonia, MI, sepsis and
DVT
5) CTPA (CT pulmonary angiography)
a) Gold standard test but not routinely
necessary though
6) Ventilation perfusion scanning
7) Ecocadiography to rule out aortic
dissection or pericardial tamponade

Treatment
 General measures
 Oxygen
 IV fluids
 Analgesics (low dose morphine)
 Anticoagulation
 LMW Heparin
 Fondaparinux atleast 5 days
(subcutaneous injection)
 Monitoring by aPTT  must be
maintained between 1.5-2 times
normal
 Oral warfarin is started at the same
time and continued for atleast 3
months
 INR must be maintained between 2-3
 Lifelong warfarin therapy is required
in cases of recurrent embolism,
malignancy and thrombotic states (ie.,
Protein C or protein S deficiencies
 Thrombolytic therapy
 Indicated in patients with massive
pulmonary embolism accompanied by
cardiogenic shock
 Agents used are streptokinase,
urokinase or tPA (tissue plasminogen
activator)
 Surgery
 Inferior vena cava filters are indicated
in patients in whom anticoagulation is
contraindicated