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Respiratory Physiology, Medicine and Critical Care > Clinical signs and examination > Flashcards

Clinical signs and examination Flashcards

1
Q

What would you differential be for someone experience sharp chest pains aggravated by breathing or movement?

A
  • MSK injury/Inflammation
  • Pneumonia with pleurisy
  • PE
  • Pneumothorax
  • Pericarditis
  • Referred cervical root pain
  • Shingles
  • Tietz syndrome
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2
Q

What would your differential diagnosis be for someone with sudeen SOB, with an onset over seconds?

A
  • PE
  • Pneumothorax
  • Anaphylaxis
  • Foreign body inhalation
  • Cardiac arrythmia
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3
Q

What would your differential be for acute breathlessness with wheeze( +/- cough)?

A
  • Exacerbation of asthma
  • Exacerbation of COPD
  • Acute viral/bacterial bronchitis
  • Acute LVF
  • Anaphylaxis
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4
Q

What would your differential diagnosis be for chronic breathlessness?

A
  • Obesity
  • Asthma
  • COPD
  • LVF
  • Pulmonary fibrosis
  • Neuromuscular disease
  • Pulmonary hypertension
  • Psychogenic SOB
  • Chronic thromboembolism +/- PEs
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5
Q

What would your differential for Frank haemoptysis/blood streaked sputum be?

A
  • Acute viral/bacterial bronchitis
  • PE
  • Carcinoma of the lung
  • Pulmonary TB
  • URTI
  • Lung abscess
  • Bronchiectasis
  • Wegener’s granulomatosis, Goodpasture’s Syndrome
  • Pneumonia
  • Pulmonary AV malformation
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6
Q

What would your differential diagnosis be for cough with sputum be?

A
  • COPD
  • Acute viral bronchitis
  • Acute bacterial bronchitis
  • Pneumonia
  • Lung Abscess
  • bronchoalveolar carcinoma
  • Bronchiectasis
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7
Q

What would your differential diagnosis for perisitent dry cough with no sputum be?

A
  • Smoking
  • Chronic asthma
  • GORD
  • Post-nasal drip
  • Viral infection with slow recovery
  • ACE inhibitors
  • COPD
  • Carcinoma of the lung
  • Pulmonary TB
  • Intersitital lung disease
  • Inhaled foreign body
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8
Q

What would your differential diagnosis for hoarseness be?

A
  • Inhaled steroids
  • Chronic laryngitis
  • Singer’s nodes
  • Laryngeal carcinoma
  • Vocal cord paralysis - trauma, cancer, TB, MS, Polio
  • Functional hoarseness
  • Myxoedema
  • Acromegaly
  • Sicca syndrome
  • Granulomas
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9
Q

What signs indicate hypoxia?

A
  • Peripheral and central cyanosis
  • Restless
  • Confused
  • Drowsy
  • Unconsious
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10
Q

What signs indicate CO2 retention?

A
  • Warm hands
  • Bounding pulse
  • Dilated veins on hands and face
  • Twitching facial muscles
  • Asterixis
  • Headaches
  • Confusion
  • Drowsy
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11
Q

What are features of hypocapnia?

A
  • Dizziness
  • Anxious
  • Paraesthesiae around the lips or fingers
  • Tachypnoea
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12
Q

What would your differential diagnosis be for someone with a RR < 10/min?

A
  • CO2 narcosis due to excess O2
  • Drugs - opiates, benzos, muscle relaxants, alcohol
  • Raised ICP
  • Head injury
  • Cervical cord trauma
  • Acute neuromuscular disease (e.g. guillain barre)
  • Severe hypothermia
  • Hypothyroidism
  • Metabolic alkalosis
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13
Q

What chest wall abnormalities can be present in a patient?

A
  • Pectus carinatum
  • Pectus excavatum
  • Kyphosis
  • Scoliosis
  • Abscence of part of chest wall
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14
Q

What might bilateral poor chest expansion be caused by?

A
  • Obesity - Obesity hypoventilation syndrome
  • Emphsema
  • Pulmonary fibrosis
  • Muscular dystrophy
  • MND
  • MS
  • Guillain barre
  • Myasthenia gravis
  • Eaton-Lambert syndrome
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15
Q

What might unilateral poor chest expansion indicate?

A
  • Pneumothorax/Haemothorax
  • Flail chest
  • Foreign body
  • Extensive consolidation
  • Fractured rib
  • Pleural effusion
  • MSK injury
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16
Q

What might a displaced trachea indicate?

A
  • Tension pneumothorax
  • Pulled by ipsilateral pneumothorax
  • Pulled by upper lobe fibrosis
  • Pushed by contralateral effusion
  • Scoliosis
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17
Q

What might be the cause of reduced tactile vocal fremitus?

