Pulmonary embolism Heart failure Pleural eff Liver cirrhosis Pneumothorax Pneumonia Asthma Lung carcinoma Cap Copd Make notes on this, definition, what history to ask, examination needed. What findings , symptom , clinical features, investigations, management. With detail notes but easy to remember.

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Here are your complete, easy-to-remember clinical notes for all 10 conditions:

🫁 RESPIRATORY & RELATED CLINICAL NOTES

1. PULMONARY EMBOLISM (PE)

Definition

Obstruction of the pulmonary arterial system by blood clots (usually from DVT in lower extremities). Part of venous thromboembolism (VTE). Two thirds of emboli reach both lungs, lodging in large/intermediate pulmonary arteries, most often in the lower lobes.

History to Ask

Virchow's Triad: Stasis (prolonged bed rest, air travel, surgery), hypercoagulability (cancer, pregnancy, OCP, inherited thrombophilia), vascular injury
Recent surgery (esp. hip/pelvic), major trauma, prolonged immobility
Previous DVT or PE
Leg swelling, calf pain/redness
Smoking, obesity, heart disease, stroke, burns
Medications: estrogen therapy
Family history of clotting disorders (Factor V Leiden, Protein C/S deficiency, antithrombin III deficiency, antiphospholipid syndrome, hyperhomocysteinemia)

Symptoms / Clinical Features

Acute onset shortness of breath (most common)
Pleuritic chest pain (sharp, worse on breathing)
Hemoptysis
Palpitations, tachycardia
Syncope or near-syncope
Leg swelling/pain (suggests DVT source)
Massive PE: acute right ventricular failure, cardiovascular collapse, shock

Examination Findings

Tachycardia (most common sign)
Tachypnea
Hypoxia (low SpO2)
Hypotension (in massive PE)
Jugular venous distension
Loud P2 (right heart strain)
Calf tenderness, asymmetric leg swelling (DVT signs)
Pleural rub (if infarction)

Investigations

D-dimer (ELISA <500 µg/L rules out PE in low-intermediate probability) - negative D-dimer is key for exclusion
CTPA (CT Pulmonary Angiography) - gold standard imaging - spiral CT with contrast
ECG: Tachycardia, S1Q3T3 pattern (S wave in lead I, Q wave and T inversion in lead III)
ABG: PaO2 often decreased, low PaCO2 (hyperventilation)
CXR: Often normal; may show wedge-shaped infarct, Hampton's hump, Westermark sign
Echo: Right ventricular strain/dilation, McConnell's sign
V/Q scan: Ventilation-perfusion mismatch (useful when CT contraindicated)
Troponin: Elevated = high risk for short-term mortality
Lower limb Doppler USS: Confirm DVT
Wells Score: Clinical pretest probability tool

Wells Score (simplified): DVT signs/symptoms (+3), alternative diagnosis less likely (+3), heart rate >100 (+1.5), immobilisation/surgery (+1.5), previous DVT/PE (+1.5), haemoptysis (+1), malignancy (+1)

Management

Anticoagulation = cornerstone
- LMWH (e.g., enoxaparin) or UFH (IV) acutely
- DOACs (rivaroxaban, apixaban) for most patients - now first-line for many
- Warfarin (INR 2-3) if DOACs unsuitable
- Duration: 3 months (provoked) vs 6+ months (unprovoked/recurrent)
Thrombolytics (alteplase): Massive PE with haemodynamic instability
Embolectomy (surgical or catheter): If thrombolytics fail or contraindicated
IVC filter: If anticoagulation contraindicated
Oxygen supplementation
Haemodynamically stable submassive PE: dose-adjusted IV or fixed-dose SC heparin
VTE prophylaxis (SC heparin) should be part of standard hospital admitting orders

2. HEART FAILURE (HF)

Definition

A clinical syndrome where the heart cannot meet the metabolic requirements of the body at normal filling pressures.

HFrEF (reduced EF): EF <45-50%, impaired contraction
HFpEF (preserved EF): EF >45-50%, impaired filling/relaxation
Mortality: ~50% within 5 years

History to Ask

Dyspnea (exertional, at rest, orthopnea, PND - paroxysmal nocturnal dyspnea)
Ankle/leg swelling
Reduced exercise tolerance
Fatigue
Cause: Hypertension, CAD/previous MI, valvular disease, diabetes, anemia, thyroid disease, alcohol use, cardiomyopathy
Medications
Weight gain

Symptoms / Clinical Features

Breathlessness (especially on exertion, lying flat)
Orthopnea (number of pillows used)
PND (waking from sleep gasping)
Ankle/leg edema
Fatigue, weakness
Reduced exercise tolerance
Weight gain (fluid retention)
Nocturia
Cough (sometimes frothy/pink - pulmonary oedema)

Examination Findings

Signs of fluid overload:

Bilateral pitting edema (ankles, sacrum)
Raised JVP
Pulmonary crackles (bibasal)
S3 gallop (third heart sound) - hallmark
Displaced apex beat (dilated LV)
Hepatomegaly (right HF)
Ascites (right HF)

Signs of reduced output:

Tachycardia
Hypotension (late)
Cold peripheries
Reduced pulse pressure
Cachexia

Investigations

Echo (2D with Doppler): KEY - determines EF, chamber size, valve function. First-line investigation
BNP/NT-proBNP: Raised - confirms HF, correlates with severity
ECG: May show LVH, previous MI, AF, BBB
CXR: Cardiomegaly (>50% of chest width), pulmonary oedema (bat-wing pattern), Kerley B lines, pleural effusions
Bloods: FBC (anaemia), U&E (electrolytes, renal function), LFTs, TFTs, glucose
Coronary angiography if ischaemia suspected

Management

Non-pharmacological:

Salt restriction (2g Na/day)
Daily weight monitoring (report 3 lb/week gain)
Fluid restriction (1L/day)
Smoking cessation, avoid alcohol
Regular exercise
Treat HTN, dyslipidaemia

Pharmacological (HFrEF):

ACE inhibitor (or ARB if intolerant) - blocks RAAS, reduces remodelling
Beta-blocker (carvedilol, metoprolol XL, bisoprolol) - reduces mortality, use in stable patients
Aldosterone antagonist (spironolactone/eplerenone) - additional mortality benefit
Diuretics (furosemide) - symptom relief for congestion
ARNI (sacubitril/valsartan): Replaces ACEi in symptomatic patients
SGLT2 inhibitors (dapagliflozin, empagliflozin): Reduce hospitalisation and mortality

Device therapy:

ICD (defibrillator): EF <35%
CRT (cardiac resynchronisation): LBBB + EF <35%

3. PLEURAL EFFUSION

Definition

Abnormal accumulation of fluid in the pleural space between the visceral and parietal pleurae.

Types:

Transudate (low protein <25g/L): Heart failure, liver cirrhosis/hepatic hydrothorax, nephrotic syndrome, hypothyroidism
Exudate (high protein >35g/L, or by Light's criteria): Pneumonia (parapneumonic), malignancy, TB, pulmonary embolism, pancreatitis

Light's Criteria (exudate if any ONE met):

Pleural:serum protein ratio >0.5
Pleural:serum LDH ratio >0.6
Pleural LDH > 2/3 upper limit of serum normal

History to Ask

Breathlessness (proportional to volume)
Pleuritic chest pain
Cough (dry or productive)
Fever (suggests infection/TB)
Weight loss, night sweats (TB, malignancy)
Leg swelling, orthopnea (heart failure)
Alcohol, liver disease (cirrhosis)
Known malignancy
Medications
Occupation (asbestos - mesothelioma)

Symptoms / Clinical Features

Dyspnoea (progressive)
Dry cough
Pleuritic chest pain (if pleuritis present)
Dullness/heaviness in chest
Hepatic hydrothorax: usually right-sided, in cirrhosis - symptomatic even without ascites

Examination Findings

(Classic triad - on affected side)

Stony dull to percussion
Reduced/absent breath sounds
Reduced vocal fremitus/resonance
Tracheal deviation (away from large effusion)
Reduced chest expansion on affected side
Bronchial breathing just above effusion (compressed lung)

Investigations

CXR: Blunting of costophrenic angle (>200mL), meniscus sign, tracheal shift
Ultrasound chest: Most sensitive - guides thoracocentesis
CT chest: Reveals underlying cause (malignancy, empyema loculation)
Pleural fluid analysis (thoracocentesis): Protein, LDH (Light's criteria), pH, glucose, cell count, culture, cytology, AFB
Bloods: Protein, LDH, FBC, LFTs, U&E, TFTs

Management

Treat underlying cause
Thoracocentesis (diagnostic and therapeutic): Drain symptomatic effusions
Chest drain: Large/recurrent effusions
Pleurodesis (talc): For malignant/recurrent effusions
TIPS (transjugular intrahepatic portosystemic shunting): For hepatic hydrothorax refractory to treatment (initial response 70-80%)
Indwelling pleural catheter: Bridge to transplant or palliation
Video-assisted thoracoscopic surgery (VATS): For refractory hepatic hydrothorax to repair diaphragmatic defects

4. LIVER CIRRHOSIS

Definition

End-stage fibrosis of the liver with replacement of normal hepatic architecture by regenerative nodules and fibrous bands, leading to portal hypertension and liver failure.

Causes (mnemonic ABCDE):

Alcohol (most common in West)
B = Biliary (PSC, PBC)
C = Chronic hepatitis C and B
D = NAFLD/NASH (metabolic)
E = Everything else (haemochromatosis, Wilson's, alpha-1-antitrypsin deficiency, autoimmune)

History to Ask

Alcohol intake (quantity, duration)
Viral hepatitis risk factors (blood transfusion, IV drug use, sexual contacts)
Fatigue, weakness
Abdominal distension (ascites)
Jaundice
Confusion, personality change (encephalopathy)
Bleeding (gums, PR, haematemesis)
Weight loss
Family history (Wilson's, haemochromatosis)
Medications (methotrexate, amiodarone)

Symptoms / Clinical Features

Fatigue, weakness
Jaundice
Abdominal distension (ascites)
Ankle oedema
Easy bruising/bleeding
Pruritus (especially PBC)
Haematemesis/melaena (varices)
Confusion (hepatic encephalopathy)
Loss of libido

Examination Findings

Classic signs:

Jaundice, scleral icterus
Spider naevi (>5 significant)
Palmar erythema
Leukonychia (white nails), Terry's nails
Dupuytren's contracture
Gynaecomastia, testicular atrophy (in men)
Parotid enlargement (alcohol)
Asterixis (flapping tremor) = encephalopathy
Caput medusae (dilated periumbilical veins)
Ascites (shifting dullness, fluid thrill)
Splenomegaly
Hepatomegaly (early) or small liver (late)
Fetor hepaticus

Investigations

LFTs: Raised bilirubin, ALT/AST (AST:ALT ratio >2 suggests alcohol), low albumin
Coagulation: Raised PT/INR (reduced clotting factors)
FBC: Thrombocytopenia (hypersplenism), anaemia
U&E: Hyponatraemia, renal impairment (hepatorenal syndrome)
Viral serology: HBsAg, HCV antibody
Autoimmune: ANA, ASMA (AIH), AMA (PBC), ANCA (PSC)
Ferritin, transferrin saturation: Haemochromatosis
Caeruloplasmin, copper, slit-lamp: Wilson's disease
Ultrasound liver + Doppler: Nodular liver, splenomegaly, ascites, portal vein flow
ARFI/Fibroscan (elastography): Non-invasive fibrosis staging
Liver biopsy: Gold standard for staging
MELD/Child-Pugh score: Prognosis and transplant listing
OGD (endoscopy): Check for varices
Ascitic tap: Protein, albumin (SAAG = serum albumin - ascitic albumin; SAAG >11g/L = portal hypertension), cell count, culture

Management

Treat underlying cause (alcohol cessation, antivirals for HBV/HCV)
Ascites: Spironolactone 100mg + furosemide 40mg (ratio 5:2), sodium restriction (88mmol/day); large volume paracentesis for tense ascites + albumin replacement
Varices: Non-selective beta-blockers (propranolol) for prophylaxis; banding + terlipressin for acute bleed
Encephalopathy: Lactulose, rifaximin; identify and treat precipitants
SBP: Cefotaxime (empirical); prophylaxis with norfloxacin
HRS (hepatorenal syndrome): Terlipressin + albumin
Liver transplant: Definitive treatment for end-stage disease

5. PNEUMOTHORAX

Definition

Air in the pleural space between the visceral and parietal pleura.

Types:

Primary spontaneous: No underlying lung disease; tall, thin young males; subpleural blebs
Secondary spontaneous: Underlying lung disease (COPD, asthma, CF, pneumonia)
Tension pneumothorax: One-way valve mechanism - air enters but cannot exit = life-threatening
Traumatic: Rib fracture, penetrating injury, iatrogenic (central line, biopsy, PPV)

History to Ask

Sudden onset chest pain (sharp, pleuritic)
Sudden breathlessness
Age, BMI (tall thin males - primary)
History of lung disease (COPD, asthma, Marfan's)
Previous pneumothorax
Trauma
Smoking
Mechanical ventilation
Recent procedures

Symptoms / Clinical Features

Acute-onset pleuritic chest pain (unilateral)
Breathlessness (proportional to size)
Reduced exercise tolerance
Tension PTX: Rapidly deteriorating with shock, cyanosis, tracheal deviation - medical emergency

Examination Findings

(On affected side)

Hyper-resonant to percussion
Reduced/absent breath sounds
Reduced chest expansion
Reduced vocal fremitus

Tension PTX (emergency signs):

Tracheal deviation AWAY from affected side
Hypotension
Tachycardia
Raised JVP
Cyanosis
Absent breath sounds
Elevated peak airway pressure (if ventilated)

Investigations

CXR (erect, PA): Visible lung edge with absent lung markings peripheral to it. Measure size.
CT chest: More accurate for size/loculation; identifies underlying bullae/disease
ABG: Hypoxia (in large/tension)

Size assessment: BTS guidelines - 2cm from lung to chest wall at apex = significant

Management

Small, stable, primary spontaneous (<2cm, no dyspnoea):

Observation + high-flow oxygen (accelerates reabsorption)
Review in 2-4 weeks

Larger/symptomatic:

Aspiration (needle, 2nd intercostal space, midclavicular line)
Chest drain (small bore, 4th/5th ICS, midaxillary line) with water seal

Tension pneumothorax (EMERGENCY):

Immediate needle decompression (2nd ICS, MCL) - do NOT wait for CXR
Follow with chest drain

Recurrent/secondary:

Chemical pleurodesis (talc)
VATS bullectomy + pleurodesis

Return to sport: Usually safe after 3-4 weeks

6. PNEUMONIA

Definition

Infection of the lung parenchyma (alveoli) causing consolidation. The most common infectious cause of hospitalisation and death.

Classification:

CAP (Community-Acquired Pneumonia) = acquired outside hospital
HAP/VAP (Hospital/Ventilator-Acquired) = acquired >48h after admission
Atypical = Mycoplasma, Chlamydia, Legionella, viruses

Common Organisms:

Typical: Streptococcus pneumoniae (most common), Haemophilus influenzae, Staphylococcus aureus, Gram-negatives
Atypical: Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila
Viruses: Influenza, RSV, COVID-19

History to Ask

Cough (productive/dry, colour of sputum, blood)
Fever, chills, rigors
Pleuritic chest pain
Dyspnoea
Malaise, myalgia (atypical pattern)
Rate of onset (rapid = typical; gradual = atypical)
Risk factors: Age, smoking, COPD, diabetes, alcohol, immunosuppression, poor dental hygiene, HIV, recent travel (Legionella - hotel water systems)
Vaccination status (pneumococcal, influenza)
Recent hospitalisation

Symptoms / Clinical Features

Typical (bacterial):

Abrupt onset
High fever, chills
Productive cough (rusty sputum in pneumococcal)
Pleuritic chest pain
WBC >15,000 with neutrophilia

Atypical:

Gradual onset
Low-grade fever
Dry cough
Fewer constitutional symptoms
May have extrapulmonary features (headache, myalgia, rash, diarrhoea - Legionella)

Examination Findings

(Consolidation signs - on affected area)

Dull to percussion
Bronchial breathing
Increased vocal fremitus/resonance
Aegophony (E-to-A change)
Tachypnoea, tachycardia
Crackles (coarse)
Reduced breath sounds (if effusion present)
Fever

Investigations

CXR: Lobar consolidation (bacterial), interstitial/bilateral pattern (atypical/viral)
Bloods: FBC (raised WBC with neutrophilia), CRP, ESR, U&E, LFTs
Sputum: Gram stain + culture (low yield but try)
Blood cultures: Before antibiotics (positive in ~10%)
Urine antigen: Pneumococcal antigen, Legionella antigen
Cold agglutinins: Mycoplasma (positive)
ABG/SpO2: Severity assessment
Severity Scoring: CURB-65

CURB-65 score (1 point each):

Confusion
Urea >7 mmol/L
Respiratory rate ≥30/min
BP <90/60 mmHg
Age ≥65

Score 0-1: Treat at home | Score 2: Hospital consider | Score 3+: Severe, ICU consider

Management

Mild (outpatient):

Amoxicillin 500mg TDS x 5-7 days
If atypical suspected: add clarithromycin/doxycycline
Or: Doxycycline or clarithromycin monotherapy

Moderate (inpatient):

Co-amoxiclav IV + clarithromycin IV/oral

Severe (ICU):

Piperacillin-tazobactam + clarithromycin +/- antifungal

Legionella: Levofloxacin or azithromycin

Prevention:

Pneumococcal vaccine (revaccinate after 10 years if first dose given <65)
Influenza vaccine annually (>50 years, chronic disease)

7. ASTHMA

Definition

Chronic inflammatory airway disease characterised by reversible bronchoconstriction from airway hyperresponsiveness to stimuli. Caused by bronchial smooth muscle contraction, mucosal oedema, and excessive secretions.

