Cardio/Respiratory Flashcards by Jane Keery

How should you go about assessing circulation on a CXR?

Is the heart in the correct position? (2/3rds left, 1/3rd right)

Is the heart the correct size? (< 50% cardiothoracic ratio)

Is the mediastinum a normal width? Can you see the vessels on either side?

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A fine physiological tremor can be caused by what medication commonly used in respiratory medicine?

Salbutamol (beta 2 agonist)

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What rate should the oxygen flow be set to when using a nebuliser?

6-8L/min

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How should you go about assessing the lungs and pleural space on a CXR?

Do both lungs look the same size?

Assess the apices and upper/mid/lower zones for any asymmetry

Are the borders of the costophrenic angles, hemidiaphragms and heart clear?

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Describe the abnormality seen on this CXR?

There is a rounded opacity in the left middle zone near to the left hilum. The most likely diagnosis here is a lung malignancy (could be primary or metastases) or potentially an infection (bacterial/fungal)

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What is a collapsing pulse a sign of?

Aortic regurgitation

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How would you describe these breath sounds?

Reduced breath sounds

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During a respiratory history exam it can be useful to ask if the patient has any pain where, to assess for referred pain from the diaphragm?

Shoulder tip

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Describe Buerger’s test, used to assess for peripheral arterial disease?

Hold patient’s legs at 45 degrees for 1-2 minutes then ask them to swing their legs round to the side of the bed- if the legs become red and flushed this is indicative of arterial disease

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Describe the abnormality seen on this CXR?

Prominent bilateral hila- likely to be bilateral lymphadenopathy, which could be caused by TB or sarcoidosis or lymphoma

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How often should you repeat a peak flow test?

Three times (use the best of the three)

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Where on the chest should you listen for the mitral valve?

5th left intercostal space, mid-clavicular line

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What are some specific things to look for on the ‘anything else’ assessment of a CXR?

Any free air under the diaphragm?

Any subcutaneous emphysema?

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A slow rising pulse is a sign of what pathology?

Aortic stenosis

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In which pathology will breath sounds always be absent?

Pneumonectomy

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What flow rate of oxygen should be used with a simple face mask?

What FiO2 does this provide?

5-10L/min

40-60%

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What should be considered when assessing the airways on a CXR?

Is the trachea in the midline and is it straight?

Are the main bronchi narrowed or cut off?

Is there any inhaled foreign body?

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In which pathologies may the trachea be deviated towards the affected side?

Lung collapse, pneumonectomy

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Which cardiovascular pathologies can result in finger clubbing?

Infective endocarditis, cyanotic congenital heart disease, atrial myxoma

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What line/tube can be seen in this CXR?

PICC line

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How would you describe these breath sounds?

Inspiratory wheeze (stridor)

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Describe the abnormality seen on this CXR?

There is a rounded opacification in the right lower zone near the periphery. This opacification has an air-fluid level. Differentials for this include a lung abscess (empyema) or potentially a malignancy.

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Describe the murmur of mitral stenosis?

A low-pitched (rumbling) mid-diastolic murmur, (GRADE), heard loudest at the apex (exacerbated by lying on LHS)

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What murmur is this?

Aortic regurgitation (early diastolic, decrescendo)

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What are the main risk factors for cardiovascular pathology that should be asked about early on in the history?

Smoking, diabetes, hypertension, hypercholesterolaemia

Asking the patient to roll onto their left side and hold their breath with the bell of your stethoscope at the apex tends to amplify which murmur?

Mitral stenosis

What % of average/best peak flow corresponds with moderate asthma?

50-75%

Describe the abnormality seen on this CXR?

Prominent upper lobe vessel dilation and enlarged hilum with blunting of the costophrenic angles, overall consistent with pulmonary oedema

What are the 3 main symptoms of aortic stenosis?

Shortness of breath, exertional syncope/pre-syncope, angina

How long should you advise patients to wait between two doses of an inhaled medication?

30 seconds

What are some potential causes of coarse bibasal crepitations?

Bronchiectasis, CF, bibasal pneumonia

Describe the abnormality seen on this CXR?

'Bat wing' appearance with blunting of the costophrenic angles consistent with pulmonary oedema

What is the first step when interpreting a chest x-ray?