A
  • Plerual effusion
  • Pneumothorax
  • Collapsed lobe with no consolidation
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18
Q

What might be the cause of increased tactile vocal fremitus?

A

Extensive consolidation due to bacterial infection/autoimmune disease/malignancy

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19
Q

What can stony dullness to percussion be caused by?

A

Transudates

  • LVF
  • SVC obstruction
  • Pericarditis
  • Hypoalbuminaemia

Exudates

  • Infective
  • Neoplastic
  • Rheumatoid, SLE
  • PE/infarction
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20
Q

What can be the difference between transudates and exudate on examination?

A

Transudates are always bilateral, whereas exudates can be either unilateral or bilateral

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21
Q

What can dullness to percussion (but not stony dullness) be caused by?

A
  • Consolidation
  • Pulmonary oedema
  • Elevated hemidiaphragm
  • Severe fibrosis
  • Severe pleural thickening
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22
Q

What can cause hyper resonance on percussion?

A
  • Emphysema
  • Large bullae
  • Pneumothorax
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23
Q

What can reduced breath sounds be caused by?

A
  • Poor respiratory effort
  • Endobronchial obstruction - foreign body, secretions, tumour
  • Severe asthma
  • Anaphylaxis
  • Obesity
  • Pneumothorax
  • Pleural effusion
  • Severe pleural thickening
  • Emphysema
  • Large bulle
  • Consolidation
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24
Q

Why are the general reasons breath sounds are reduced?

A
  • Air is not entering/Leaving lungs
  • Excess air, fat or fluid between lung and stethoscope
  • Good air entry but abnormal lung parenchyma
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25
Q

What can bronchial breathing be caused by?

A
  • Consolidation
  • Lung cavity
  • Pulmonary fibrosis
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26
Q

What can cause fine inspiratory crackles?

A
  • Normal secretions
  • Pulmonary oedema - Ventricular failure, lung injury/ARDS
  • Pulmonary fibrosis
  • Chronic bronchitis
  • Emphysema
  • Consolidation
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27
Q

What can cause coarse crackles?

A
  • Bronchiectasis
  • Pulmonary fibrosis
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28
Q

What can cause a pleural rub?

A
  • Pneumonia with pleurisy
  • PE
  • Severe pleural thicking
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29
Q

What can cause stridor (+/- inspiratory wheeze)?

A
  • Epiglottitis
  • Croup
  • Inhlaed foreign body
  • Rapidly progressive laryngomalacia
  • Laryngeal papillomas
  • Anyphalaxis - laryngeal oedema
  • Peritonsillar abscess
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30
Q

What does an inspiratory stridor indicate?

A

Laryngeal/supraglottic lesion

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31
Q

What does expiratory stridor indicate?

A

Tracheobronchial lesion - below thorac inlet

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32
Q

What does biphasic stridor indicate?

A

Subglottic/glottic to tracheal ring

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33
Q

What is important to remember in terms of the volume of stidulous breathing?

A

Stridor is believed to represent a significant narrowing of the airway, but a sudden drop in volume may indicate impending airway collapse

34
Q

What does high-pitched stridor indicate?

A

Obstruction at the level of the glottis

35
Q

What does low-pitched stridor indicate?

A

Higher lesions in the nose, nasopharynx and supraglottic larynx

36
Q
A
37
Q

What can cause an inspiratory monophonic wheeze?

A
  • Acute bilateral vocal cord paralysis
  • Inhlalation of foreign body
  • Tracheal tumours
  • Stenosis after ventilation
  • Extrinsic compression of large airways by mediastinal masses/oesophagela tumours
  • Tracheal blunt trauma
38
Q

What can cause an inspiratory monophnic wheeze?

A
  • Endobronchial carcinoma
  • Acute bilateral vocal cord paralysis
  • Inhalation of foreign body
  • Tracheal tumours
  • Extrinsic compression by mediastinal masses/oesophageal tumours
  • Tracheal blunt trauma
39
Q

Which airways are implicated in inspiratory and expiratory monophonic wheeze?

A

Large airways

40
Q

What can cause an expiratory polyphonic, high pitched wheeze?

A
  • Exacerbation of asthma
  • Bronchitis
  • Viral wheeze
  • Anaphylaxis
  • Pulmonary oedema
41
Q

What is agonal breathing?

A

Slow inspirations with irregular pauses. Patients are often described as gasping for air. Agonal breathing is usually closely followed by death unless intervention is provided.

42
Q

Why does agonal breathing occur?

A

Agonal respiration is thought to be a brainstem reflex, providing a last-ditch respiratory effort for the body to try to save itself. It is thought of as the last respiratory effort before terminal apnoea

43
Q

What is apneustic breathing?