Atopic asthma: Th2/IgE-mediated (allergens) - most common
Non-atopic: Triggered by viral infections, cold air, exercise, pollutants
Key cells: Eosinophils, mast cells, T lymphocytes
Airway remodelling (subbasement membrane thickening) may add irreversible component

History to Ask

Wheeze, cough (often nocturnal/early morning), breathlessness, chest tightness (classic tetrad)
Triggers: Exercise, cold air, allergens (pollen, dust, animal dander, mould), NSAIDs, aspirin, beta-blockers, stress, respiratory infections, smoke
Atopy history: Eczema, allergic rhinitis, hay fever
Family history of asthma/atopy
Occupational exposure
Symptoms worse at night or early morning (diurnal variation)
Response to bronchodilators
Current medications
Previous hospitalisations, ICU admissions, intubation (severity markers)

Symptoms / Clinical Features

Episodic wheeze
Dry cough (especially nocturnal)
Chest tightness
Breathlessness
Symptoms vary with time and triggers
Silent chest (severe attack - no air moving)

Examination Findings

Between attacks: Often normal

During attack:

Wheeze (expiratory, polyphonic)
Prolonged expiratory phase
Tachypnoea, tachycardia
Use of accessory muscles
Hyperinflated chest (barrel chest in chronic)
Reduced air entry

Severe/Life-threatening:

Cannot complete sentences
SpO2 <92%
Peak flow <50% predicted
Silent chest (ominous)
Cyanosis
Bradycardia
Confusion

Investigations

Peak flow (PEFR): Reduced; >20% diurnal variation = asthma
Spirometry: Obstructive pattern (FEV1/FVC <0.7); reversibility test (>12% and 200mL improvement with salbutamol = asthma)
Bronchial provocation test (methacholine/histamine): If spirometry normal
CXR: Usually normal or hyperinflated; exclude other causes
ABG: Hypoxia; PaCO2 - if normal/rising in acute attack = very severe (respiratory fatigue)
FeNO (fractional exhaled nitric oxide): Elevated in eosinophilic asthma
Skin prick tests/serum IgE + RAST: Identify allergens (atopic asthma)
Sputum eosinophils

Management

Step-up approach (BTS/SIGN):

SABA (salbutamol inhaler) PRN - short-acting beta-2-agonist
Add ICS (inhaled corticosteroid: beclometasone, budesonide, fluticasone)
Add LABA (long-acting beta-2: salmeterol, formoterol) = combined ICS/LABA inhaler
Increase ICS dose; consider LTRA (montelukast), theophylline
Specialist referral; oral prednisolone; add-ons (omalizumab, mepolizumab for severe eosinophilic)

Inhaler technique: ALWAYS check and teach! Step down when controlled for 3 months

Acute asthma attack:

Sit upright, high-flow O2
Salbutamol nebuliser (2.5-5mg) +/- ipratropium (0.5mg)
Oral/IV prednisolone 40-50mg
IV magnesium sulphate 1.2-2g if severe
IV aminophylline if unresponsive
Intubation/ICU if life-threatening

Pre-exercise prevention: Salbutamol 15-30 mins before exercise; add montelukast or cromolyn if needed

8. LUNG CARCINOMA

Definition

Malignant tumours arising from the bronchial/alveolar epithelium. Most common cause of cancer death worldwide.

Histological subtypes (Non-Small Cell = 80%):

Adenocarcinoma (most common overall; peripheral; women/non-smokers; EGFR mutations)
Squamous cell carcinoma (central; smokers; cavitating; PTHrP = hypercalcaemia)
Large cell carcinoma (peripheral; poorly differentiated)

Small Cell Lung Cancer (SCLC = 20%):

Central, highly aggressive
Almost always metastatic at presentation
TP53 and RB mutations
Best treated with chemo (surgery rarely)
Multiple paraneoplastic syndromes

History to Ask

SMOKER history (pack-years) - most important risk factor
Occupational: Asbestos, radon, arsenic exposure
Cough (new, persistent, changed character)
Haemoptysis (blood in sputum)
Chest pain (pleuritic or dull)
Dyspnoea (progressive)
Weight loss, anorexia, fatigue (constitutional)
Hoarse voice (recurrent laryngeal nerve palsy - left-sided tumours)
Dysphagia (oesophageal compression)
Facial/arm swelling (SVC obstruction)
Bone pain (metastases)
Headache, seizures, neurological symptoms (brain mets)
Family history

Symptoms / Clinical Features

Local effects:

Cough, haemoptysis, breathlessness, wheeze
Chest pain, pleurisy
Recurrent pneumonia (post-obstructive)

Regional effects:

Hoarse voice (RLN palsy)
Phrenic nerve palsy (raised hemidiaphragm)
SVC syndrome (facial oedema, arm oedema, venous distension)
Dysphagia
Horner's syndrome (Pancoast tumour = ptosis, miosis, anhidrosis, enophthalmos) - apex tumour

Metastatic:

Bone pain, pathological fracture
Headache, seizures, personality change (brain)
Jaundice, hepatomegaly (liver)
Adrenal insufficiency

Paraneoplastic syndromes:

SCLC: SIADH (hyponatraemia), Cushing's syndrome (ectopic ACTH), Lambert-Eaton myasthenic syndrome, SCLC neuropathy
Squamous: Hypercalcaemia (PTHrP)
Adenocarcinoma: Hypertrophic pulmonary osteoarthropathy (HPOA)
All types: Clubbing, venous thrombosis

Examination Findings

Clubbing
Lymphadenopathy (supraclavicular, cervical)
Signs of consolidation/collapse/effusion
Horner's syndrome (apex)
SVC obstruction (non-pulsatile JVP, facial plethora/oedema, arm oedema, dilated chest veins)
Cachexia
Signs of metastases (hepatomegaly, bone tenderness, focal neurology)

Investigations

CXR: Hilar mass, consolidation, collapse, pleural effusion, coin lesion
CT chest/abdomen/pelvis with contrast: Staging, lymph node assessment
PET-CT: Distant metastasis staging
Bronchoscopy + biopsy: Central tumours
CT-guided biopsy: Peripheral tumours
Sputum cytology: Low yield but non-invasive
Bone scan or MRI head: Metastasis
Bloods: FBC, LFTs, Ca2+, LDH, U&E
Lung function tests (spirometry): Pre-operative assessment
Molecular testing: EGFR, ALK, KRAS, BRAF, RET, NTRK mutations; PD-L1 expression (for targeted therapy/immunotherapy decisions)
Mediastinoscopy/EBUS: Lymph node staging

Management

NSCLC:

Stage I-II: Surgery (lobectomy preferred)
Stage III: Chemo-radiotherapy (concurrent)
Stage IV: Palliative - systemic therapy:
- Targeted therapy if EGFR+ (gefitinib, erlotinib, osimertinib), ALK+ (crizotinib, alectinib)
- Immunotherapy (pembrolizumab, nivolumab) if PD-L1 positive
- Chemotherapy (carboplatin + paclitaxel/pemetrexed)

SCLC:

Limited stage: Chemo-radiation (platinum + etoposide) +/- prophylactic cranial irradiation
Extensive stage: Chemotherapy (cisplatin/etoposide) + immunotherapy (atezolizumab)

Palliative care: Pain, breathlessness management throughout

9. COMMUNITY-ACQUIRED PNEUMONIA (CAP)

(Extended notes - see Pneumonia above for core features)

Definition

Pneumonia acquired outside the hospital setting or within 48 hours of admission.

Most common cause: Streptococcus pneumoniae

Key Organisms to Know

Setting	Organism
Typical community	S. pneumoniae, H. influenzae
Atypical	Mycoplasma, Chlamydia, Legionella
Viral	Influenza, RSV, COVID-19 (20-30%)
Aspiration	Anaerobes, Gram-negatives
Immunocompromised	PCP (Pneumocystis), Crypto, Aspergillus
Elderly/nursing home	Gram-negatives, S. aureus

CURB-65 Score (Critical to know)

0-1: Low severity → Outpatient
2: Moderate → Inpatient
3-5: Severe → ICU consideration

Antibiotic Summary

Severity	Setting	Antibiotic
Mild	Outpatient	Amoxicillin 500mg TDS or doxycycline or clarithromycin
Moderate	Inpatient	IV co-amoxiclav + clarithromycin
Severe	ICU	Pip-tazo + clarithromycin
Legionella	Any	Levofloxacin or azithromycin

Duration: Minimum 5 days, at least 48-72h afebrile
Complications: Empyema (3-5%), parapneumonic effusion, bacteraemia, sepsis, AF

10. COPD (Chronic Obstructive Pulmonary Disease)

Definition

Progressive, largely irreversible airflow obstruction caused by a mixture of:

Emphysema (destruction of alveolar walls distal to terminal bronchioles; loss of elastic recoil; enlarged air spaces)
Chronic bronchitis (productive cough ≥3 consecutive months in ≥2 consecutive years)

Key pathology:

Smoking is the #1 risk factor (90%)
Emphysema: Neutrophil proteases destroy elastic tissue; centriacinar (smoking) vs. panacinar (alpha-1-antitrypsin deficiency)
Chronic bronchitis: Hyperplasia of mucus glands, goblet cell metaplasia, small airway inflammation
Progressive - may lead to cor pulmonale (right heart failure)
FEV1/FVC <0.7 (obstructive) with FEV1 reduction; does NOT fully reverse

History to Ask

Smoking history (pack-years) - most critical
Progressive breathlessness (initially exertional)
Chronic productive cough (morning worse)
Sputum: Amount, colour, change in character
Wheeze
Recurrent chest infections
Occupational dust/fumes/smoke exposure
Alpha-1-antitrypsin deficiency (family history, young non-smoker)
Exercise tolerance (MRC dyspnoea scale)
Previous hospitalisations, oxygen use
Current medications

Symptoms / Clinical Features

Stable COPD:

Progressive exertional dyspnoea
Chronic cough with sputum (usually white/clear)
Wheeze

"Pink puffer" (emphysema):

Thin, breathless, uses accessory muscles
Pursed lip breathing
Barrel chest
Relatively normal PaO2 (hyperventilates to compensate)

"Blue bloater" (chronic bronchitis):

Overweight, cyanotic
Productive cough
Hypoxaemia + hypercapnia
Peripheral oedema (cor pulmonale)

Acute exacerbation (AECOPD):

Increased dyspnoea, sputum production, sputum purulence (Anthonisen criteria)
Triggered by infection (S. pneumoniae, H. influenzae, Moraxella, viruses)

Examination Findings

Hyperinflated chest (increased AP diameter "barrel chest")
Reduced chest expansion
Hyper-resonant percussion
Reduced breath sounds
Wheeze (expiratory)
Prolonged expiratory phase
Use of accessory muscles (sternomastoid, intercostals)
Pursed lip breathing
Tracheal tug
Cyanosis (central - in severe)
Cor pulmonale signs: Peripheral oedema, raised JVP, loud P2
Cachexia

Investigations

Spirometry (post-bronchodilator): FEV1/FVC <0.7 confirms COPD; FEV1 % predicted for severity

GOLD Staging by FEV1 % predicted:

GOLD 1 (mild): FEV1 ≥80%
GOLD 2 (moderate): 50-79%
GOLD 3 (severe): 30-49%
GOLD 4 (very severe): <30%
CXR: Hyperinflation, flat diaphragm, increased retrosternal space, bullae, tubular heart
CT chest: Emphysema distribution, bullae, exclude malignancy
ABG: Hypoxia +/- hypercapnia; T2RF (type 2 respiratory failure: low pO2 + high pCO2)
FBC: Polycythaemia (secondary to hypoxia)
Alpha-1-antitrypsin levels: If young, non-smoker, panacinar emphysema
ECG, Echo: Cor pulmonale assessment
6-minute walk test: Functional assessment

Management

Non-pharmacological (most important first):

Smoking cessation (slows disease progression - single most effective intervention)
Pulmonary rehabilitation
Influenza + pneumococcal vaccination
Nutritional support
Long-term oxygen therapy (LTOT): PaO2 ≤7.3 kPa, ≥15 hours/day

Pharmacological (inhaler step-up):

SABA (salbutamol) and/or SAMA (ipratropium) PRN
Add regular LABA (salmeterol) and/or LAMA (tiotropium) - cornerstone of maintenance
Add ICS (in those with frequent exacerbations or eosinophilia)

Triple therapy: ICS + LABA + LAMA = best for frequent exacerbators

Oral medications:

Roflumilast (PDE4 inhibitor): For severe COPD with chronic bronchitis + frequent exacerbations
Azithromycin (prophylactic): Reduce exacerbation frequency in selected patients
Mucolytics (carbocysteine): Chronic productive cough

Acute Exacerbation (AECOPD):

Controlled oxygen: Target SpO2 88-92% (avoid over-oxygenation - hypercapnic drive)
Nebulised salbutamol + ipratropium
Oral prednisolone 30-40mg for 5 days
Antibiotics (if purulent sputum or sepsis): Amoxicillin, doxycycline, or co-amoxiclav
NIV (BiPAP): If Type 2 RF persists despite treatment (pH <7.35)
Intubation if NIV fails

🔑 QUICK COMPARISON: OBSTRUCTIVE vs RESTRICTIVE LUNG DISEASE

Feature	Obstructive (Asthma/COPD)	Restrictive (Fibrosis)
FEV1	↓	↓
FVC	Normal/↓	↓↓
FEV1/FVC	<0.7	Normal or ↑
TLC	Normal/↑	↓

🔑 QUICK COMPARISON: TRANSUDATE vs EXUDATE (Light's Criteria)

	Transudate	Exudate
Protein	<25 g/L	>35 g/L
LDH	Low	High
Causes	HF, cirrhosis, nephrotic	Pneumonia, TB, malignancy, PE

🔑 SIGNS BY PERCUSSION NOTE

Condition	Percussion	Breath Sounds	Vocal Resonance
Pneumothorax	Hyper-resonant	Absent	Absent
Pleural Effusion	Stony dull	Absent/reduced	Reduced
Pneumonia/Collapse	Dull	Bronchial	Increased
Normal/Asthma/COPD	Resonant/Hyperresonant	Wheeze	Normal

Sources: Murray & Nadel's Textbook of Respiratory Medicine; Textbook of Family Medicine 9e; Robbins & Kumar Basic Pathology; Goldman-Cecil Medicine; Bailey & Love's Surgery; Brenner & Rector's The Kidney

For the heart failure divide i to rhf and lhf and add regarding col pulmonale

Finding Sources

Reading File

I now have all the information needed. Here is the fully expanded Heart Failure section divided into LHF, RHF, and Cor Pulmonale:

2. HEART FAILURE (HF) — COMPLETE NOTES

DEFINITION

Heart failure is a clinical syndrome where the heart cannot meet the metabolic requirements of the body at normal filling pressures.

Key concept: LV remodelling (stretching, dilation, reduced function) driven by neurohormonal activation (RAAS + SNS) is the central mechanism.

By ejection fraction (EF):

Type	EF	Mechanism
HFrEF (reduced)	≤40%	Impaired contraction (systolic)
HFmrEF (mildly reduced)	41-49%	Mixed
HFpEF (preserved)	≥50%	Impaired filling/relaxation (diastolic)
HFimpEF (improved)	EF risen >40% after Rx	Post-treatment recovery

LEFT HEART FAILURE (LHF)

Definition

Failure of the left ventricle to pump adequate blood into the systemic circulation, leading to pulmonary congestion as blood backs up into the pulmonary circulation.