Confirm it is of the correct patient with name and DOB Confirm what type of CXR it is (PA/AP) Confirm when and where the CXR was taken and for what reason

Which pathology typically causes a hyper-resonant percussion note?

Pneumothorax

What % of average/best peak flow corresponds with mild asthma?

\> 75%

Sacral and peripheral oedema are signs of what?

Right-sided heart failure

Describe the abnormality seen on this CXR?

Widespread round opacifications throughout both lung fields, consistent with pleural metastases

Where on the chest should you listen for the aortic valve?

2nd right intercostal space, parasternal

What tube can be seen in this image? How can you tell that it is correctly positioned?

NG tube The tube should descend down the midline, bisect the carina, cross the diaphragm in the midline and sit just below the diaphragm

How would you describe this breath sound?

Bronchial breathing

Horner's syndrome (ptosis, myosis, anhydrosis) in the context of respiratory symptoms can be a sign of what?

Pancoast tumour (invasion of the sympathetic chain)

Describe the abnormality seen on this CXR?

Complete white-out on the right side with tracheal deviation towards the right side consistent with a previous pneumonectomy

How would you describe these breath sounds?

Expiratory wheeze

What system should you use when describing the pulse?

Rate (tachycardia/bradycardia) Rhythm (regular/irregular) Volume (thready/bounding) Character

Describe the abnormality seen on this CXR?

Reticulo-nodular opacities throughout both lung fields which could be consistent with pulmonary fibrosis or miliary TB

What three things do you assess to make sure a CXR is of adequate quality?

Rotation, penetration, inspiration

Which pathologies may cause a dull percussion note?

Consolidation, lung collapse or pneumonectomy

How would you describe these breath sounds?

Coarse crepitations

Describe the murmur of aortic stenosis?

Ejection systolic murmur in a crescendo-decrescendo pattern, (GRADE), heard loudest at the aortic area, raidting to the carotids

How can you tell that a CXR is adequately inspired?

You should be able to visualise 10-11 posterior ribs

Describe the abnormality seen on this CXR?

Free air under both hemidiaphragms - can be caused by bowel perforation or a normal post-op occurrence

Describe the abnormality seen on this CXR?

There is an opacification in the right upper zone, most likely consistent with consolidation from pneumonia

Where should you assess for any bony pathology on a CXR?

Ribs, clavicles, shoulders, vertebrae

If a patient has a sputum pot by their bedside, you should look in it and comment on what features?

Colour, purulence, presence/absence of blood

A flapping tremor can be a sign of what?

CO2 retention or hepatic/renal failure

Koilonychia is a sign of what?

Iron deficiency anaemia

Venturi masks state on them what flow rate of oxygen is required to achieve the desired FiO2. What is the range of FiO2 that can be provided by Venturi masks?

24-60%

Describe the abnormality seen on this CXR?

No lung markings on the right side- large right sided pneumothorax

Describe the abnormality seen on this CXR?

There is opacification in the left lower-mid zone with a fluid level (meniscus). The opacification is blunting the left costophrenic angle and obscuring the lower left heart border. This picture is consistent with a diagnosis of a left sided pleural effusion.

If a non-smoker has a dry cough, what non cardiorespiratory cause should you consider?

GORD

What % of average/best peak flow corresponds with life-threatening asthma?

\< 33%

In which pathologies may the trachea be deviated away from the affected side?

Tension pneumothorax, large pleural effusions

What murmur is this?

Aortic stenosis

What are some potential causes of fine bibasal crepitations?

Pulmonary oedema or interstitial lung disease

In terms of respiratory pathology, what can finger clubbing be a sign of?

Lung cancer, interstitial lung disease, suppurative lung disease

Describe the abnormality seen on this CXR?

Aortic arch is on the wrong side, the left hemidiaphragm is higher than the right and there is dextrocardia- consistent with a diagnosis of situs invertus (can be associated with primary ciliary dyskinesia)

Where is the tibialis posterior pulse palpated?

Behind the medial malleolus

Where is the dorsalis pedis pulse palpated?

Lateral to the extensor hallucis longus tendon

What specific symptoms should you ask about as part of a respiratory history?

Shortness of breath/difficulty breathing (+ orthopnoea and PND), cough (+ sputum production and haemoptysis), chest pain, wheeze, leg swelling, coryzal symptoms

Which valvular pathology causes a murmur which may radiate to the carotids?