A

https://www.youtube.com/watch?v=qDMqw1XHkUc

Apneusis is characterised by prolonged periods of deep, gasping inspirations interrupted by occasional and insufficient expiration brought on by elastic recoil of the lung. Apneustic breathing involves repetitive gasps, with pauses at full inspiration lasting a few seconds.

44
Q

What is apnoea?

A

A pause in breathing.

45
Q

What are causes of asterixis?

A
  • Hypercapnia (e.g. CO2 retention in COPD)
  • Liver disease
  • Renal failure
  • Alcoholism
  • CNS ischaemia or haemorrhage
  • Drug-induced (e.g. clozapine)
  • Electrolyte abnormalities (e.g. hypokalaemia and hypomagnesemia)
  • Unilateral asterixis – thalamic stroke
46
Q

What are the three broad categories of causes of dyspnoea?

A
  • Conditions in which central respiratory drive is increased (‘air hunger’)
  • Conditions where there is an increased respiratory load (‘increased work of breathing’)
  • Conditions where there is lung irritation (‘chest tightness’, ‘constriction’)
47
Q

What is the mechanism behind hoover’s sign?

A

When the chest becomes severely hyperinflated, the diaphragm often becomes stretched. As a consequence, contraction of the diaphragm at inspiration results in an inward movement, bringing the costal margins with it, as opposed to normal downward movement.

48
Q

What can cause Hoover’s sign?

A
  • Emphysema
  • Chest hyperinflation
49
Q

What is hoover’s sign?

A

The paradoxical inward movement of the lower lateral costal margins on inspiration.

50
Q

What is Kussmaul’s Breathing?

A

https://www.youtube.com/watch?v=TG0vpKae3Js

Also described as ‘air hunger’, Kussmaul’s breathing is typified by deep, rapid inspirations

51
Q

What are common causes of Kussmaul’s breathing?

A
  • Diabetic ketoacidosis
  • Sepsis
  • Lactic acidosis
  • Diarrhoea
  • Renal tubular acidosis
  • Severe haemorrhage
52
Q

What is the mechanism behind Kussmal’s Breathing?

A

Kussmaul’s breathing is an adaptive response to metabolic acidosis. By producing deep, rapid inspirations, anatomical dead space is minimised, allowing for more efficient ‘blowing off’ of carbon dioxide, thus decreasing acidosis and increasing pH.

53
Q

What conditions can cause orthopnoea?

A
  • Congestive heart failure (CHF)
  • Bilateral diaphragm paralysis
  • COPD
  • Asthma
54
Q

What can cause paradoxical abdominal movements?

A
  • Neuromuscular disease – bilateral diaphragm weakness
  • Diaphragmatic paralysis
  • Diaphragmatic fatigue
55
Q

What is platypnoea/orthodexia?

A

Refers to shortness of breath while sitting or standing that is relieved by lying supine. It is the opposite of orthopnoea. Orthodeoxia refers to arterial desaturation noted when sitting up as opposed to lying down. These are not common signs but are quite striking when present.

56
Q

What conditions is sputum production associated with?

A
  • COPD
  • Pneumonia
  • Tuberculosis (TB)
  • Bronchiectasis
  • Malignancy
  • Cystic fibrosis
  • Asthma
57
Q

What is stertor?

A

A form of noisy breathing - it is a sign easily appreciated with the naked ear. Unlike stridor, stertor does not have a musical quality, is low pitched and is heard only on inspiration. It is the type of breathing usually associated with nasal congestion and usually originates at the level of naso/oropharynx. It is most often heard in (and associated with) paediatric patients, especially infants, in part due to the smaller proportions of the associated anatomy.

58
Q

What conditions can cause stertor?

A
  • Nasopharyngeal and/or oropharyngeal obstruction
  • Nasal obstruction and deformity
  • Adenoid hypertrophy
  • Epiglottitis
  • Glioma (if blocking nasal passage)
59
Q

What can cause tachypnoea?

A

Any state causing a derangement in oxygen (hypoxia), pCO2 (hypercapnia) or acid/base status (acidosis) will stimulate respiratory drive and increase respiratory rate.

Tachypnoea occurs in most situations as a compensatory response to either a drop in pO2 (hypoxaemia) or a rise in pCO2 (hypercapnia). Central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch and carotid body measure a combination of these variables and send messages to the central ventilatory systems to increase respiratory rate and tidal volume to compensate for any fluctuations

60
Q

What is tracheal tugging?

A

https://www.youtube.com/watch?v=xM92cP5pE_Q

Downward displacement of the thyroid cartilage during inspiration.

61
Q

What conditions can cause tracheal tug?

