Important respiratory presentations

Question 1

Pneumonia: inspection

Answer 1

Look for sputum pot at bedside.
Tachypnoeic, tachycardia, or hypotensive?
Warm peripheries.
Bounding pulse.
Sweaty and clammy.

Question 2

Pneumonia: palpation

Answer 2

Reduced expansion on the affected side.

Increased tactile vocal fremitus if consolidation.

Question 3

Pneumonia: percussion

Answer 3

Dull.

Question 4

Pneumonia: auscultation

Answer 4

Coarse crackles, localised.
Bronchial breathing (possible).
Whispering pectoriloquy.
Reduced air entry.
Increased vocal resonance.

Question 5

Lobar collapse: palpation

Answer 5

Mediastinal shift towards the abnormality.

Potentially decreased chest wall movement locally.

Question 6

Lobar collapse: percussion

Answer 6

Dullness to percussion restricted to affected lobe.

Question 7

Lobar collapse: auscultation

Answer 7

Decreased breath sounds usually.

Question 8

Pleural effusion: inspection

Answer 8

Reduced chest expansion unilaterally (if large).

Question 9

Pleural effusion: palpation

Answer 9

Trachea may be pushed away from the effusion.
Apex beat: a large right effusion will displace the cardiac apex to the left; a large left effusion may make the apex beat difficult to palpate.

Question 10

Pleural effusion: percussion

Answer 10

‘Stony dull’.

Question 11

Pleural effusion: auscultation

Answer 11

Markedly reduced breath sounds.
Reduced vocal resonance.
Collapsed or consolidated lung above the effusion may produce an overlying region of bronchial breathing.

Question 12

Pneumothorax: inspection

Answer 12

No mediastinal shift (only occurs with tension pneumothorax).
Chest wall asymmetry may be evident with a large pneumothorax (greater volume on affected side).

Question 13

Pneumothorax: percussion

Answer 13

Hyper-resonant.

Question 14

Pneumothorax: auscultation

Answer 14

Reduced breath sounds on affected side.

Reduced vocal resonance on affected side.

Question 15

Interstitial fibrosis: inspection

Answer 15

Patients may be cyanosed.
There may also be signs of connective tissue disease or skin changes of radiotherapy.
Clubbing is common.

Question 16

Interstitial fibrosis: palpation

Answer 16

Trachea may move towards the fibrosis in upper lobe disease.

Normal or reduced chest wall movement.

Question 17

Interstitial fibrosis: percussion

Answer 17

Normal percussion note.

Question 18

Interstital fibrosis: auscultation

Answer 18

Normal breath sounds.
Normal vocal resonance usually, may be increased if dense fibrosis.
Fine velcro crackles.

Question 19

COPD: inspection

Answer 19

Inhalers at the bedside.
Sputum pot?
Thin skin with bruising (use of steroids).
Use of accessory muscles/ brace position.
Tachypnoea.
No mediastinal shift.
Chest hyper-expanded with little additional excursion.
Prolonged expiration and pursed lip breathing.

Question 20

COPD: percussion

Answer 20

May be globally hyper-resonant to percussion.

Question 21

COPD: auscultation

Answer 21

Reduced breath sounds globally, may be additional polyphonic wheeze.
Reduced vocal resonance usually in the upper lobes (where bullae are commonest).
Heart sounds often quiet.

Question 22

Bronchiectasis: inspection

Answer 22

Often copious sputum (usually purulent, may contain blood).
Digital clubbing may be present.
Low BMI.

Question 23

Bronchiectasis: palpation

Answer 23

No mediastinal shift.

Chest wall expansion equal.

Question 24

Bronchiectasis: percussion

Answer 24

Percussion resonant.

Question 25

Bronchiectasis: auscultation

Answer 25

Mixed, predominant coarse crackles.
Often additional polyphonic wheeze.
Vocal resonance normal.

Question 26

Neuromuscular insufficiency: respiratory inspection

Answer 26

Non-respiratory signs of neuromuscular illness (e.g. altered phonation, limited mobility).
Rapid shallow breathing, sometimes with abdominal paradox.

Question 27

Neuromuscular insufficiency: respiratory palpation

Answer 27

Chest wall expansion equal but limited excursion.

Question 28

Neuromuscular insufficiency: respiratory percussion

Answer 28

Percussion note resonant.

Question 29

Neuromuscular insufficiency: respiratory auscultation

Answer 29

Breath sounds normal.

Basal crackles common from atelectasis (impaired cough).