Causes

Most common: Coronary artery disease (MI), Hypertension
Valvular disease (aortic stenosis, mitral regurgitation)
Cardiomyopathy (dilated, hypertrophic)
Myocarditis
Arrhythmias (AF)
Diabetes, anaemia, thyroid disease, alcohol
Congenital heart defects

History to Ask

Dyspnoea on exertion (earliest symptom)
Orthopnoea (how many pillows? sitting up to sleep)
Paroxysmal nocturnal dyspnoea (PND) - woken from sleep, gasping
Reduced exercise tolerance
Dry cough (pulmonary oedema)
Palpitations
History of MI, hypertension, valvular disease
Medications (betablockers, NSAIDs worsening)

Symptoms / Clinical Features

Breathlessness (exertional → rest)
Orthopnoea, PND
Dry cough / frothy pink sputum (acute pulmonary oedema)
Fatigue
Reduced exercise capacity
Wheeze ("cardiac asthma" - bronchospasm from pulmonary congestion)
Cold, clammy peripheries (low output)
Confusion (cerebral hypoperfusion)

Examination Findings

Pulmonary congestion signs:

Bilateral basal fine crackles (pulmonary oedema)
S3 gallop rhythm (third heart sound - volume overload) = hallmark
Tachycardia
Tachypnoea
Displaced apex beat (cardiomegaly / LV dilation)
Murmur (valvular cause)
Cheyne-Stokes breathing (advanced)
Wheeze ("cardiac asthma")

Note: Peripheral oedema is NOT a prominent feature of pure LHF (that is RHF)

Investigations

Echo: Reduced EF, dilated LV, wall motion abnormalities
CXR: ABCDE of pulmonary oedema:
- A = Alveolar oedema (bat-wing shadowing)
- B = Kerley B lines (horizontal lines at lung bases - interstitial oedema)
- C = Cardiomegaly (>50% of thoracic width)
- D = Diversion of blood flow upper lobe (upper lobe venous diversion)
- E = Effusions (bilateral pleural)
BNP/NT-proBNP: Elevated - confirms HF, correlates with severity
ECG: LVH, AF, previous MI, LBBB
Bloods: FBC, U&E, LFTs, TFTs, BNP, glucose, lipids
Coronary angiography: If ischaemia suspected

RIGHT HEART FAILURE (RHF)

Definition

Failure of the right ventricle to pump blood into the pulmonary circulation, leading to systemic venous congestion as blood backs up into the systemic and portal venous systems.

Causes

Most common cause = Left heart failure (raised pulmonary pressure overloads RV)

Isolated RHF causes:

Cor pulmonale (primary lung disease - see below)
Pulmonary hypertension (primary or secondary)
Recurrent pulmonary embolism
Right-sided valve disease (tricuspid regurgitation, pulmonary stenosis)
Right ventricular infarction (RCA occlusion)
Congenital heart disease (ASD, VSD, Eisenmenger's)
Obstructive sleep apnoea
Cardiomyopathy

History to Ask

Ankle/leg swelling (worse by end of day, relieved by elevation)
Abdominal distension (ascites)
Right upper quadrant discomfort (hepatic congestion)
Nausea, reduced appetite
History of lung disease (COPD, asthma, pulmonary fibrosis - suggests cor pulmonale)
History of LHF, valvular disease
Reduced exercise tolerance

Symptoms / Clinical Features

Ankle and leg oedema (pitting, dependent)
Abdominal bloating/discomfort (from hepatomegaly/ascites)
Nausea, anorexia (gut congestion)
Reduced exercise tolerance
Fatigue
NO significant pulmonary symptoms in pure RHF (this distinguishes from LHF)
Oliguria (reduced renal perfusion)

Examination Findings

The hallmarks are all "systemic venous congestion" signs:

Raised JVP (jugular venous pressure) - key sign; hepatojugular reflux positive
Pitting peripheral oedema (ankles → legs → sacrum in bed-bound)
Hepatomegaly (tender, pulsatile in tricuspid regurgitation) = congestive hepatomegaly = "nutmeg liver"
Ascites (from portal hypertension + hypoalbuminaemia)
Splenomegaly (congestive splenomegaly)
Pleural effusion (transudates, right-sided or bilateral)
Right ventricular heave (parasternal)
Loud P2 (pulmonary hypertension)
Tricuspid regurgitation murmur (pansystolic, louder on inspiration)
Cyanosis (late, peripheral)

Key difference: Pure RHF has systemic congestion; LHF has pulmonary congestion. When combined (biventricular failure) - both sets of signs present.

Investigations

Echo: RV dilation/hypertrophy, tricuspid regurgitation, elevated pulmonary artery pressure
CXR: Cardiomegaly (right heart), dilated azygos vein, pleural effusions; no pulmonary oedema (unless LHF co-existing)
ECG: Right axis deviation, RBBB, tall P waves (P pulmonale), RV strain (T inversion V1-V4)
BNP/NT-proBNP: Elevated
Bloods: U&E (renal impairment), LFTs (raised from hepatic congestion), FBC, albumin
ABG: Hypoxia (if cor pulmonale)
Spirometry: Assess for underlying lung disease

COR PULMONALE

Definition

Right ventricular hypertrophy and dilation - frequently leading to right heart failure - caused by pulmonary hypertension arising from primary lung disease (parenchymal or pulmonary vascular).

Key distinction: RV changes from LHF or congenital heart disease are excluded from this definition. Cor pulmonale = RHF caused by the lungs, NOT the left heart.

Pathophysiology (the chain)

Lung disease (COPD/fibrosis/PE/OSA)
  ↓
Hypoxaemia + hypercapnia
  ↓
Pulmonary vasoconstriction (hypoxic vasoconstriction)
  ↓
Pulmonary vascular remodelling + loss of vascular bed
  ↓
Pulmonary hypertension (↑ pulmonary artery pressure)
  ↓
Increased RV afterload (pressure overload)
  ↓
RV hypertrophy → RV dilation → RV failure
  ↓
Cor pulmonale

Additional contributor: Polycythaemia (hypoxia → EPO → increased RBC → increased blood viscosity → further raised pulmonary vascular resistance)

Important: Unlike LHF, cardiac output is normal or increased in cor pulmonale until very late. Oedema in cor pulmonale is largely due to renal sodium retention (hypercapnia → kidneys retain bicarbonate + sodium), not just pump failure.

Causes of Cor Pulmonale

Parenchymal lung disease:

COPD (most common cause) - especially "Blue bloater" phenotype
Pulmonary fibrosis (interstitial lung disease)
Bronchiectasis, cystic fibrosis
Severe pneumonia, ARDS

Pulmonary vascular disease:

Recurrent pulmonary embolism (chronic thromboembolic pulmonary hypertension - CTEPH)
Primary pulmonary arterial hypertension (PAH)

Ventilatory disorders:

Obstructive sleep apnoea (OSA)
Obesity hypoventilation syndrome
Chest wall deformities (kyphoscoliosis)
Neuromuscular diseases

Forms:

Acute cor pulmonale: Massive PE - sudden RV dilation (RV shows only dilation, no hypertrophy)
Chronic cor pulmonale: Gradual RV hypertrophy + dilation from sustained pulmonary hypertension

History to Ask

Underlying lung disease history: COPD (smoking history), OSA (snoring, witnessed apnoea, daytime sleepiness), pulmonary fibrosis, PE
Chronic dyspnoea (progressive)
Ankle/leg swelling
Reduced exercise tolerance
Syncope on exertion (low fixed cardiac output)
Chronic productive cough (COPD)
Exertional chest pain

Symptoms / Clinical Features

Progressive exertional breathlessness
Ankle oedema
Fatigue
Reduced exercise tolerance
Cyanosis (central, from underlying lung disease)
Syncope (rare, exertional - from low cardiac output)
Symptoms of underlying lung disease (cough, wheeze, etc.)

Examination Findings

Cor pulmonale signs:

Cyanosis (central - from lung disease)
Clubbing (if bronchiectasis, fibrosis)
Raised JVP (prominent A and V waves)
Right ventricular heave (left parasternal)
Loud/palpable P2 (pulmonary hypertension)
Tricuspid regurgitation murmur (pansystolic, louder on inspiration = Carvallo's sign)
Pulmonary regurgitation murmur (Graham Steell murmur - early diastolic, pulmonary area)
Pitting peripheral oedema
Hepatomegaly (tender)
Ascites (late)

Plus signs of underlying lung disease (hyperinflation, wheeze, crackles in COPD/fibrosis)

Investigations

For cor pulmonale:

ECG: Right axis deviation, P pulmonale (tall peaked P waves >2.5mm in lead II), RV hypertrophy (tall R wave in V1), RV strain (T inversion V1-V4), RBBB; Supraventricular tachycardias (atrial flutter, AF, multifocal atrial tachycardia)
CXR: Enlarged right heart, prominent pulmonary artery knuckle, peripheral pruning of pulmonary vessels
Echo: RV hypertrophy/dilation, tricuspid regurgitation (estimate pulmonary artery systolic pressure via TR jet), septal bowing into LV
ABG: Hypoxia (PaO2 <8 kPa), hypercapnia (type 2 respiratory failure in COPD)
FBC: Polycythaemia (raised Hb, Hct)
BNP/NT-proBNP: Elevated
Spirometry/PFTs: Obstructive (COPD) or restrictive (fibrosis) pattern
CT pulmonary angiography / V/Q scan: If CTEPH suspected
Right heart catheterisation: Gold standard - confirms pulmonary hypertension (mPAP >20 mmHg at rest)
Sleep study (polysomnography): If OSA suspected

Management of Cor Pulmonale

Principle: Treat the underlying lung disease

Most important interventions:

Long-term oxygen therapy (LTOT): Most effective for reducing pulmonary vasoconstriction and improving survival; target PaO2 >8 kPa; ≥15 hours/day; indicated when PaO2 ≤7.3 kPa (or ≤8 kPa if polycythaemia/cor pulmonale present)
Smoking cessation: Slows COPD progression
Optimise respiratory mechanics: Bronchodilators, ICS, pulmonary rehabilitation (for COPD)
Non-invasive ventilation (NIV/BiPAP): For OSA, obesity hypoventilation
Venesection: For symptomatic polycythaemia (Hct >55%)
Diuretics: Furosemide for oedema (with care - avoid hypovolaemia)
Anticoagulation: If CTEPH underlying cause (warfarin/DOAC)
Pulmonary endarterectomy (PEA): For CTEPH - potentially curative
Pulmonary vasodilators (e.g., sildenafil, riociguat, bosentan): Reserved for pulmonary arterial hypertension group; not routinely used in COPD-related cor pulmonale
Lung transplantation: End-stage, selected cases

HEART FAILURE MANAGEMENT SUMMARY

Non-Pharmacological (All HF)

Salt restriction (2g Na/day)
Daily weights (report 3 lb/week gain)
Fluid restriction 1L/day
Smoking cessation, alcohol avoidance
Regular exercise, cardiac rehab
Screen and treat sleep apnoea

Pharmacological: HFrEF (EF ≤40%) - "The Fantastic Four"

All four should be prescribed in any order, wherever possible:

ARNI (sacubitril/valsartan) - or ACEi/ARB if ARNI not tolerated
Beta-blocker (carvedilol, metoprolol XL, bisoprolol) - start low, titrate slowly; only in stable patients
MRA (spironolactone or eplerenone) - aldosterone antagonist
SGLT2 inhibitor (dapagliflozin or empagliflozin) - reduces hospitalisation + mortality

Add diuretics (furosemide) for congestion/fluid overload symptoms

Device Therapy (HFrEF)

ICD: EF ≤35% (sudden cardiac death prevention)
CRT-D: LBBB + EF ≤35% + NYHA class II-IV (resynchronisation)

HFpEF (EF ≥50%)

SGLT2 inhibitors (dapagliflozin) - now have evidence
Diuretics for congestion
Treat underlying hypertension, AF, ischaemia, obesity

NYHA Functional Classification

Class	Description
I	No symptoms with ordinary activity
II	Slight limitation - comfortable at rest
III	Marked limitation - comfortable at rest only
IV	Symptoms at rest

QUICK COMPARISON: LHF vs RHF vs COR PULMONALE

Feature	LHF	RHF	Cor Pulmonale
Primary problem	LV pump failure	RV pump failure	RV failure from lung disease
Main consequence	Pulmonary congestion	Systemic congestion	Systemic congestion
Breathlessness	Prominent	Absent/mild	From lung disease
Oedema	Minimal	Ankle/leg/sacral	Ankle/leg
JVP	Normal/slightly raised	Raised	Raised
Basal crackles	Present	Absent	Absent (unless co-existing LHF)
Hepatomegaly	Absent	Present	Present
CXR	Pulmonary oedema, cardiomegaly	Right heart enlargement	Right heart + prominent PA
ECG	LVH, LBBB	RAD, RVH, P pulmonale	RAD, RVH, P pulmonale
Cardiac output	Reduced	Reduced (late)	Normal/↑ (until late)
Cause	CAD, HTN, cardiomyopathy	LHF (usually)	Lung disease

Sources: Robbins & Kumar Basic Pathology; Fuster & Hurst's The Heart 15e; Goldman-Cecil Medicine; Textbook of Family Medicine 9e

Make all suggestion

Asking for Preferences

Here is the complete combined document with all 10 conditions, with Heart Failure fully expanded into LHF, RHF, and Cor Pulmonale:

🫁 COMPLETE RESPIRATORY & RELATED CLINICAL NOTES

1. PULMONARY EMBOLISM (PE)

Definition

Obstruction of the pulmonary arterial system by blood clots, usually from DVT in the lower extremities. Part of venous thromboembolism (VTE). Two thirds of emboli lodge in large/intermediate pulmonary arteries, most often in the lower lobes.

History to Ask

Virchow's Triad: Stasis (prolonged bed rest, air travel, surgery), hypercoagulability, vascular injury
Recent surgery (esp. hip/pelvic), major trauma, prolonged immobility
Previous DVT or PE
Leg swelling, calf pain/redness
Smoking, obesity, heart disease, stroke, pregnancy
Medications: oestrogen/OCP
Inherited thrombophilia: Factor V Leiden, Protein C/S deficiency, antithrombin III deficiency, antiphospholipid syndrome, hyperhomocysteinaemia
Known malignancy

Symptoms / Clinical Features

Acute onset SOB (most common)
Pleuritic chest pain (sharp, worse on breathing)
Haemoptysis
Palpitations, tachycardia
Syncope / near-syncope
Leg swelling / pain (DVT source)
Massive PE: acute RV failure, cardiovascular collapse, shock

Examination Findings

Tachycardia (most common sign)
Tachypnoea
Hypoxia (low SpO2)
Hypotension (in massive PE)
Raised JVP
Loud P2 (right heart strain)
Calf tenderness, asymmetric leg swelling (DVT)
Pleural rub (if infarction)

Investigations

D-dimer (ELISA): <500 µg/L rules out PE in low-intermediate probability
CTPA (CT pulmonary angiography): Gold standard
ECG: Tachycardia; S1Q3T3 (S in I, Q + T inversion in III)
ABG: Low PaO2, low PaCO2 (hyperventilation)
CXR: Often normal; may show Hampton's hump, Westermark sign, wedge infarct
Echo: RV dilation/strain, McConnell's sign
V/Q scan: Alternative when CT contraindicated
Troponin: If elevated = high risk for short-term mortality
Lower limb Doppler USS: Confirm DVT
Wells Score: Clinical pre-test probability

Wells Score: DVT signs (+3), PE most likely diagnosis (+3), HR >100 (+1.5), immobilisation/surgery (+1.5), previous DVT/PE (+1.5), haemoptysis (+1), malignancy (+1)

Score ≤4 = PE unlikely | Score >4 = PE likely

Management

LMWH (enoxaparin) or UFH IV acutely
DOACs (rivaroxaban, apixaban): First-line for most patients
Warfarin (INR 2-3): If DOACs unsuitable
Duration: 3 months (provoked) vs 6+ months (unprovoked/recurrent)
Thrombolytics (alteplase): Massive PE + haemodynamic instability
Embolectomy: If thrombolytics fail/contraindicated
IVC filter: If anticoagulation contraindicated
Supplemental oxygen
VTE prophylaxis (SC heparin) as standard hospital admitting order

2. HEART FAILURE (HF)

Definition

A clinical syndrome where the heart cannot meet the metabolic requirements of the body at normal filling pressures. Central mechanism = LV remodelling driven by neurohormonal activation (RAAS + SNS).

By ejection fraction:

Type	EF	Mechanism
HFrEF	≤40%	Impaired contraction (systolic)
HFmrEF	41-49%	Mixed
HFpEF	≥50%	Impaired filling/relaxation (diastolic)
HFimpEF	EF risen >40% after Rx	Post-treatment recovery

LEFT HEART FAILURE (LHF)

Definition

Failure of the left ventricle to pump adequately → blood backs up → pulmonary congestion.

Causes

CAD / MI (most common)
Hypertension (LVH → diastolic dysfunction → HFpEF)
Valvular disease (aortic stenosis, mitral regurgitation)
Cardiomyopathy (dilated, hypertrophic)
Arrhythmias (AF)
Diabetes, anaemia, thyroid disease, alcohol

History to Ask

Dyspnoea on exertion (earliest symptom)
Orthopnoea (how many pillows?)
Paroxysmal nocturnal dyspnoea (woken from sleep gasping)
Reduced exercise tolerance
Dry cough / frothy pink sputum
Palpitations, syncope
History of MI, hypertension, valvular disease

Symptoms

Breathlessness (exertional → rest)
Orthopnoea, PND
Dry cough / frothy pink sputum (acute pulmonary oedema)
Fatigue, reduced effort tolerance
Wheeze ("cardiac asthma")
Confusion (cerebral hypoperfusion)

Examination Findings

Tachycardia, tachypnoea
Bilateral basal fine crackles
S3 gallop (third heart sound) = hallmark of volume overload
Displaced apex beat (LV dilation)
Cheyne-Stokes breathing (advanced)
Wheeze (cardiac asthma)
Cold, clammy peripheries (low output)
Peripheral oedema is NOT prominent in pure LHF

Investigations

Echo: Reduced EF, dilated LV, wall motion abnormalities
CXR - ABCDE:
- A = Alveolar oedema (bat-wing shadowing)
- B = Kerley B lines (horizontal lines at lung bases)
- C = Cardiomegaly (>50% of thoracic width)
- D = Diversion (upper lobe venous diversion)
- E = Effusions (bilateral pleural)
BNP/NT-proBNP: Elevated
ECG: LVH, AF, previous MI, LBBB
Bloods: FBC, U&E, LFTs, TFTs, glucose, lipids

RIGHT HEART FAILURE (RHF)

Definition

Failure of the right ventricle → blood backs up → systemic venous congestion.

