Resp Flashcards
Please present your respiratory examination.
I performed a respiratory examination on this gentleman, who was alert and not breathless with no paraphernalia of note at his bedside.
He had a regular pulse of 72 beats per minute and a respiratory rate of 16.
Examination of the hands and face showed no stigmata of respiratory disease.
The JVP was not raised and the trachea was central.
On closer inspection of the chest, there were no scars noted.
There was good expansion symmetrically and the percussion note was resonant throughout.
On auscultation, vesicular breath sounds were heard throughout the lung fields with no added sounds.
Finally, there was no peripheral oedema, no lymphadenopathy and the calves were soft and non tender.
In summary, this as a normal respiratory examination with no remarkable findings
I would like to complete my examination by taking a full set of observations, sending off any sputum and taking a peak flow measurement.
Please listen to these lung sounds and discuss your findings.
(Bilateral end-inspiratory fine crepitations with dry cough)
I heard fine expiratory crepitations, which would be consistent with pulmonary fibrosis. Other causes of crepitations include pulmonary oedema, pneumonia and bronchiectasis. I would ask the patient to cough to see if this would shift the crepitation.
Causes of interstitial lung disease include infection, inflammation and drugs, it can also be idiopathic.
Infective - mycoplasma, PCP, aspergillosis
Inflammation - sarcoidosis, CTD
Drugs - amiodarone, methotrexate.
Following my history and examination, I would investigate this patient with bedside tests, bloods and imaging. At the bedside I would take a full set of observations, send off a sputum sample and request lung function testing. I would take bloods for FBC, U&Es, CRP and autoimmune screen. I would request a CXR in the first instance and discuss with my senior the need for a high res CT chest.
Management can be conservative, medical or surgical, including chest physiotherapy, smoking cessation, flu vaccination. Medical Rx would depend on the cause but may include steroids. Lung transplant could be considered for severe disease.
The patient has clubbing. What causes clubbing?
Cardiac - cyanotic heart disease, infective endocarditis
Respiratory - bronchiectasis, pulmonary fibrosis, cystic fibrosis, lung cancer
Abdo - cirrhosis, coeliac, IBD
Please listen to these lung sounds and discuss your findings.
(Coarse crepitations in right base, productive cough, fever)
I heard coarse crepitations in the right base, which would be consistent with pneumonia. Other causes of crepitations include pulmonary oedema and bronchiectasis. I would ask the patient to cough to see if this would shift the crepitation. Following my history and examination, I would investigate this patient with bedside tests, bloods and imaging. At the bedside I would take a full set of observations, send off a sputum sample and send off urine for urinary antigens. I would take bloods for FBC, U&Es, CRP, blood cultures, and consider an ABG. I would request a CXR in the first instance.
If this patient showed signs of sepsis I would follow the sepsis 6, otherwise I would use the CURB-65 score to guide my management.
confusion raised urea over 7 raised RR (30 breaths per minute or more) BP low blood pressure <90/<60 age 65 years or more.
0-1 home treatment possible, 2 hospital therapy, ≥ 3 severe, consider ITU
Rx: ABCDE, Abx amoxicillin and clarithromycin to cover atypicals. May benefit from chest physio. F/U in 6 weeks.
Comps: resp failure, sepsis, empyema/abscess, effusion
Please listen to these lung sounds and discuss your findings.
(Coarse crepitations bilaterally with clubbing)
I heard coarse crepitations present bilaterally, which along with clubbing and productive cough would be consistent with bronchiectasis. Other causes of crepitations include pulmonary oedema and pneumonia. I would ask the patient to cough to see if this would shift the crepitations. Following my history and examination, I would investigate this patient with bedside tests, blood tests and imaging. At the bedside I would take a full set of observations, send off a sputum sample and request lung function testing. I would take bloods for FBC, U&Es, CRP, blood cultures, VBG. I would request a CXR in the first instance and discuss with my senior the need for a high res CT chest.
Bronchiectasis is an abnormal, permanent dilation of the bronchi. Causes include post-infectious (due to repeated childhood infections, TB), pulmonary disease (COPD/asthma exacs), congenital (CF, PCD), inflammation (rheumatoid, sarcoidosis), obstruction (bronchial carcinoma) & idiopathic.
Management can be conservative, medical or surgical, including chest physiotherapy, smoking cessation, mucoactive agents and long term antibiotics, and lung resection or transplant.
Please listen to these lung sounds and discuss your findings.
(Wheeze+/- crep, hyperexpanded)
I heard coarse crepitations in the right base, which would be consistent with an obstructive lung disease such as COPD. Other causes of crepitations include pulmonary oedema and bronchiectasis. Following my history and examination, I would investigate this patient with bedside tests, bloods and imaging. At the bedside I would take a full set of observations, send off a sputum sample and order lung function tests. I would take bloods for FBC, U&Es, CRP, blood cultures, and consider an ABG. I would request a CXR in the first instance.
Management can be conservative, medical or surgical, including smoking cessation, chest physiotherapy, influenza vaccine and personalised Rx plan. Medical options include inhalers such as SABA and LABA (salmeterol), LAMA (tiotropium), and ICS. Patients may require long term oxygen. Surgical options may be considered for severe refractory COPD (bullectomy, lung volume reduction (LVRS) and lung transplantation)
Complications: exacerbations/infection, pneumothoraces, polycythaemia, cor pulmonale
Please listen to these lung sounds and discuss your findings.
(Focal creps + cachexia, clubbing)
In this case I would consider lung cancer as a differential. Cough, haemoptysis, dyspnoea, chest pain, FLAWS, pneumonia, hoarseness.
I would investigate this patient with bedside tests, bloods and imaging. At the bedside I would take a full set of observations, send off a sputum sample and order lung function tests. I would take bloods for FBC, U&Es, CRP, LFTs, Ca. I would request a CXR in the first instance and discuss with my senior the need for a CT chest. Other tests could include bronchoalveolar lavage and pleural tap for MC&S and cytology. If a lesion was found, a biopsy would be required - percutaneous or via bronchoscopy.
I would send this patient to the lung cancer MDT who would consider the patient’s treatment options, which could be surgical, radiotherapy or chemotherapy.
Complications: local invasion (Horner’s), paraneoplastic (PTHrP, SIADH, Cushing’s), metastases (bone, liver, brain)