Aortic stenosis

Describe the abnormality seen on this CXR?

Rib fractures on the right side resulting in subcutaneous emphysema and pneumomediastinum

Which valvular pathology causes a murmur which may radiate to the axilla?

Mitral regurgitation

How would you describe these breath sounds?

Fine crepitations

What is the easiest way to describe a murmur?

Timing and pitch Grade Where is it heard loudest Where does it radiate to

How would you describe these breath sounds?

Normal (vestibular) breath sounds

How can you tell that a CXR is not rotated?

The distance between the medial clavicles and spinous processes should be equal

What is the cause of a 3rd heart sound?

Rapid ventricular filling - can be normal in young people but associated with heart failure in the elderly

Hearing a wheeze on auscultation of the lungs is most suggestive of what pathology?

Small airway obstruction e.g. asthma or COPD

Asking the patient to sit up and hold their breath with the diaphragm of your stethoscope at the left lower sternal edge tends to amplify which murmur?

Aortic regurgitation

What are the main risk factors for respiratory pathology that should be asked about early in the history?

Smoking and occupation/hobbies

Where on the chest should you listen for the tricuspid valve?

4th left intercostal space, lower sternal edge

What flow rate of oxygen should be used with a non-rebreather mask? What FiO2 does this provide?

12-15L/min 60-80%

Where is the apex beat usually located?

5th intercostal space, mid-clavicular line

What % of average/best peak flow corresponds with severe asthma?

33-50%

Where is the femoral pulse palpated?

At the mid-inguinal point, halfway between the ASIS and pubic symphysis

Pulmonary oedema (crepitations at the lung bases) is a sign of which type of heart failure?

Left sided heart failure

A normal JVP should be what height above the sternal angle?

\< 3-4cm

A wide pulse pressure is a sign of what pathology?

Aortic regurgitation

Which pathology typically causes a stony dull percussion note?

Pleural effusion

Where on the chest should you listen for the pulmonary valve?

2nd left intercostal space, parasternal

What is the cause of a 4th heart sound?

Hypertrophic ventricle - always abnormal (AS, hypertension, HCM)

How would you describe this breath sound?

Pleural rub

Malar flush is a sign of what cardiovascular pathology?

Mitral stenosis

How can you tell that a CXR is adequately penetrated?

You should be able to visualise the spinous processes of the thoracic vertebrae

Describe the murmur of aortic regurgitation?

A high-pitched early diastolic murmur, (GRADE), heard loudest at the left lower sternal edge (exacerbated by sitting upright)

What murmur is this?

Mitral regurgitation (blowing, pansystolic)

In which pathology will breath sounds be bronchial or reduced?

Consolidation

What murmur is this?

Mitral stenosis (low-pitched/rumbling mid-diastolic)

In which pathologies may the JVP be elevated?

Right-sided heart failure, fluid overload, PE, SVC obstruction

A narrow pulse pressure is a sign of what pathology?

Aortic stenosis

What specific symptoms should you ask about as part of a cardio history?

Shortness of breath/difficulty breathing (+ orthopnoea and PND), chest pain/tightness, cough, palpitations, syncope, ankle swelling

In which pathology will breath sounds be reduced or absent?

Lung collapse, pneumothorax or effusion

How can you tell if an ET tube is in the correct position on a CXR?

The tip should be 5cm above the carina and taking up 2/3rds of the diameter of the trachea

What flow rate of oxygen should be used with a nasal cannula? What percentage FiO2 does this provide?

2-6L/min 24-50%

Cushingoid features (moon face, plethora, acne, hirsutism) can be caused by what medication commonly used in respiratory medicine?

Steroids

How should the patient be positioned in order to palpate the popliteal pulse?

Legs relaxed, knees bent to 30 degrees

What is the difference between tender and non-tender lymph nodes?

Tender is more suggestive of infection while non-tender is more suggestive of malignancy

Describe the murmur of mitral regurgitation?

A blowing, pansystolic murmur, (GRADE), heard loudest at the apex and radiating to the left axilla

What is the most important investigation to do for someone presenting with signs/symptoms of aortic stenosis? If symptomatic, how is this condition managed?

ECHO Valve replacement