Causes

Most common = Left heart failure (pulmonary hypertension from LHF overloads RV)
Isolated RHF causes:
- Cor pulmonale (lung disease - see below)
- Pulmonary hypertension (primary or secondary)
- Recurrent PE (CTEPH)
- RV infarction (RCA occlusion)
- Tricuspid/pulmonary valve disease
- Congenital heart disease (ASD, VSD)
- Obstructive sleep apnoea

History to Ask

Ankle/leg swelling (worse evenings, relieved by elevation)
Abdominal distension (ascites)
Right upper quadrant discomfort (hepatic congestion)
Nausea, reduced appetite (gut congestion)
Underlying lung disease (COPD, fibrosis - suggests cor pulmonale)
Prior LHF, valvular disease

Symptoms

Ankle and leg oedema (pitting, dependent)
Abdominal distension/discomfort
Nausea, anorexia
Fatigue, reduced exercise tolerance
No significant pulmonary symptoms in pure RHF - key distinguishing feature

Examination Findings

(All "systemic venous congestion" signs)

Raised JVP - key sign; hepatojugular reflux positive
Pitting peripheral oedema (ankles → legs → sacrum in bed-bound)
Hepatomegaly (tender, pulsatile in TR) = "nutmeg liver"
Ascites (portal hypertension + low albumin)
Splenomegaly (congestive)
Pleural effusion (transudates, usually right-sided or bilateral)
Parasternal RV heave
Loud P2 (pulmonary hypertension)
Tricuspid regurgitation murmur (pansystolic, louder on inspiration)
Cyanosis (late)

Investigations

Echo: RV dilation/hypertrophy, TR, elevated PA pressure
CXR: Right heart enlargement, dilated azygos vein, effusions; no pulmonary oedema
ECG: Right axis deviation, RBBB, P pulmonale (tall P waves), RV strain (T inversion V1-V4)
BNP: Elevated
Bloods: U&E (renal impairment), LFTs (raised from hepatic congestion), albumin

COR PULMONALE

Definition

RV hypertrophy and dilation - frequently causing RHF - from pulmonary hypertension arising from primary lung disease.

Key point: NOT caused by LHF or congenital heart disease - it is the lung that causes the heart to fail here.

Pathophysiology Chain

Lung disease (COPD / fibrosis / PE / OSA)
  ↓
Hypoxaemia ± hypercapnia
  ↓
Hypoxic pulmonary vasoconstriction + vascular remodelling
  ↓
↑ Pulmonary vascular resistance → Pulmonary hypertension
  ↓
↑ RV afterload (pressure overload)
  ↓
RV hypertrophy → RV dilation → RV failure (Cor Pulmonale)
  ↓
Systemic venous congestion + oedema

Additional: Polycythaemia (hypoxia → EPO → ↑ RBC mass → ↑ blood viscosity → further ↑ PVR)

Important: Unlike LHF, cardiac output is normal or increased in early/mid cor pulmonale. Oedema is largely from renal sodium retention (hypercapnia → kidneys retain Na+ and HCO3-), not just pump failure. Only late in the course does overt RHF with reduced CO occur.

Causes

Parenchymal lung disease:

COPD (most common; especially "blue bloater" phenotype)
Pulmonary fibrosis (ILD)
Bronchiectasis, cystic fibrosis
Severe pneumonia, ARDS

Pulmonary vascular disease:

Recurrent PE → CTEPH (chronic thromboembolic pulmonary hypertension)
Idiopathic/primary pulmonary arterial hypertension

Ventilatory/extrapulmonary:

Obstructive sleep apnoea (OSA)
Obesity hypoventilation syndrome
Kyphoscoliosis, neuromuscular disease

Types:

Acute cor pulmonale: Massive PE → sudden RV dilation (no hypertrophy, may even be normal-sized)
Chronic cor pulmonale: COPD/fibrosis → gradual RV hypertrophy + dilation

History to Ask

Underlying lung disease (COPD, IPF, bronchiectasis, OSA)
Smoking history (pack-years)
Progressive exertional dyspnoea
Ankle swelling
Snoring, witnessed apnoeas, daytime somnolence (OSA)
Previous PE or clotting history
Syncope on exertion (low fixed CO)

Symptoms

Progressive exertional breathlessness
Ankle/leg oedema
Fatigue, reduced exercise tolerance
Central cyanosis (from lung disease)
Symptoms of underlying lung disease (cough, wheeze, sputum)
Syncope (rare, exertional - very low CO)

Examination Findings

Central cyanosis
Clubbing (bronchiectasis, fibrosis)
Raised JVP (prominent A and V waves)
Parasternal RV heave (right heart hypertrophy)
Loud/palpable P2
Tricuspid regurgitation murmur (pansystolic, louder on inspiration = Carvallo's sign)
Graham Steell murmur (early diastolic, pulmonary area - pulmonary regurgitation from PHT)
Pitting peripheral oedema
Hepatomegaly (tender)
Ascites (late, severe)
Signs of underlying lung disease (barrel chest, wheeze, crackles)

Investigations

ECG: Right axis deviation, P pulmonale (tall P >2.5mm in II), RVH (tall R in V1), RV strain (T inversion V1-V4), RBBB; arrhythmias (AF, atrial flutter, MAT)
CXR: Enlarged right heart, prominent pulmonary artery knuckle, peripheral vascular pruning
Echo: RV hypertrophy/dilation, TR jet (estimates PASP), septal flattening/bowing into LV ("D-shape")
ABG: Hypoxia (PaO2 <8kPa), hypercapnia (type 2 RF in COPD)
FBC: Polycythaemia (raised Hb, raised haematocrit)
BNP/NT-proBNP: Elevated
Spirometry: Obstructive (COPD) or restrictive (fibrosis) pattern
CTPA / V/Q scan: If CTEPH suspected
Right heart catheterisation: Gold standard - mPAP >20 mmHg at rest confirms PHT
Sleep study (polysomnography): If OSA suspected

Management

Principle = treat underlying lung disease

LTOT (Long-term oxygen therapy): Most effective; ≥15 hrs/day; target PaO2 >8kPa; indicated when PaO2 ≤7.3kPa (or ≤8kPa if polycythaemia/cor pulmonale present) → reduces vasoconstriction + improves survival
Smoking cessation: Slows COPD progression
Optimise respiratory mechanics: Bronchodilators (LABA, LAMA), ICS, pulmonary rehab
NIV (BiPAP): For OSA, obesity hypoventilation, hypercapnic COPD
Diuretics (furosemide): Oedema relief (with care - avoid hypovolaemia)
Venesection: For symptomatic polycythaemia (Hct >55%)
Anticoagulation: For CTEPH (warfarin/DOAC)
Pulmonary endarterectomy (PEA): For CTEPH - potentially curative
Pulmonary vasodilators (sildenafil, riociguat, bosentan, macitentan): For PAH group; NOT routine in COPD cor pulmonale
Lung transplantation: End-stage selected cases

HEART FAILURE MANAGEMENT SUMMARY

"Fantastic Four" for HFrEF (all should be prescribed)

ARNI (sacubitril/valsartan) or ACEi/ARB if not tolerated
Beta-blocker (carvedilol, metoprolol XL, bisoprolol)
MRA (spironolactone/eplerenone)
SGLT2i (dapagliflozin/empagliflozin)

Add furosemide for congestion
ICD if EF ≤35%; CRT-D if LBBB + EF ≤35% + NYHA II-IV

HFpEF

SGLT2i (dapagliflozin now has evidence)
Diuretics for congestion
Treat hypertension, AF, obesity, ischaemia

NYHA Classification

I	No symptoms with ordinary activity
II	Slight limitation; comfortable at rest
III	Marked limitation; comfortable at rest only
IV	Symptoms at rest

QUICK COMPARISON: LHF vs RHF vs COR PULMONALE

Feature	LHF	RHF	Cor Pulmonale
Primary failure	LV	RV	RV (from lung)
Main consequence	Pulmonary congestion	Systemic congestion	Systemic congestion
Breathlessness	Prominent	Absent/mild	From lung disease
Oedema	Minimal	Prominent	Prominent
JVP	Mildly raised	Raised	Raised
Basal crackles	Present	Absent	Absent
Hepatomegaly	Absent	Present	Present
CXR	Pulmonary oedema, LV enlargement	RH enlargement	RH + prominent PA
ECG	LVH, LBBB, AF	RAD, RVH, P pulmonale	RAD, RVH, P pulmonale
Cardiac output	Reduced	Reduced (late)	Normal/↑ (until late)
Cause	CAD, HTN, cardiomyopathy	Usually from LHF	Lung disease

3. PLEURAL EFFUSION

Definition

Abnormal accumulation of fluid in the pleural space.

Types:

Transudate (low protein <25g/L): HF, liver cirrhosis, nephrotic syndrome, hypothyroidism
Exudate (high protein >35g/L): Pneumonia, malignancy, TB, PE, pancreatitis

Light's Criteria (exudate if ANY ONE met):

Pleural:serum protein ratio >0.5
Pleural:serum LDH ratio >0.6
Pleural LDH >2/3 upper limit of serum normal

History to Ask

Breathlessness (progressive)
Pleuritic chest pain
Cough
Fever (infection/TB)
Weight loss, night sweats (TB, malignancy)
Orthopnoea, ankle swelling (heart failure)
Alcohol, liver disease (cirrhosis)
Known malignancy
Occupation (asbestos - mesothelioma)

Symptoms

Progressive dyspnoea
Dry cough
Pleuritic chest pain
Heaviness/dullness in chest

Examination Findings (on affected side)

Stony dull to percussion (pathognomonic)
Absent/reduced breath sounds
Reduced vocal fremitus/resonance
Reduced chest expansion
Tracheal deviation AWAY from large effusion
Bronchial breathing just ABOVE effusion (compressed lung)

Investigations

CXR: Blunting of costophrenic angle (>200mL), meniscus sign, tracheal shift
USS chest: Most sensitive; guides thoracocentesis
CT chest: Reveals underlying cause (malignancy, loculation, empyema)
Pleural fluid analysis: Protein, LDH, pH, glucose, cell count, culture, cytology, AFB
Bloods: Protein, LDH, FBC, LFTs, U&E, TFTs

Management

Treat underlying cause
Thoracocentesis: Diagnostic and therapeutic
Chest drain: Large/recurrent effusions
Pleurodesis (talc): Malignant/recurrent effusions
TIPS: For hepatic hydrothorax refractory to treatment (70-80% response)
Indwelling pleural catheter: Bridge to transplant or palliation
VATS: For refractory hepatic hydrothorax - repair diaphragmatic defects

4. LIVER CIRRHOSIS

Definition

End-stage liver fibrosis with replacement of normal hepatic architecture by regenerative nodules and fibrous bands, leading to portal hypertension and liver failure.

Causes (ABCDE):

A = Alcohol (most common in West)
B = Biliary (PSC, PBC)
C = Chronic hepatitis C and B
D = NAFLD/NASH (metabolic)
E = Everything else (haemochromatosis, Wilson's, alpha-1-antitrypsin, autoimmune hepatitis)

History to Ask

Alcohol (quantity, duration)
Viral hepatitis risk factors (IV drug use, blood products, sexual contacts)
Fatigue, weakness, jaundice
Abdominal distension (ascites)
Bleeding (gums, haematemesis, PR)
Confusion (encephalopathy)
Weight loss
Pruritus
Family history (Wilson's, haemochromatosis)
Medications (methotrexate, amiodarone)

Symptoms

Fatigue, jaundice
Abdominal distension (ascites)
Ankle oedema
Easy bruising/bleeding
Pruritus (PBC)
Haematemesis/melaena (varices)
Confusion (hepatic encephalopathy)
Loss of libido

Examination Findings

Classic signs (spider and stars):

Jaundice, scleral icterus
Spider naevi (>5 = significant)
Palmar erythema
Leukonychia (white nails), Terry's nails
Dupuytren's contracture
Gynaecomastia, testicular atrophy (men)
Parotid enlargement (alcohol)
Asterixis (flapping tremor) = hepatic encephalopathy
Caput medusae (dilated periumbilical veins)
Ascites (shifting dullness, fluid thrill)
Splenomegaly, hepatomegaly (early)/small liver (late)
Fetor hepaticus

Investigations

LFTs: Raised bilirubin, ALT/AST (AST:ALT >2 = alcohol), low albumin
Coagulation: Raised PT/INR
FBC: Thrombocytopenia (hypersplenism), anaemia
U&E: Hyponatraemia, renal impairment (hepatorenal syndrome)
Viral serology: HBsAg, anti-HCV
Autoimmune: ANA, ASMA (AIH); AMA (PBC); pANCA (PSC)
Ferritin, transferrin saturation: Haemochromatosis
Caeruloplasmin/copper/slit-lamp: Wilson's disease
USS liver + Doppler: Nodular liver, portal flow, ascites, splenomegaly
Fibroscan/ARFI: Non-invasive fibrosis staging
Liver biopsy: Gold standard for staging
MELD/Child-Pugh score: Prognosis/transplant listing
OGD: Check for oesophageal varices
Ascitic tap: Protein, albumin (SAAG >11g/L = portal hypertension), cell count, culture (SBP if PMN >250)

Management

Treat underlying cause (alcohol cessation, antivirals HBV/HCV)
Ascites: Spironolactone 100mg + furosemide 40mg (5:2 ratio); Na restriction 88mmol/day; large volume paracentesis (LVP) + albumin for tense ascites
Varices: Non-selective beta-blockers (propranolol/carvedilol) prophylaxis; variceal banding + terlipressin for acute bleed
Encephalopathy: Lactulose, rifaximin; treat precipitants
SBP: IV cefotaxime (empirical); oral norfloxacin for prophylaxis
HRS: Terlipressin + albumin
Liver transplant: Definitive treatment

5. PNEUMOTHORAX

Definition

Air in the pleural space between visceral and parietal pleura.

Types:

Primary spontaneous: No lung disease; tall thin young males; subpleural blebs
Secondary spontaneous: Underlying lung disease (COPD, asthma, CF)
Tension: One-way valve - air enters, cannot exit - LIFE-THREATENING EMERGENCY
Traumatic: Rib fracture, penetrating injury, iatrogenic (central line, PPV)

History to Ask

Sudden onset unilateral chest pain (sharp, pleuritic)
Sudden breathlessness
Age, BMI (tall thin males - primary)
History of lung disease (COPD, asthma, Marfan's)
Previous pneumothorax
Trauma, recent procedures
Smoking
Mechanical ventilation

Symptoms

Acute-onset pleuritic chest pain (unilateral)
Breathlessness (proportional to size)
Tension: Rapidly deteriorating with shock, cyanosis - EMERGENCY

Examination Findings (on affected side)

Hyper-resonant to percussion (key finding)
Reduced/absent breath sounds
Reduced chest expansion
Reduced vocal fremitus

Tension PTX emergency signs:

Tracheal deviation AWAY from affected side
Hypotension, tachycardia
Raised JVP
Cyanosis
Absent breath sounds

Investigations

CXR (erect PA): Visible lung edge, absent lung markings peripherally
CT chest: More accurate for size/loculations; identifies blebs/bullae
ABG: Hypoxia in large/tension

Size (BTS): ≥2cm from lung to chest wall at apex = significant

Management

Small/stable primary (<2cm, no dyspnoea):

High-flow oxygen + observation
Review in 2-4 weeks

Larger/symptomatic:

Aspiration (2nd ICS, MCL)
Chest drain (4th/5th ICS, midaxillary line) with water seal

Tension (EMERGENCY - DO NOT WAIT FOR CXR):

Immediate needle decompression (2nd ICS, MCL, large bore cannula)
Follow with formal chest drain

Recurrent/secondary:

Chemical pleurodesis (talc)
VATS bullectomy + pleurodesis

Return to sport: ~3-4 weeks after resolution

6. PNEUMONIA

Definition

Infection of the lung parenchyma causing alveolar consolidation. Most common infectious cause of hospitalisation and death.