A
  • Respiratory distress/COPD (Campbell’s sign)
  • Arch of aorta aneurysm (Oliver’s sign)
62
Q

Why does tracheal tug occur in respiratory distress or COPD?

A

Patients in respiratory distress have increased work of breathing and the movements of the chest wall, muscles and diaphragm are transmitted along the trachea, pulling it rhythmically downwards.

Tracheal tug also occurs in patients who have intercostal weakness but preserved diaphragmatic strength. This can be caused by muscle relaxants and deep sedation from anaesthetic agents and is due to the unopposed action of the crura pulling on the diaphragm, which also pulls the pericardium and lung structures during inspiration.

63
Q

Why does an arch of Aorta aneurysm cause tracheal tugging?

A

Tracheal tug in this situation refers to downward displacement of the cricoid cartilage in time with ventricular contraction, in the presence of an aortic arch aneurysm. With the patient’s chin lifted, the clinician can grasp the cricoid cartilage and push it upwards.

This movement brings the aortic arch and the aortic aneurysm (if present) closer to the left main bronchus (which it overrides). The pulsation of the aorta and the aneurysm is then transmitted up the bronchus to the trachea, creating Oliver’s sign.

64
Q

What is trepopnoea?

A

Dyspnoea which is worse when the patient is lying on one side (in lateral decubitus position), which is relieved by lying on the opposite side.

65
Q

What can cause trepopnoea?

A
  • Unilateral lung disease
  • Congestive heart failure – dilated cardiomyopathy
  • Lung tumour
66
Q

What would you want to ask about in a respiratory history?

A
  • Signs of URTI
    • Facial pain
    • Reduced smell
    • Rhinorrhoea/sinusitis
    • Blocked/Painful ears
    • Sore throat
  • SOB - exertion, rest, PND, orthopnoea
  • Wheeze
  • Cough +/- Sputum +/- Haemoptysis
  • Chest pain
  • Ankle/calf swelling (+/-pain)
67
Q

What conditions is clear mucoid mucus produced in??

A
  • Chronic bronchitis
  • Non-infective COPD
68
Q

What is the cause of yellow sputum?

A
  • Acute LRTI (live neutrophils)
  • Asthma (eosinophils)
69
Q

What can cause green purulent sputum?

A

Chronic infection - COPD or bronchiectasis - Purulent sputum is green because lysed neutrophils release the green-pigmented enzyme, verdoperoxidase. The first sputum produced in the morning by a patient with COPD may be green because of nocturnal stagnation of neutrophils.

70
Q

What is the cause of rusty red sputum?

A

Early pneumococcal pneumonia - as pneumonic inflammation causes lysis of red cells

71
Q

What are causes of platypnoea?

A
  • Right-to-left shunting through a patent foramen ovale
  • Atrial septal defect
  • Large intrapulmonary shunt
72
Q

What is Cheyne-Stoke breathing?

A

A breathing pattern characterised by alternating apnoeas and tachypnoeas with a crescendo–decrescendo pattern of tidal volume. In practice, what will be seen is a rhythmic waxing and waning of the depth of respiration.

The patient breathes deeply for a short time and then breathes very shallowly or stops breathing altogether. When looking at the flow, in the chest and abdomen leads there is rhythmic movement, followed by an apnoea.

73
Q

What is the cause of cheyne stokes breathing?

A
  • Congestive heart failure
  • Stroke
  • Traumatic brain injury
  • Brain tumours
  • Carbon monoxide poisoning
  • Morphine administration
74
Q

What can be the cause of early inspiratory crackles?

A

Small airway disease - e.g. bronchiolitis

75
Q

What can be the cause of inspiratory crackles which occur in the middle of inspiration?

A

Pulmonary oedema

76
Q

What can be the cause of late inspiratory crackles?

A
  • Pulmonary fibrosis - fine
  • Pulmonary oedema
  • Bronchial secretions - COPD, lung abscess, tubercular cavity
77
Q

What can cause biphasic crackles?

A

Bronchiectasis

78
Q

What is whispering perctoriloquy?

A

Whispered words are clearly heard, also called ‘whispering pectoriloquy

79
Q

What is aegophony?

A

The voice has a nasal, bleating quality (like a goat); implies high resonance.

80
Q

What are causes of aegophony and whispering pectorilquy?

A
  • Consolidation: tumour, pneumonia
  • Pleural effusion
81
Q

What can cause wheezing?

A

Asthma

Respiratory tract infections

COPD

Foreign body aspiration - bronchial foreign bodies in children may present with a ‘triad’ of unilateral wheeze + cough + decreased breath sounds.

Respiratory Physiology, Medicine and Critical Care (42 decks)

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