Classification:

CAP: Acquired outside hospital / within 48h of admission
HAP/VAP: >48h after admission / on ventilator
Atypical: Mycoplasma, Chlamydia, Legionella, viruses

Common Organisms:

Pattern	Organisms
Typical bacterial	S. pneumoniae (most common), H. influenzae, S. aureus
Atypical	Mycoplasma, Chlamydia, Legionella
Viral	Influenza, RSV, COVID-19
Aspiration	Anaerobes, Gram-negatives
Immunocompromised	PCP, Cryptococcus, Aspergillus

History to Ask

Cough (productive/dry, sputum colour, haemoptysis)
Fever, chills, rigors
Pleuritic chest pain
Dyspnoea
Rate of onset (rapid = typical; gradual = atypical)
Malaise, myalgia (atypical)
Risk factors: Age, smoking, COPD, diabetes, alcohol, immunosuppression
Recent travel (Legionella - hotel water, air conditioning)
Vaccination status
Recent hospitalisation

Symptoms

Typical (bacterial):

Abrupt onset, high fever, productive cough
Rusty sputum (pneumococcal)
Pleuritic chest pain

Atypical:

Gradual onset, low-grade fever, dry cough
Extrapulmonary features (headache, myalgia, rash, diarrhoea - Legionella)

Examination Findings (consolidation signs on affected area)

Dull to percussion
Bronchial breathing
Increased vocal resonance/fremitus
Aegophony (E-to-A change)
Tachypnoea, tachycardia, fever
Coarse crackles
Reduced breath sounds (if effusion)

Investigations

CXR: Lobar consolidation (bacterial); interstitial/bilateral (atypical/viral)
FBC: Raised WBC + neutrophilia (bacterial); lymphocytosis (viral)
CRP, ESR: Elevated
U&E: Urea for CURB-65
Blood cultures: Before antibiotics
Sputum: Gram stain + culture
Urine antigen: Pneumococcal and Legionella antigens
Cold agglutinins: Mycoplasma
ABG/SpO2: Severity
CURB-65 scoring

CURB-65 (1 point each):

Confusion
Urea >7 mmol/L
Respiratory rate ≥30/min
BP <90/60 mmHg
Age ≥65

Score	Severity	Management
0-1	Low	Outpatient
2	Moderate	Consider inpatient
3-5	Severe	Inpatient ± ICU

Management

Severity	Setting	Antibiotic
Mild	Outpatient	Amoxicillin 500mg TDS or doxycycline or clarithromycin
Moderate	Inpatient	IV co-amoxiclav + clarithromycin
Severe	ICU	Piperacillin-tazobactam + clarithromycin
Legionella	Any	Levofloxacin or azithromycin

Duration: Min 5 days; ≥48-72h afebrile
Complications: Empyema (3-5%), parapneumonic effusion, bacteraemia, AF
Prevention: Pneumococcal vaccine (revaccinate after 10yr if first given <65); influenza vaccine annually (>50yr, chronic disease)

7. ASTHMA

Definition

Chronic inflammatory airway disease with reversible bronchoconstriction from airway hyperresponsiveness. Caused by smooth muscle contraction, mucosal oedema, and excess secretions.

Atopic: Th2/IgE-mediated, allergen-driven
Non-atopic: Triggers include viral infections, cold, exercise, pollutants
Key cells: Eosinophils, mast cells, T lymphocytes (IL-4, IL-5, IL-13 are key cytokines)
Airway remodelling may add an irreversible component over time

History to Ask

Classic tetrad: Wheeze, cough (nocturnal/early morning), breathlessness, chest tightness
Triggers: Exercise, cold air, allergens (pollen, dust, animal dander), NSAIDs/aspirin, beta-blockers, stress, infections, smoke
Atopy history: Eczema, allergic rhinitis, hay fever
Family history
Occupational exposure
Diurnal variation (symptoms worse at night/early morning)
Response to bronchodilators
Previous hospitalisations, ICU admissions, intubation (severity markers)

Symptoms

Episodic wheeze
Nocturnal/morning dry cough
Chest tightness
Breathlessness
Symptoms vary with time and triggers
"Silent chest" in very severe attack (no air movement)

Examination Findings

Between attacks: Often normal

During attack:

Expiratory wheeze (polyphonic)
Prolonged expiratory phase
Tachypnoea, tachycardia
Use of accessory muscles
Hyperinflation
Reduced air entry

Severe/life-threatening:

Cannot complete sentences
SpO2 <92%, PEF <50% predicted
Silent chest (ominous)
Cyanosis, bradycardia, confusion

Investigations

Peak flow (PEFR): Reduced; >20% diurnal variation = diagnostic
Spirometry: FEV1/FVC <0.7 (obstructive); reversibility >12% + 200mL after salbutamol = asthma
Bronchial provocation (methacholine/histamine): If spirometry normal
CXR: Usually normal or hyperinflated; exclude other causes
ABG: Hypoxia; normal/rising PaCO2 in acute attack = very severe (fatigue)
FeNO: Elevated in eosinophilic asthma
Skin prick/RAST/IgE: Identify allergens in atopic asthma
Sputum eosinophils

Management

Stepwise approach (step up / step down):

SABA (salbutamol) PRN
Add ICS (beclometasone, budesonide, fluticasone)
Add LABA → combined ICS/LABA inhaler
Increase ICS; add LTRA (montelukast) or theophylline
Specialist referral; oral prednisolone; biologics (omalizumab, mepolizumab for severe eosinophilic)

Step down when controlled for 3 months

Acute Asthma:

Sit upright, high-flow O2
Salbutamol nebuliser 2.5-5mg ± ipratropium 0.5mg
Oral/IV prednisolone 40-50mg
IV magnesium sulphate 1.2-2g if severe
IV aminophylline if unresponsive
Intubation/ICU if life-threatening

Pre-exercise: Salbutamol 15-30 mins before; add montelukast/cromolyn if needed

8. LUNG CARCINOMA

Definition

Malignant tumours from bronchial/alveolar epithelium. Leading cause of cancer death worldwide. Smoking is the most important risk factor for all types.

Histological subtypes:

Non-Small Cell (NSCLC = 80%):

Type	Features
Adenocarcinoma (most common overall)	Peripheral; women/non-smokers; EGFR mutations; arises from AAH
Squamous cell	Central; smokers; cavitates; PTHrP → hypercalcaemia
Large cell	Peripheral; poorly differentiated

Small Cell (SCLC = 20%):

Central; highly aggressive; almost always metastatic at presentation
TP53 + RB mutations
Treat with chemo (surgery rarely)
Multiple paraneoplastic syndromes

History to Ask

Smoking (pack-years) - most important
Occupational: Asbestos, radon, arsenic exposure
Cough (new, persistent, changed character)
Haemoptysis
Chest pain
Progressive dyspnoea
Weight loss, anorexia, fatigue (constitutional)
Hoarse voice (RLN palsy)
Dysphagia (oesophageal compression)
Facial/arm swelling (SVC obstruction)
Bone pain (mets)
Headache, seizures (brain mets)

Symptoms / Clinical Features

Local:

Cough, haemoptysis, breathlessness
Post-obstructive pneumonia (recurrent)

Regional:

Hoarse voice (RLN palsy - left-sided tumours)
Phrenic nerve palsy (raised hemidiaphragm)
SVC syndrome (facial/arm oedema, venous distension)
Horner's syndrome (Pancoast - apex tumour): ptosis, miosis, anhidrosis, enophthalmos
Dysphagia

Metastatic:

Bone pain, pathological fracture
Headache/seizures (brain)
Hepatomegaly/jaundice (liver)

Paraneoplastic:

Cancer	Syndrome
SCLC	SIADH (hyponatraemia), Cushing's (ectopic ACTH), Lambert-Eaton, neuropathy
Squamous	Hypercalcaemia (PTHrP)
Adenocarcinoma	HPOA (hypertrophic pulmonary osteoarthropathy)
All	Clubbing, DVT/VTE

Examination Findings

Clubbing
Supraclavicular/cervical lymphadenopathy
Signs of consolidation/collapse/effusion
Horner's syndrome (apex)
SVC obstruction (non-pulsatile JVP, facial plethora, dilated chest veins)
Cachexia
Hepatomegaly, bone tenderness, focal neurology (mets)

Investigations

CXR: Hilar mass, coin lesion, consolidation, collapse, pleural effusion
CT chest/abdomen/pelvis: Staging, lymph nodes
PET-CT: Distant metastasis staging
Bronchoscopy + biopsy: Central tumours
CT-guided biopsy: Peripheral tumours
MRI head / bone scan: Metastasis staging
Bloods: FBC, LFTs, Ca2+, LDH, U&E
Spirometry: Pre-op assessment
Molecular testing: EGFR, ALK, KRAS, BRAF, RET, NTRK mutations; PD-L1 expression
EBUS/mediastinoscopy: Lymph node staging

Management

NSCLC:

Stage I-II: Surgery (lobectomy)
Stage III: Concurrent chemo-radiotherapy
Stage IV (palliative):
- EGFR+: Gefitinib, erlotinib, osimertinib
- ALK+: Crizotinib, alectinib
- PD-L1+: Pembrolizumab, nivolumab (immunotherapy)
- Otherwise: Carboplatin + paclitaxel/pemetrexed (chemo)

SCLC:

Limited stage: Chemo-radiation (cisplatin/etoposide) ± prophylactic cranial irradiation
Extensive stage: Chemo (cisplatin/etoposide) + immunotherapy (atezolizumab)

Palliative care throughout for pain and breathlessness management

9. COMMUNITY-ACQUIRED PNEUMONIA (CAP)

(Extended notes - core features covered in Pneumonia section above)

Definition

Pneumonia acquired outside hospital or within 48h of admission.

Most common cause: Streptococcus pneumoniae

Key Organisms by Context

Context	Organism
Typical community	S. pneumoniae, H. influenzae
Atypical (walking pneumonia)	Mycoplasma, Chlamydia, Legionella
Viral	Influenza, RSV, COVID-19 (~20-30%)
Aspiration	Anaerobes, Gram-negatives
Immunocompromised/HIV	PCP, Crypto, Aspergillus, atypical mycobacteria
Elderly/nursing home	Gram-negatives, S. aureus
Alcoholism	H. influenzae, anaerobes

Epidemiology Points

Hospitalisation rates: 1-2/1000 young adults → 40/1000 in >85yr
~35% of hospitalisations in patients with recent healthcare exposure
Peaks November to March (influenza season)
No pathogen confirmed in >50% of cases

Diagnosis

Clinical: Cough + fever + dyspnoea + infiltrate on CXR
CURB-65 to guide admission and severity
ABG if SpO2 <94% or CURB ≥3
Blood cultures + sputum cultures before antibiotics
Urinary Legionella and pneumococcal antigens

Antibiotic Summary

Severity (CURB-65)	Setting	Antibiotic	Duration
0-1 (mild)	Outpatient	Amoxicillin 500mg TDS or doxycycline or clarithromycin	5 days
2 (moderate)	Inpatient	IV co-amoxiclav + clarithromycin	5-7 days
3-5 (severe)	ICU	Piperacillin-tazobactam + clarithromycin	7-10 days
Legionella	Any	Levofloxacin or azithromycin	7-14 days

Complications: Empyema (3-5%), parapneumonic effusion, bacteraemia, AF (20-25%), myocardial ischaemia

Mortality: ~6% during hospitalisation; ~15% by 1 month

Prevention:

Pneumococcal vaccine (revaccinate after 10yr if first given <65)
Influenza vaccine annually (age >50 or chronic disease)

10. COPD (Chronic Obstructive Pulmonary Disease)

Definition

Progressive, largely irreversible airflow obstruction = mixture of:

Emphysema: Destruction of alveolar walls distal to terminal bronchioles; loss of elastic recoil; enlarged air spaces
Chronic bronchitis: Productive cough ≥3 months in ≥2 consecutive years

Key pathology:

Smoking = #1 risk factor (90%)
Emphysema: Neutrophil proteases destroy elastic tissue
- Centriacinar = smoking-related
- Panacinar = alpha-1-antitrypsin deficiency
Chronic bronchitis: Mucous gland hyperplasia, goblet cell metaplasia, small airway inflammation
Can lead to cor pulmonale (see Heart Failure section above)
FEV1/FVC <0.7 post-bronchodilator = diagnostic; does NOT fully reverse

History to Ask

Smoking history (pack-years) - most critical
Progressive dyspnoea (initially exertional, then at rest)
Chronic productive cough (morning worse)
Sputum: amount, colour, change in character
Wheeze
Recurrent chest infections
Occupational dust/fumes exposure
Alpha-1-antitrypsin deficiency (young non-smoker, family history)
MRC dyspnoea scale (1-5)
Previous hospitalisations, oxygen use
Current medications

Symptoms

Stable COPD:

Progressive exertional dyspnoea
Chronic productive cough
Wheeze

"Pink puffer" (emphysema):

Thin, breathless, pursed lip breathing
Barrel chest
Uses accessory muscles
Relatively normal PaO2 (hyperventilates to compensate)

"Blue bloater" (chronic bronchitis):

Overweight, cyanotic
Productive cough
Hypoxaemia + hypercapnia
Peripheral oedema (cor pulmonale)
More prone to overt pulmonary vascular disease

Acute Exacerbation (AECOPD) - Anthonisen criteria:

Increased dyspnoea
Increased sputum production
Increased sputum purulence
Triggered by: S. pneumoniae, H. influenzae, Moraxella, viruses

Examination Findings

Hyperinflated "barrel chest" (increased AP diameter)
Reduced chest expansion
Hyper-resonant percussion
Reduced breath sounds
Expiratory wheeze
Prolonged expiratory phase
Accessory muscle use (sternomastoid, intercostals)
Pursed lip breathing, tracheal tug
Central cyanosis (severe)
Cor pulmonale signs: Peripheral oedema, raised JVP, loud P2, RV heave

Investigations

Spirometry (post-bronchodilator): FEV1/FVC <0.7 = diagnosis

GOLD Staging by FEV1 % predicted:

Stage	FEV1	Severity
GOLD 1	≥80%	Mild
GOLD 2	50-79%	Moderate
GOLD 3	30-49%	Severe
GOLD 4	<30%	Very severe

CXR: Hyperinflation, flat diaphragm, increased retrosternal space, bullae, tubular heart
CT chest: Emphysema distribution, bullae, exclude malignancy
ABG: Hypoxia ± hypercapnia; Type 2 RF (low PaO2 + high PaCO2)
FBC: Polycythaemia (secondary to hypoxia)
Alpha-1-antitrypsin levels: Young non-smoker, panacinar emphysema
ECG/Echo: Cor pulmonale assessment
6-minute walk test: Functional assessment

Management

Non-pharmacological:

Smoking cessation - single most effective intervention (slows decline)
Pulmonary rehabilitation
Influenza + pneumococcal vaccination
Nutritional support
LTOT: PaO2 ≤7.3 kPa; ≥15 hours/day; improves survival in COPD

Inhaler step-up:

SABA (salbutamol) and/or SAMA (ipratropium) PRN
Regular LABA (salmeterol) and/or LAMA (tiotropium) - cornerstone of maintenance
Add ICS (in frequent exacerbators or eosinophilia)

Triple therapy (ICS + LABA + LAMA): Best for frequent exacerbators

Oral medications:

Roflumilast (PDE4 inhibitor): Severe COPD + chronic bronchitis + frequent exacerbations
Prophylactic azithromycin: Reduce exacerbation frequency
Mucolytics (carbocysteine): Chronic productive cough

Acute Exacerbation (AECOPD):

Controlled O2: Target SpO2 88-92% (hypercapnic drive - do NOT over-oxygenate)
Nebulised salbutamol + ipratropium
Oral prednisolone 30-40mg x 5 days
Antibiotics (if purulent sputum/sepsis): Amoxicillin, doxycycline, or co-amoxiclav
NIV (BiPAP): Type 2 RF persisting (pH <7.35)
Intubation: If NIV fails

🔑 QUICK REFERENCE COMPARISON TABLES

Lung Examination by Condition

Condition	Percussion	Breath Sounds	Vocal Resonance	Added Sounds
Pneumothorax	Hyper-resonant	Absent	Absent	None
Pleural effusion	Stony dull	Absent/reduced	Reduced	Bronchial above effusion
Consolidation/Pneumonia	Dull	Bronchial	Increased + aegophony	Crackles
Asthma/COPD	Resonant/Hyperresonant	Reduced	Normal	Wheeze (expiratory)
Normal	Resonant	Vesicular	Normal	None

Obstructive vs Restrictive

	Obstructive (Asthma/COPD)	Restrictive (Fibrosis)
FEV1	↓	↓
FVC	Normal/↓	↓↓
FEV1/FVC	<0.7	Normal or ↑
TLC	Normal/↑	↓

Transudate vs Exudate

	Transudate	Exudate
Protein	<25 g/L	>35 g/L
LDH	Low	High
Colour	Clear/straw	Turbid
Causes	HF, cirrhosis, nephrotic	Infection, TB, malignancy, PE

CURB-65 Quick Ref

Score	Action
0-1	Home treatment
2	Consider admission
3+	Admit; ICU if 4-5

Sources: Murray & Nadel's Textbook of Respiratory Medicine; Textbook of Family Medicine 9e; Robbins & Kumar Basic Pathology; Fuster & Hurst's The Heart 15e; Goldman-Cecil Medicine; Bailey & Love's Surgery 28e; Brenner & Rector's The Kidney

Create a printable study guide / PDF reference card with mnemonics

Reading File

Running Command

ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace && echo "workspace ready"

Running Command

mkdir -p /tmp/workspace/respiratory-guide && cat > /tmp/workspace/respiratory-guide/build_pdf.py << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import mm, cm from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, KeepTogether, PageBreak) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY from reportlab.platypus import BaseDocTemplate, Frame, PageTemplate # ── Colour palette ────────────────────────────────────────────────────────── C_NAVY = colors.HexColor('#1a2e4a') C_TEAL = colors.HexColor('#1a6b6b') C_RED = colors.HexColor('#c0392b') C_ORANGE = colors.HexColor('#d35400') C_GREEN = colors.HexColor('#1a7a4a') C_PURPLE = colors.HexColor('#6c3483') C_BLUE = colors.HexColor('#1565c0') C_DARK = colors.HexColor('#2c3e50') C_LIGHT_BLUE = colors.HexColor('#e8f4fd') C_LIGHT_GREEN = colors.HexColor('#e8f8f0') C_LIGHT_RED = colors.HexColor('#fdecea') C_LIGHT_GREY = colors.HexColor('#f5f5f5') C_LIGHT_YELLOW= colors.HexColor('#fffde7') C_LIGHT_PURPLE= colors.HexColor('#f3e5f5') C_LIGHT_TEAL = colors.HexColor('#e0f2f1') C_LIGHT_ORANGE= colors.HexColor('#fff3e0') C_WHITE = colors.white C_MUTED = colors.HexColor('#666666') PAGE_W, PAGE_H = A4 MARGIN = 14 * mm doc = BaseDocTemplate( '/tmp/workspace/respiratory-guide/Respiratory_Study_Guide.pdf', pagesize=A4, leftMargin=MARGIN, rightMargin=MARGIN, topMargin=MARGIN, bottomMargin=MARGIN, ) # Full-width frame frame = Frame(MARGIN, MARGIN, PAGE_W - 2*MARGIN, PAGE_H - 2*MARGIN, id='normal', leftPadding=0, rightPadding=0, topPadding=0, bottomPadding=0) def draw_page(canvas, doc): canvas.saveState() # Header bar canvas.setFillColor(C_NAVY) canvas.rect(0, PAGE_H - 10*mm, PAGE_W, 10*mm, fill=1, stroke=0) canvas.setFillColor(C_WHITE) canvas.setFont('Helvetica-Bold', 8) canvas.drawCentredString(PAGE_W/2, PAGE_H - 7*mm, '🫁 RESPIRATORY & RELATED CONDITIONS — CLINICAL STUDY GUIDE') # Footer bar canvas.setFillColor(C_NAVY) canvas.rect(0, 0, PAGE_W, 8*mm, fill=1, stroke=0) canvas.setFillColor(C_WHITE) canvas.setFont('Helvetica', 7) canvas.drawString(MARGIN, 3*mm, 'Sources: Murray & Nadel • Goldman-Cecil • Robbins Pathology • Fuster & Hurst • Bailey & Love') canvas.drawRightString(PAGE_W - MARGIN, 3*mm, f'Page {doc.page}') canvas.restoreState() page_template = PageTemplate(id='main', frames=[frame], onPage=draw_page) doc.addPageTemplates([page_template]) # ── Styles ─────────────────────────────────────────────────────────────────── def S(name, **kw): base = getSampleStyleSheet()['Normal'] return ParagraphStyle(name, parent=base, **kw) sTitle = S('sTitle', fontSize=20, textColor=C_WHITE, alignment=TA_CENTER, fontName='Helvetica-Bold', leading=24, spaceAfter=0) sSec = S('sSec', fontSize=11, textColor=C_WHITE, fontName='Helvetica-Bold', leading=14, spaceAfter=0, spaceBefore=0) sSubsec = S('sSubsec', fontSize=9, textColor=C_NAVY, fontName='Helvetica-Bold', leading=12, spaceAfter=1, spaceBefore=3) sBody = S('sBody', fontSize=7.5, textColor=C_DARK, fontName='Helvetica', leading=10, spaceAfter=1) sBullet = S('sBullet', fontSize=7.5, textColor=C_DARK, fontName='Helvetica', leading=10, leftIndent=8, spaceAfter=0.5, bulletIndent=2) sMnem = S('sMnem', fontSize=8.5, textColor=C_NAVY, fontName='Helvetica-Bold', leading=11, spaceAfter=1) sMnemBody = S('sMnemBody', fontSize=7.5, textColor=C_DARK, fontName='Helvetica', leading=10, leftIndent=12, spaceAfter=0.5) sWarning = S('sWarning', fontSize=7.5, textColor=C_RED, fontName='Helvetica-BoldOblique', leading=10, spaceAfter=1) sCaption = S('sCaption', fontSize=7, textColor=C_MUTED, fontName='Helvetica-Oblique', leading=9, alignment=TA_CENTER) # ── Helper builders ────────────────────────────────────────────────────────── def section_header(title, color=C_TEAL, icon=''): full = f'{icon} {title}' if icon else title t = Table([[Paragraph(full, sSec)]], colWidths=[PAGE_W - 2*MARGIN]) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,-1), color), ('TOPPADDING', (0,0), (-1,-1), 4), ('BOTTOMPADDING', (0,0), (-1,-1), 4), ('LEFTPADDING', (0,0), (-1,-1), 8), ('RIGHTPADDING', (0,0), (-1,-1), 8), ('ROUNDEDCORNERS', [3]), ])) return t def subsection(title): return Paragraph(f'▸ {title}', sSubsec) def bullet(text): return Paragraph(f'• {text}', sBullet) def body(text): return Paragraph(text, sBody) def mnem_box(title, items, bg=C_LIGHT_BLUE, border=C_BLUE): rows = [[Paragraph(f'🔤 {title}', sMnem)]] for item in items: rows.append([Paragraph(item, sMnemBody)]) t = Table(rows, colWidths=[PAGE_W - 2*MARGIN - 4*mm]) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (0,0), border), ('TEXTCOLOR', (0,0), (0,0), C_WHITE), ('BACKGROUND', (0,1), (-1,-1), bg), ('BOX', (0,0), (-1,-1), 0.8, border), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 6), ('RIGHTPADDING', (0,0), (-1,-1), 6), ])) return t def alert_box(text, bg=C_LIGHT_RED, border=C_RED): t = Table([[Paragraph(f'⚠ {text}', sWarning)]], colWidths=[PAGE_W - 2*MARGIN - 4*mm]) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,-1), bg), ('BOX', (0,0), (-1,-1), 1, border), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 6), ('RIGHTPADDING', (0,0), (-1,-1), 6), ])) return t def info_box(text, bg=C_LIGHT_GREEN, border=C_GREEN): t = Table([[Paragraph(f'✓ {text}', S('ib', fontSize=7.5, textColor=C_GREEN, fontName='Helvetica-Bold', leading=10))]], colWidths=[PAGE_W - 2*MARGIN - 4*mm]) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,-1), bg), ('BOX', (0,0), (-1,-1), 1, border), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 6), ('RIGHTPADDING', (0,0), (-1,-1), 6), ])) return t def two_col(left_items, right_items, left_title='', right_title='', lbg=C_LIGHT_BLUE, rbg=C_LIGHT_GREEN): col_w = (PAGE_W - 2*MARGIN - 3*mm) / 2 left_rows = [] right_rows = [] if left_title: left_rows.append(Paragraph(f'{left_title}', sSubsec)) if right_title: right_rows.append(Paragraph(f'{right_title}', sSubsec)) for item in left_items: left_rows.append(Paragraph(f'• {item}', sBullet)) for item in right_items: right_rows.append(Paragraph(f'• {item}', sBullet)) left_cell = left_rows right_cell = right_rows t = Table([[left_cell, right_cell]], colWidths=[col_w, col_w]) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (0,-1), lbg), ('BACKGROUND', (1,0), (1,-1), rbg), ('VALIGN', (0,0), (-1,-1), 'TOP'), ('TOPPADDING', (0,0), (-1,-1), 5), ('BOTTOMPADDING', (0,0), (-1,-1), 5), ('LEFTPADDING', (0,0), (-1,-1), 6), ('RIGHTPADDING', (0,0), (-1,-1), 6), ('BOX', (0,0), (0,-1), 0.5, C_BLUE), ('BOX', (1,0), (1,-1), 0.5, C_GREEN), ('LINEAFTER', (0,0), (0,-1), 1, C_MUTED), ])) return t def simple_table(headers, rows, col_widths=None, header_color=C_NAVY): usable = PAGE_W - 2*MARGIN if col_widths is None: col_widths = [usable / len(headers)] * len(headers) data = [[Paragraph(f'{h}', S('th', fontSize=7, textColor=C_WHITE, fontName='Helvetica-Bold', leading=9)) for h in headers]] for row in rows: data.append([Paragraph(str(c), S('td', fontSize=7, textColor=C_DARK, fontName='Helvetica', leading=9)) for c in row]) t = Table(data, colWidths=col_widths, repeatRows=1) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,0), header_color), ('ROWBACKGROUNDS', (0,1), (-1,-1), [C_WHITE, C_LIGHT_GREY]), ('GRID', (0,0), (-1,-1), 0.3, colors.HexColor('#cccccc')), ('VALIGN',(0,0), (-1,-1), 'TOP'), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 5), ('RIGHTPADDING', (0,0), (-1,-1), 5), ])) return t SP = lambda n=4: Spacer(1, n) HR = lambda: HRFlowable(width='100%', thickness=0.5, color=colors.HexColor('#dddddd'), spaceAfter=3, spaceBefore=3) # ═══════════════════════════════════════════════════════════════════════════ # CONTENT BUILDER # ═══════════════════════════════════════════════════════════════════════════ story = [] # ── COVER ─────────────────────────────────────────────────────────────────── cover_title = Table( [[Paragraph('RESPIRATORY & RELATED CONDITIONS', S('ct', fontSize=22, textColor=C_WHITE, fontName='Helvetica-Bold', alignment=TA_CENTER, leading=26))], [Paragraph('Complete Clinical Study Guide with Mnemonics', S('cs', fontSize=13, textColor=colors.HexColor('#a8d8ea'), fontName='Helvetica-Oblique', alignment=TA_CENTER, leading=16))], [Spacer(1, 6)], [Paragraph('PE • Heart Failure (LHF / RHF / Cor Pulmonale) • Pleural Effusion • Cirrhosis', S('cd', fontSize=9, textColor=colors.HexColor('#ccddee'), fontName='Helvetica', alignment=TA_CENTER, leading=12))], [Paragraph('Pneumothorax • Pneumonia • CAP • Asthma • Lung Ca • COPD', S('cd2', fontSize=9, textColor=colors.HexColor('#ccddee'), fontName='Helvetica', alignment=TA_CENTER, leading=12))], ], colWidths=[PAGE_W - 2*MARGIN] ) cover_title.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,-1), C_NAVY), ('TOPPADDING', (0,0), (-1,-1), 12), ('BOTTOMPADDING', (0,0), (-1,-1), 12), ('LEFTPADDING', (0,0), (-1,-1), 20), ('RIGHTPADDING', (0,0), (-1,-1), 20), ('ROUNDEDCORNERS', [5]), ])) story += [SP(30), cover_title, SP(12)] # Quick legend legend_data = [ ['🔤 Mnemonic box', '⚠ Emergency / Warning', '✓ Key point / Tip', '▸ Category heading'], ] leg_t = Table(legend_data, colWidths=[(PAGE_W-2*MARGIN)/4]*4) leg_t.setStyle(TableStyle([ ('FONTSIZE',(0,0),(-1,-1),7.5), ('FONTNAME',(0,0),(-1,-1),'Helvetica'), ('TEXTCOLOR',(0,0),(-1,-1),C_MUTED), ('ALIGN',(0,0),(-1,-1),'CENTER'), ('TOPPADDING',(0,0),(-1,-1),3), ('BOTTOMPADDING',(0,0),(-1,-1),3), ('BOX',(0,0),(-1,-1),0.5,C_MUTED), ('GRID',(0,0),(-1,-1),0.3,C_LIGHT_GREY), ])) story += [leg_t, SP(8)] # ═══════════════════════════════════════════════════════════════════════════ # 1. PULMONARY EMBOLISM # ═══════════════════════════════════════════════════════════════════════════ story += [KeepTogether([section_header('1. PULMONARY EMBOLISM (PE)', C_RED, '🩸'), SP(4)])] story += [mnem_box("VIRCHOW'S TRIAD — causes of DVT/PE", ['V = Venostasis (immobility, surgery, long flights)', 'I = Injury to vessel wall (trauma, surgery)', 'R = hypercoagulability (cancer, OCP, pregnancy, thrombophilia)'], bg=C_LIGHT_RED, border=C_RED), SP(4)] story += [mnem_box('RISK FACTORS mnemonic — "STOP CLOTS"', ['S = Surgery (esp. hip/pelvic)', 'T = Trauma / Travel (prolonged sitting)', 'O = OCP / Oral oestrogens', 'P = Pregnancy / Puerperium', 'C = Cancer (hypercoagulable)', 'L = Long immobility / Bed rest', 'O = Obesity', 'T = Thrombophilia (Factor V Leiden, Protein C/S deficiency, ATIII deficiency)', 'S = Stroke / Heart disease / Burns'], bg=C_LIGHT_RED, border=C_RED), SP(4)] story += [ two_col( left_title='SYMPTOMS', right_title='EXAMINATION', left_items=[ 'Acute-onset SOB (most common)', 'Pleuritic chest pain', 'Haemoptysis', 'Palpitations', 'Syncope / near-syncope', 'Leg swelling/pain (DVT source)', ], right_items=[ 'Tachycardia (most common sign)', 'Tachypnoea, hypoxia', 'Hypotension (massive PE)', 'Raised JVP', 'Loud P2', 'Calf tenderness, asymmetric leg swelling', 'Pleural rub (if infarction)', ], lbg=C_LIGHT_RED, rbg=C_LIGHT_YELLOW ), SP(4) ] story += [mnem_box("INVESTIGATIONS — Wells Score variables", ['DVT signs/symptoms → +3', 'PE most likely diagnosis → +3', 'Heart rate > 100 → +1.5', 'Immobilisation / surgery in last 4 weeks → +1.5', 'Previous DVT or PE → +1.5', 'Haemoptysis → +1', 'Malignancy → +1', '━━ ≤4 = PE UNLIKELY (D-dimer) | >4 = PE LIKELY (CTPA) ━━'], bg=C_LIGHT_YELLOW, border=C_ORANGE), SP(4)] story += [ simple_table( ['Investigation', 'Finding / Purpose'], [['D-dimer (ELISA)', '<500 µg/L rules out PE in low-intermediate probability'], ['CTPA', 'Gold standard — confirms PE; may also show DVT'], ['ECG', 'Tachycardia; S1Q3T3 (S in I, Q + T inversion in III)'], ['ABG', 'Low PaO2, low PaCO2 (hyperventilation)'], ['CXR', "Often normal; Hampton's hump / Westermark sign"], ['Echo', 'RV dilation, McConnell\'s sign'], ['Troponin', 'Raised = high risk short-term mortality'], ['Lower limb Doppler USS', 'Confirm DVT source']], col_widths=[80*mm, PAGE_W - 2*MARGIN - 80*mm] ), SP(4) ] story += [mnem_box('MANAGEMENT — "HATE clots"', ['H = Heparin (LMWH/UFH) acutely, then DOACs (rivaroxaban/apixaban) first-line', 'A = Anticoagulation duration: 3 months provoked; 6+ months unprovoked', 'T = Thrombolytics (alteplase) for massive PE + haemodynamic instability', 'E = Embolectomy (surgical/catheter) if thrombolytics fail'], bg=C_LIGHT_RED, border=C_RED), SP(4)] story += [alert_box('MASSIVE PE = Shock + hypotension. Thrombolytics or embolectomy. Do NOT delay!'), SP(6)] # ═══════════════════════════════════════════════════════════════════════════ # 2. HEART FAILURE # ═══════════════════════════════════════════════════════════════════════════ story += [PageBreak()] story += [KeepTogether([section_header('2. HEART FAILURE — LHF / RHF / COR PULMONALE', C_BLUE, '❤'), SP(4)])] story += [mnem_box("LHF CAUSES — 'CHAV MADS'", ['C = CAD / MI (most common)', 'H = Hypertension', 'A = Arrhythmias (AF)', 'V = Valvular disease', 'M = Myocarditis / Cardiomyopathy', 'A = Anaemia / Alcohol', 'D = Diabetes / Drugs (cardiotoxic chemo)', 'S = Structural (congenital)'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(4)] story += [ two_col( left_title='LHF SYMPTOMS (Pulmonary)', right_title='RHF SYMPTOMS (Systemic)', left_items=[ 'Dyspnoea on exertion (first)', 'Orthopnoea (ask no. of pillows)', 'Paroxysmal nocturnal dyspnoea', 'Dry cough / frothy pink sputum', '"Cardiac asthma" (wheeze)', 'Fatigue, cold peripheries', ], right_items=[ 'Ankle/leg oedema (pitting, dependent)', 'Abdominal distension (ascites)', 'RUQ discomfort (hepatomegaly)', 'Nausea, anorexia (gut congestion)', 'Fatigue', 'NO pulmonary symptoms (pure RHF)', ], lbg=C_LIGHT_BLUE, rbg=C_LIGHT_GREEN ), SP(4) ] story += [ two_col( left_title='LHF EXAMINATION', right_title='RHF EXAMINATION', left_items=[ 'S3 gallop ← hallmark', 'Bibasal crackles', 'Displaced apex beat', 'Tachycardia, tachypnoea', 'Cheyne-Stokes breathing (late)', ], right_items=[ 'Raised JVP ← hallmark', 'Pitting peripheral oedema', 'Hepatomegaly (nutmeg liver)', 'Ascites, splenomegaly', 'Parasternal RV heave, loud P2', 'Tricuspid regurgitation murmur', ], lbg=C_LIGHT_BLUE, rbg=C_LIGHT_GREEN ), SP(4) ] story += [mnem_box("CXR in LHF — 'ABCDE'", ['A = Alveolar oedema (bat-wing shadowing)', 'B = Kerley B lines (horizontal lines at lung bases)', 'C = Cardiomegaly (>50% of thoracic width)', 'D = Diversion of blood flow to upper lobes', 'E = Effusions (bilateral pleural)'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(4)] # COR PULMONALE BOX cp_items = [ Paragraph('COR PULMONALE = RV hypertrophy/failure FROM lung disease (not LHF)', S('cpH', fontSize=8, textColor=C_NAVY, fontName='Helvetica-Bold', leading=11)), Paragraph('Pathophysiology chain:', sSubsec), Paragraph('Lung disease → Hypoxaemia → Pulmonary vasoconstriction → Pulmonary hypertension → ↑ RV afterload → RV hypertrophy → RV dilation/failure', sBody), SP(3), Paragraph('Common causes: COPD (most common), Pulmonary fibrosis, Recurrent PE (CTEPH), Obstructive sleep apnoea, Kyphoscoliosis', sBody), SP(3), Paragraph('KEY DIFFERENCE: Cardiac output is NORMAL or INCREASED early in cor pulmonale (unlike LHF). Oedema = renal Na retention from hypercapnia, not just pump failure.', S('cpK', fontSize=7.5, textColor=C_RED, fontName='Helvetica-Bold', leading=10)), SP(3), Paragraph('ECG: Right axis deviation • P pulmonale • RVH • T inversion V1-V4 • RBBB', sBody), Paragraph('Echo: RV hypertrophy/dilation • TR jet • Septal D-shape', sBody), Paragraph('ABG: Type 2 RF (low PaO2, high PaCO2) in COPD-related cor pulmonale', sBody), ] cp_table = Table([[cp_items]], colWidths=[PAGE_W - 2*MARGIN - 4*mm]) cp_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,-1), C_LIGHT_TEAL), ('BOX', (0,0), (-1,-1), 1.5, C_TEAL), ('TOPPADDING', (0,0), (-1,-1), 8), ('BOTTOMPADDING', (0,0), (-1,-1), 8), ('LEFTPADDING', (0,0), (-1,-1), 8), ('RIGHTPADDING', (0,0), (-1,-1), 8), ])) story += [cp_table, SP(4)] story += [mnem_box("HFrEF TREATMENT — 'The Fantastic Four' (+ Diuretics)", ['1. ARNI (sacubitril/valsartan) or ACEi/ARB if not tolerated', '2. Beta-blocker (carvedilol / metoprolol XL / bisoprolol) — only in STABLE patients', '3. MRA / Aldosterone antagonist (spironolactone / eplerenone)', '4. SGLT2 inhibitor (dapagliflozin / empagliflozin) — reduces hospitalisation + mortality', '+ Furosemide for congestion', '+ ICD if EF ≤35% | CRT-D if LBBB + EF ≤35% + NYHA II-IV'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(4)] story += [mnem_box("COR PULMONALE MANAGEMENT — 'LTOT SAVES'", ['L = LTOT (Long-term O2 therapy) — most effective; ≥15h/day; PaO2 ≤7.3kPa; reduces vasoconstriction', 'T = Treat underlying lung disease (COPD optimisation, NIV for OSA)', 'O = Optimise inhaler therapy (LABA + LAMA ± ICS for COPD)', 'T = Trim blood (Venesection for polycythaemia, Hct >55%)', 'S = Smoking cessation', 'A = Anticoagulation if CTEPH (± pulmonary endarterectomy)', 'V = Vasodilators (sildenafil/bosentan) for PAH group only — NOT routine COPD', 'E = Eliminate fluid overload (diuretics — use carefully)', 'S = Surgery (lung transplant for end-stage)'], bg=C_LIGHT_TEAL, border=C_TEAL), SP(4)] # Comparison table LHF vs RHF vs Cor Pulmonale story += [subsection('Quick Comparison: LHF vs RHF vs Cor Pulmonale'), SP(2)] story += [ simple_table( ['Feature', 'LHF', 'RHF', 'Cor Pulmonale'], [['Primary failure', 'LV', 'RV', 'RV (from lung)'], ['Main consequence', 'Pulmonary congestion', 'Systemic congestion', 'Systemic congestion'], ['Breathlessness', 'Prominent (PND, orthopnoea)', 'Absent/mild', 'From lung disease'], ['Oedema', 'Minimal', 'Prominent pitting', 'Prominent pitting'], ['JVP', 'Mildly raised', 'Raised', 'Raised'], ['Basal crackles', 'Present', 'Absent', 'Absent'], ['Hepatomegaly', 'Absent', 'Present', 'Present'], ['Cardiac output', 'Reduced', 'Reduced (late)', 'Normal/↑ (until late)'], ['NYHA / EF', 'HFrEF ≤40% / HFpEF ≥50%', 'Depends on cause', 'RV function by echo'], ['Cause', 'CAD, HTN, CM', 'Usually from LHF', 'Lung disease']], col_widths=[45*mm, 42*mm, 42*mm, 42*mm], header_color=C_BLUE ), SP(6) ] # NYHA story += [subsection('NYHA Functional Classification'), SP(2)] story += [ simple_table( ['Class', 'Description'], [['I', 'No symptoms with ordinary activity'], ['II', 'Slight limitation — comfortable at rest'], ['III', 'Marked limitation — comfortable at rest only'], ['IV', 'Symptoms at rest']], col_widths=[20*mm, PAGE_W - 2*MARGIN - 20*mm], header_color=C_BLUE ), SP(6) ] # ═══════════════════════════════════════════════════════════════════════════ # 3. PLEURAL EFFUSION # ═══════════════════════════════════════════════════════════════════════════ story += [PageBreak()] story += [KeepTogether([section_header('3. PLEURAL EFFUSION', colors.HexColor('#5d4037'), '💧'), SP(4)])] story += [mnem_box("TRANSUDATE causes — 'CHIN'", ['C = Cardiac failure (heart failure)', 'H = Hepatic failure (cirrhosis / hepatic hydrothorax)', 'I = renal Impairment (nephrotic syndrome / uraemia)', 'N = No albumin / hypothyroidism'], bg=C_LIGHT_YELLOW, border=C_ORANGE), SP(3)] story += [mnem_box("EXUDATE causes — 'PIMP'", ['P = Pneumonia (parapneumonic effusion / empyema)', 'I = Infections (TB — lymphocytic exudate)', 'M = Malignancy (lung, mesothelioma, breast, lymphoma)', 'P = PE / Pancreatitis / Rheumatoid / SLE'], bg=C_LIGHT_YELLOW, border=C_ORANGE), SP(3)] story += [mnem_box("LIGHT'S CRITERIA — Exudate if ANY ONE met", ['1. Pleural protein / Serum protein > 0.5', '2. Pleural LDH / Serum LDH > 0.6', '3. Pleural LDH > 2/3 upper limit of normal serum LDH'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(4)] story += [ two_col( left_title='EXAMINATION (affected side)', right_title='INVESTIGATIONS', left_items=[ 'STONY DULL percussion ← pathognomonic', 'Absent / reduced breath sounds', 'Reduced vocal resonance', 'Reduced chest expansion', 'Tracheal deviation AWAY (large)', 'Bronchial breathing just ABOVE effusion', ], right_items=[ 'CXR: blunting costophrenic angle (>200mL)', 'USS: most sensitive; guides tap', 'CT: reveals cause (malignancy, loculation)', 'Pleural tap: protein, LDH, pH, glucose,', ' cell count, culture, cytology, AFB', 'Bloods: protein, LDH, FBC, LFTs, U&E', ], lbg=C_LIGHT_YELLOW, rbg=C_LIGHT_BLUE ), SP(4) ] story += [info_box('Management: Treat cause. Thoracocentesis (diagnostic & therapeutic). Chest drain (large/recurrent). Pleurodesis (talc) for malignant/recurrent. TIPS for hepatic hydrothorax (70-80% response).'), SP(6)] # ═══════════════════════════════════════════════════════════════════════════ # 4. LIVER CIRRHOSIS # ═══════════════════════════════════════════════════════════════════════════ story += [KeepTogether([section_header('4. LIVER CIRRHOSIS', colors.HexColor('#795548'), '🫀'), SP(4)])] story += [mnem_box("CAUSES — 'ABCDE'", ['A = Alcohol (most common in Western world)', 'B = Biliary (PSC, PBC)', 'C = Chronic hepatitis C and B', 'D = NAFLD / NASH (metabolic — most common globally)', 'E = Everything else (Haemochromatosis, Wilson\'s, Alpha-1-AT, Autoimmune)'], bg=colors.HexColor('#fef9e7'), border=colors.HexColor('#795548')), SP(3)] story += [mnem_box("SIGNS mnemonic — 'SPIDER CLAWS'", ['S = Spider naevi (>5 significant)', 'P = Palmar erythema', 'I = Icterus (jaundice)', 'D = Dupuytren\'s contracture', 'E = Encephalopathy (asterixis — flapping tremor)', 'R = Raised JVP / Renal failure (hepatorenal syndrome)', 'C = Caput medusae', 'L = Leukonychia (white nails)', 'A = Ascites (shifting dullness, fluid thrill)', 'W = Wasted muscles (cachexia) / Wasted testes (testicular atrophy)', 'S = Splenomegaly / Spiders / Fetor hepaticus'], bg=colors.HexColor('#fef9e7'), border=colors.HexColor('#795548')), SP(4)] story += [ simple_table( ['Complication', 'Management'], [['Ascites', 'Spironolactone 100mg + furosemide 40mg (5:2 ratio) + Na restriction. LVP + albumin for tense ascites.'], ['Variceal bleeding', 'Terlipressin IV + prophylactic antibiotics + endoscopic banding. Propranolol for primary/secondary prophylaxis.'], ['Hepatic encephalopathy', 'Lactulose (1st line) + Rifaximin (2nd line). Identify + treat precipitants.'], ['SBP (PMN >250)', 'IV Cefotaxime empirically. Prophylaxis: oral norfloxacin.'], ['Hepatorenal syndrome', 'Terlipressin + albumin infusion.'], ['End-stage disease', 'Liver transplantation — definitive treatment.']], col_widths=[50*mm, PAGE_W - 2*MARGIN - 50*mm], header_color=colors.HexColor('#795548') ), SP(4) ] story += [ simple_table( ['Lab', 'What it tells you'], [['Bilirubin ↑, albumin ↓, PT ↑', 'Liver synthetic function failing'], ['AST:ALT ratio > 2', 'Suggests alcoholic liver disease'], ['SAAG > 11 g/L', 'Portal hypertension (transudate ascites)'], ['Thrombocytopenia', 'Hypersplenism (portal HTN)'], ['AFP ↑↑', 'Suspect hepatocellular carcinoma'], ['Child-Pugh / MELD score', 'Prognosis and transplant listing']], col_widths=[70*mm, PAGE_W - 2*MARGIN - 70*mm], header_color=colors.HexColor('#795548') ), SP(6) ] # ═══════════════════════════════════════════════════════════════════════════ # 5. PNEUMOTHORAX # ═══════════════════════════════════════════════════════════════════════════ story += [PageBreak()] story += [KeepTogether([section_header('5. PNEUMOTHORAX', colors.HexColor('#37474f'), '🫁'), SP(4)])] story += [mnem_box("TYPES — '4 T's'", ['T = Traumatic (rib Fx, penetrating, iatrogenic — central line, biopsy, PPV)', 'T = Tension ← EMERGENCY (one-way valve mechanism)', 'T = The Primary spontaneous (tall thin male, subpleural blebs)', 'T = The Secondary spontaneous (COPD, asthma, CF, Marfan\'s)'], bg=C_LIGHT_GREY, border=C_DARK), SP(4)] story += [ two_col( left_title='EXAMINATION (affected side)', right_title='TENSION PTX EMERGENCY', left_items=[ 'HYPER-RESONANT percussion ← key', 'Absent / reduced breath sounds', 'Reduced chest expansion', 'Reduced vocal fremitus', ], right_items=[ 'Tracheal deviation AWAY', 'Hypotension + tachycardia', 'Raised JVP', 'Absent breath sounds', 'Cyanosis', '⚠ DO NOT WAIT FOR CXR — needle decompress!', ], lbg=C_LIGHT_GREY, rbg=C_LIGHT_RED ), SP(4) ] story += [alert_box('TENSION PNEUMOTHORAX: Immediate needle decompression — 2nd ICS, midclavicular line. Then chest drain. DO NOT wait for CXR.'), SP(4)] story += [ simple_table( ['Size / Situation', 'Management'], [['Small (<2cm), no dyspnoea, primary spontaneous', 'High-flow O2 + observe. Review 2-4 weeks.'], ['Larger / symptomatic', 'Aspiration (2nd ICS MCL) or chest drain (4th/5th ICS MAL)'], ['Tension pneumothorax', 'IMMEDIATE needle decompression → chest drain'], ['Recurrent / secondary', 'Chemical pleurodesis (talc) or VATS bullectomy'], ['Return to sport', '~3-4 weeks after resolution']], col_widths=[65*mm, PAGE_W - 2*MARGIN - 65*mm], header_color=C_DARK ), SP(6) ] # ═══════════════════════════════════════════════════════════════════════════ # 6. PNEUMONIA + 9. CAP # ═══════════════════════════════════════════════════════════════════════════ story += [KeepTogether([section_header('6 & 9. PNEUMONIA / COMMUNITY-ACQUIRED PNEUMONIA (CAP)', colors.HexColor('#e65100'), '🦠'), SP(4)])] story += [mnem_box("TYPICAL vs ATYPICAL — think 'STALL vs CALM'", ['TYPICAL (Bacterial / STALL): Sudden onset, Temp high, Awful cough (productive), Lobar consolidation, Leukocytosis', 'ATYPICAL (CALM): Creeping onset, Afebrile (low-grade), Lung sounds near normal, Mild constitutional symptoms'], bg=C_LIGHT_ORANGE, border=C_ORANGE), SP(3)] story += [mnem_box("ORGANISMS to remember — 'SHMACK'", ['S = Strep. pneumoniae (most common CAP)', 'H = H. influenzae (COPD, smokers)', 'M = Mycoplasma (young adults, walking pneumonia, cold agglutinins +ve)', 'A = Atypical: Chlamydia, Legionella (travel, hotel, raised urine antigen)', 'C = Community bugs: Staph. aureus (post-viral, aggressive)', 'K = Klebsiella (alcoholics, aspiration — currant jelly sputum)'], bg=C_LIGHT_ORANGE, border=C_ORANGE), SP(4)] story += [mnem_box("CURB-65 SCORE — 1 point each", ['C = Confusion (new)', 'U = Urea > 7 mmol/L', 'R = Respiratory rate ≥ 30 /min', 'B = Blood pressure < 90/60 mmHg', '65 = Age ≥ 65 years', '━━ 0-1 = HOME | 2 = HOSPITAL consider | 3+ = SEVERE / ICU consider ━━'], bg=C_LIGHT_ORANGE, border=C_ORANGE), SP(4)] story += [ two_col( left_title='EXAMINATION (consolidation)', right_title='INVESTIGATIONS', left_items=[ 'DULL percussion', 'Bronchial breathing', 'Increased vocal resonance', 'Aegophony (E→A change)', 'Coarse crackles', 'Tachypnoea, tachycardia, fever', ], right_items=[ 'CXR: lobar consolidation (bacterial)', 'FBC: raised WBC, neutrophilia', 'Blood cultures (before abx)', 'Sputum Gram stain + culture', 'Urine: Legionella + pneumococcal Ag', 'Cold agglutinins (Mycoplasma)', 'ABG if SpO2 <94% or CURB ≥3', ], lbg=C_LIGHT_ORANGE, rbg=C_LIGHT_BLUE ), SP(4) ] story += [ simple_table( ['Severity (CURB-65)', 'Setting', 'Antibiotic', 'Duration'], [['0-1 (Mild)', 'Outpatient', 'Amoxicillin 500mg TDS OR Doxycycline OR Clarithromycin', '5 days'], ['2 (Moderate)', 'Inpatient', 'IV Co-amoxiclav + Clarithromycin', '5-7 days'], ['3-5 (Severe)', 'ICU', 'Pip-tazo + Clarithromycin', '7-10 days'], ['Legionella', 'Any', 'Levofloxacin or Azithromycin', '7-14 days']], col_widths=[30*mm, 25*mm, 90*mm, 26*mm], header_color=colors.HexColor('#e65100') ), SP(4) ] story += [info_box('Prevention: Pneumococcal vaccine (revaccinate after 10yr if given <65). Influenza vaccine annually (>50yr, chronic disease).'), SP(6)] # ═══════════════════════════════════════════════════════════════════════════ # 7. ASTHMA # ═══════════════════════════════════════════════════════════════════════════ story += [PageBreak()] story += [KeepTogether([section_header('7. ASTHMA', colors.HexColor('#1565c0'), '💨'), SP(4)])] story += [body('Definition: Chronic inflammatory, REVERSIBLE bronchoconstriction (smooth muscle contraction + oedema + secretions) from airway hyperresponsiveness.'), SP(3)] story += [mnem_box("CLASSIC TETRAD (ask about all 4)", ['W = Wheeze (episodic, expiratory)', 'C = Cough (dry, nocturnal / early morning)', 'B = Breathlessness (episodic)', 'T = Tightness in chest'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(3)] story += [mnem_box("TRIGGERS — 'EXERCISE and 6 P's'", ['E = Exercise (cold air bronchoconstriction)', 'X = eXogenous allergens (pollen, dust mite, animal dander, mould)', 'P = Pollutants (smoke, fumes)', 'P = Pharmaceutical (NSAIDs, aspirin, beta-blockers)', 'P = Pathogens (viral URTI)', 'P = Psychological (stress)', 'P = Pregnancy', 'P = Physical cold air'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(4)] story += [ simple_table( ['Severity', 'PEFR', 'SpO2', 'Key features'], [['Mild / Moderate', '>50% predicted', '≥92%', 'Able to talk. Wheeze, tachypnoea.'], ['Severe', '33-50% predicted', '<92%', 'Cannot complete sentences. Tachycardia >110.'], ['Life-threatening', '<33% predicted (or too breathless to measure)', '<92%', 'Silent chest. Bradycardia. Confusion. Cyanosis. CALL ICU.']], col_widths=[28*mm, 30*mm, 20*mm, PAGE_W - 2*MARGIN - 78*mm], header_color=C_BLUE ), SP(4) ] story += [mnem_box("STEPWISE MANAGEMENT (step up / step down every 3 months)", ['Step 1: SABA (salbutamol) PRN — reliever', 'Step 2: Add ICS (beclometasone / budesonide / fluticasone) — preventer', 'Step 3: Add LABA (salmeterol / formoterol) → combined ICS/LABA inhaler', 'Step 4: Increase ICS dose + add LTRA (montelukast) or theophylline', 'Step 5: Specialist referral + biologics (omalizumab for allergic; mepolizumab for eosinophilic)'], bg=C_LIGHT_BLUE, border=C_BLUE), SP(3)] story += [mnem_box("ACUTE ATTACK — 'SIPO + Mg'", ['S = Sit upright + high-flow O2', 'I = Inhaled salbutamol nebuliser 2.5-5mg + Ipratropium 0.5mg', 'P = Prednisolone oral/IV 40-50mg', 'O = O2 target SpO2 94-98%', 'Mg = IV Magnesium sulphate 1.2-2g (if severe)', 'If unresponsive → IV aminophylline → ICU / intubation'], bg=C_LIGHT_RED, border=C_RED), SP(4)] story += [alert_box('SILENT CHEST = no air moving = LIFE-THREATENING. Normal/rising PaCO2 in acute attack = respiratory fatigue. Call ICU.'), SP(6)] # ═══════════════════════════════════════════════════════════════════════════ # 8. LUNG CARCINOMA # ═══════════════════════════════════════════════════════════════════════════ story += [KeepTogether([section_header('8. LUNG CARCINOMA', colors.HexColor('#4a148c'), '🔬'), SP(4)])] story += [mnem_box("HISTOLOGY — remember '2 big groups, 4 types'", ['NSCLC (80%):', ' • Adenocarcinoma — most common overall; peripheral; women/non-smokers; EGFR mutations', ' • Squamous cell Ca — central; smokers; cavitates; PTHrP → hypercalcaemia', ' • Large cell Ca — peripheral; poorly differentiated', 'SCLC (20%):', ' • Small cell — central; metastatic at presentation; TP53+RB mutations; treat with chemo'], bg=C_LIGHT_PURPLE, border=C_PURPLE), SP(3)] story += [mnem_box("PARANEOPLASTIC SYNDROMES — 'SCLC EATS and Squamous CALLS'", ['SCLC EATS:', ' S = SIADH (hyponatraemia) ← most common paraneoplastic in SCLC', " C = Cushing's syndrome (ectopic ACTH)", ' L = Lambert-Eaton myasthenic syndrome (proximal weakness, improves with use)', ' C = Cerebellar degeneration / neuropathy', 'Squamous CALLS:', ' Ca = Calcium raised (PTHrP — hypercalcaemia of malignancy)', 'ALL types:', ' Clubbing, DVT/PE, HPOA (hypertrophic pulmonary osteoarthropathy — adenoCa)'], bg=C_LIGHT_PURPLE, border=C_PURPLE), SP(3)] story += [mnem_box("APICAL / PANCOAST TUMOUR → 'HEAPS'", ['H = Horner\'s syndrome (ptosis, miosis, anhidrosis, enophthalmos)', 'E = Elbow/arm pain (brachial plexus — T1)', 'A = Arm weakness (T1 wasting)', 'P = Pancoast tumour = apex of lung', 'S = Shoulder/rib destruction'], bg=C_LIGHT_PURPLE, border=C_PURPLE), SP(3)] story += [mnem_box("SVC OBSTRUCTION signs — 'SVC FADS'", ['S = Swelling of face, neck, arms', 'V = Venous distension (non-pulsatile JVP, collateral veins on chest)', 'C = Cyanosis (face + arms)', 'F = Facial plethora / flushing', 'A = Arms / neck oedema', 'D = Dyspnoea', 'S = Stridor / dysphagia'], bg=C_LIGHT_PURPLE, border=C_PURPLE), SP(4)] story += [ simple_table( ['Stage / Type', 'Treatment'], [['NSCLC Stage I-II', 'Surgery (lobectomy preferred)'], ['NSCLC Stage III', 'Concurrent chemo-radiotherapy'], ['NSCLC Stage IV — EGFR+', 'Targeted therapy: gefitinib / erlotinib / osimertinib'], ['NSCLC Stage IV — ALK+', 'Crizotinib / alectinib'], ['NSCLC Stage IV — PD-L1+', 'Immunotherapy: pembrolizumab / nivolumab'], ['NSCLC Stage IV — other', 'Chemo: carboplatin + paclitaxel/pemetrexed'], ['SCLC Limited', 'Cisplatin/etoposide + concurrent RT ± prophylactic cranial irradiation'], ['SCLC Extensive', 'Cisplatin/etoposide + atezolizumab (immunotherapy)']], col_widths=[65*mm, PAGE_W - 2*MARGIN - 65*mm], header_color=C_PURPLE ), SP(6) ] # ═══════════════════════════════════════════════════════════════════════════ # 10. COPD # ═══════════════════════════════════════════════════════════════════════════ story += [PageBreak()] story += [KeepTogether([section_header('10. COPD — Chronic Obstructive Pulmonary Disease', colors.HexColor('#827717'), '🌬'), SP(4)])] story += [body('Definition: PROGRESSIVE, largely IRREVERSIBLE airflow obstruction = Emphysema + Chronic Bronchitis. FEV1/FVC <0.7 post-bronchodilator.'), SP(3)] story += [mnem_box("CHRONIC BRONCHITIS definition — '3-3-2'", ['Productive cough for ≥ 3 consecutive months', 'In ≥ 2 consecutive years', '(Remember: 3 months × 2 years)'], bg=C_LIGHT_YELLOW, border=colors.HexColor('#827717')), SP(3)] story += [ two_col( left_title='"PINK PUFFER" (Emphysema)', right_title='"BLUE BLOATER" (Chronic Bronchitis)', left_items=[ 'Thin, breathless, pursed lip breathing', 'Barrel chest (↑ AP diameter)', 'Accessory muscle use', 'Hyper-resonant, reduced sounds', 'Relatively normal PaO2 (hyperventilates)', 'α1-antitrypsin deficiency if young', ], right_items=[ 'Overweight, cyanotic', 'Productive cough (white/mucoid sputum)', 'Hypoxaemia + hypercapnia (type 2 RF)', 'Peripheral oedema (cor pulmonale)', 'Polycythaemia (secondary to hypoxia)', 'More prone to overt pulmonary vascular disease', ], lbg=C_LIGHT_YELLOW, rbg=C_LIGHT_BLUE ), SP(4) ] story += [mnem_box("GOLD STAGING by FEV1 % predicted", ['GOLD 1 (Mild) → FEV1 ≥ 80%', 'GOLD 2 (Moderate) → FEV1 50 – 79%', 'GOLD 3 (Severe) → FEV1 30 – 49%', 'GOLD 4 (Very severe) → FEV1 < 30%'], bg=C_LIGHT_YELLOW, border=colors.HexColor('#827717')), SP(3)] story += [mnem_box("MANAGEMENT — 'STOP and BREATHE'", ['S = Smoking cessation (MOST EFFECTIVE — slows FEV1 decline)', 'T = Treatment: Inhaler step-up (SABA/SAMA → LABA/LAMA → add ICS)', 'O = Oxygen therapy (LTOT ≥15h/day when PaO2 ≤7.3kPa)', 'P = Pulmonary rehabilitation', 'B = Bronchodilators (LAMA tiotropium = cornerstone of maintenance)', 'R = Roflumilast (PDE4i) for severe + chronic bronchitis + frequent exacerbators', 'E = Exacerbation management (controlled O2 88-92%, nebulisers, prednisolone 30-40mg, Abx)', 'A = Azithromycin prophylaxis (reduce exacerbation frequency)', 'T = Triple therapy (ICS + LABA + LAMA) for frequent exacerbators', 'H = Hospitalise for NIV (BiPAP) if type 2 RF persists (pH <7.35)', 'E = Eliminate smoking triggers + vaccinate (influenza + pneumococcal)'], bg=C_LIGHT_YELLOW, border=colors.HexColor('#827717')), SP(4)] story += [alert_box('AECOPD: Target SpO2 88-92% (NOT 98-100%). Over-oxygenation blunts hypoxic respiratory drive → worsening hypercapnia → CO2 narcosis.'), SP(4)] story += [ simple_table( ['AECOPD Treatment Step', 'Detail'], [['1. Controlled O2', 'Target SpO2 88-92% via Venturi mask (28% or 24%)'], ['2. Nebulised bronchodilators', 'Salbutamol 2.5mg + Ipratropium 500mcg q4-6h'], ['3. Oral prednisolone', '30-40mg OD for 5 days'], ['4. Antibiotics', 'If purulent sputum: Amoxicillin / Doxycycline / Co-amoxiclav'], ['5. NIV (BiPAP)', 'If type 2 RF with pH <7.35 despite above'], ['6. Intubation', 'If NIV fails / contraindicated']], col_widths=[50*mm, PAGE_W - 2*MARGIN - 50*mm], header_color=colors.HexColor('#827717') ), SP(6) ] # ═══════════════════════════════════════════════════════════════════════════ # FINAL: MASTER COMPARISON TABLES # ═══════════════════════════════════════════════════════════════════════════ story += [PageBreak()] story += [KeepTogether([section_header('MASTER QUICK REFERENCE TABLES', C_NAVY, '📋'), SP(4)])] # Percussion / breath sounds story += [subsection('Lung Examination by Condition'), SP(2)] story += [ simple_table( ['Condition', 'Percussion', 'Breath Sounds', 'Vocal Resonance', 'Added Sounds'], [['Pneumothorax', 'HYPER-RESONANT', 'Absent', 'Absent', 'None'], ['Pleural Effusion', 'STONY DULL', 'Absent/reduced', 'Reduced', 'Bronchial above'], ['Consolidation/Pneumonia', 'DULL', 'Bronchial', 'Increased + aegophony', 'Crackles (coarse)'], ['Asthma (during attack)', 'Resonant', 'Reduced', 'Normal', 'Expiratory wheeze'], ['COPD / Emphysema', 'Hyperresonant', 'Reduced', 'Normal', 'Wheeze, prolonged exp'], ['Normal', 'Resonant', 'Vesicular', 'Normal', 'None']], col_widths=[38*mm, 32*mm, 32*mm, 35*mm, 34*mm], header_color=C_NAVY ), SP(5) ] # Obstructive vs Restrictive story += [subsection('Obstructive vs Restrictive Lung Disease'), SP(2)] story += [ simple_table( ['Parameter', 'Obstructive (Asthma/COPD)', 'Restrictive (Fibrosis/Effusion)', 'Normal'], [['FEV1', '↓', '↓', 'Normal'], ['FVC', 'Normal / ↓', '↓↓', 'Normal'], ['FEV1/FVC', '<0.7 ← diagnostic', 'Normal or ↑ (≥0.7)', '0.7-0.8'], ['TLC', 'Normal / ↑', '↓', 'Normal'], ['Reversibility', '>12%+200mL = Asthma', 'None significant', '—']], col_widths=[35*mm, 55*mm, 55*mm, 26*mm], header_color=C_NAVY ), SP(5) ] # Transudate vs Exudate story += [subsection("Transudate vs Exudate (Light's Criteria)"), SP(2)] story += [ simple_table( ['Feature', 'Transudate', 'Exudate'], [['Protein', '<25 g/L', '>35 g/L'], ["Light's criteria", 'None of the 3 criteria met', 'At least 1 criterion met'], ['LDH', 'Low', 'High'], ['Colour', 'Clear / straw', 'Turbid / cloudy'], ['pH', '>7.3', '<7.2 (empyema/malignancy)'], ['Causes', 'HF, Cirrhosis, Nephrotic, Hypothyroidism', 'Pneumonia, TB, Malignancy, PE, Pancreatitis']], col_widths=[30*mm, 65*mm, 76*mm], header_color=C_NAVY ), SP(5) ] # All-conditions summary story += [subsection('Condition Quick Summary'), SP(2)] story += [ simple_table( ['Condition', 'Key Definition', 'Hallmark Sign', 'Gold Std Ix', 'Key Treatment'], [['PE', 'Clot in pulmonary artery (from DVT)', 'Tachycardia + hypoxia', 'CTPA', 'Anticoagulation (DOAC/LMWH)'], ['LHF', 'LV fails → pulmonary congestion', 'S3 gallop + crackles', 'Echo', 'Fantastic Four (ARNI+BB+MRA+SGLT2i)'], ['RHF', 'RV fails → systemic congestion', 'Raised JVP + oedema', 'Echo', 'Treat cause; diuretics'], ['Cor Pulmonale', 'RV failure from lung disease', 'RV heave + loud P2', 'Echo + RHC', 'LTOT + treat lung disease'], ['Pleural Eff.', 'Fluid in pleural space', 'Stony dull + absent BS', 'USS chest', 'Thoracocentesis + treat cause'], ['Cirrhosis', 'End-stage liver fibrosis', 'Spider naevi + ascites', 'Fibroscan/biopsy', 'Treat cause; spiro+furo; OGD'], ['Pneumothorax', 'Air in pleural space', 'Hyper-resonant + absent BS', 'CXR', 'Aspiration / Drain / Needle'], ['Pneumonia', 'Alveolar infection', 'Bronchial breathing + crackles', 'CXR + cultures', 'Antibiotics (CURB-65 guided)'], ['Asthma', 'Reversible bronchoconstriction', 'Expiratory wheeze (reversible)', 'Spirometry + reversibility', 'ICS + SABA; step-up'], ['Lung Ca', 'Malignant airway tumour', 'Clubbing + haemoptysis', 'CT + biopsy', 'Surgery / Chemo / Targeted Rx'], ['COPD', 'Progressive irreversible obstruction', 'Barrel chest + wheeze', 'Spirometry FEV1/FVC <0.7', 'Smoking cessation + LAMA']], col_widths=[24*mm, 45*mm, 38*mm, 30*mm, 34*mm], header_color=C_NAVY ), SP(6) ] # MNEMONICS CHEAT SHEET story += [KeepTogether([section_header('ALL MNEMONICS AT A GLANCE', C_TEAL, '🔤'), SP(4)])] mnem_summary = [ ['PE Risk factors', 'STOP CLOTS'], ['PE Management', 'HATE clots'], ['LHF CXR', 'ABCDE'], ['LHF Causes', 'CHAV MADS'], ['HFrEF Treatment', 'Fantastic Four (ARNI + BB + MRA + SGLT2i)'], ['Cor Pulmonale Mx', 'LTOT SAVES'], ['Pleural transudates', 'CHIN'], ['Pleural exudates', 'PIMP'], ['Cirrhosis causes', 'ABCDE'], ['Cirrhosis signs', 'SPIDER CLAWS'], ['Pneumothorax types', "4 T's"], ['Asthma tetrad', 'WCBT (Wheeze, Cough, Breathless, Tightness)'], ['Asthma triggers', 'EXERCISE + 6 P\'s'], ['Asthma acute Mx', 'SIPO + Mg'], ['Lung Ca organisms (Pneumonia)', 'SHMACK'], ['CAP severity', 'CURB-65'], ['Lung Ca paraneoplastic', 'SCLC EATS + Squamous CALLS'], ['Pancoast tumour', 'HEAPS'], ['SVC obstruction', 'SVC FADS'], ['Chronic bronchitis def', '3-3-2 rule'], ['COPD Management', 'STOP and BREATHE'], ['GOLD Staging', '4 levels by FEV1 (≥80 / 50-79 / 30-49 / <30)'], ] story += [ simple_table( ['Condition', 'Mnemonic'], mnem_summary, col_widths=[60*mm, PAGE_W - 2*MARGIN - 60*mm], header_color=C_TEAL ), SP(4) ] story += [info_box('Study Tip: For EACH condition remember — Definition → Causes (mnemonic) → History (key questions) → Exam (pattern of signs) → Ix (gold standard first) → Mx (first-line + escalation)')] doc.build(story) print("PDF created successfully!") PYEOF echo "Script written"