Resp Exam Flashcards
What is pulsus paradoxus?
An exaggeration of the normal variability of pulse volume with the respiratory cycle.
A fall in pulse volume and consequent fall in systolic blood pressure of >10mmHg during inspiration is abnormal and can occur in cardiac tamponade.
What is erythema nodosum?
Erythema nodosum over the shins is a feature of acute sarcoidosis and tuberculosis.
Raised, firm, non-tender subcutaneous nodules may occur in patients with disseminated cancer
What does clubbing indicate?
The majority of patients with finger clubbing have thoracic disease (lung cancer, bronchiectasis, interstitial lung disease, bronchiectasis).
It is also associated with gastrointestinal disorders (liver cirrhosis, malabsorption and IBS) and can be familial.
Rarely, clubbing develops relatively quickly over several weeks, in empyema.
What does a fine finger terror and a corse flapping tremor (asterixis) indicate?
A fine finger tremor is often caused by excessive use of Beta-agonist or theophylline bronchodilator drugs.
A coarse flapping tremor is seen with severe ventilators failure and carbon dioxide retention. This is the result of intermittent failure of parietal mechanisms required to maintain posture.
Unilateral asterixis is due to structural abnormality in the contralateral cerebral hemisphere.
What does a raised JVP indicate
Raised in right heart failure,
Chronic hypoxia in COPD leads to pulmonary arterial vasoconstriction, pulmonary hypertension, right heart dilatation and peripheral oedema with elevation of the JVP. This is cor pulmonale
The JVP is high if the intrathoracic pressure is raised in tension pneumothorax or severe acute asthma.
Massive PE may cause the JVP to be so high that the patient has to be sitting upright to see it.
In superior vena canal obstruction, the JVP is raised and non-pulsatile and the abdominojugular reflex is absent. Most cases are due to lung cancer compressing the SVC. Other causes include lymphoma, thymoma, and mediastinal fibrosis.
Facial flushing, distension of neck veins and strider can occur in SVCO when the arms are raised about the head
Describe abnormal lymph node findings
Scalene lymph node enlargement may be the first evidence of metastatic lung cancer
Localised cervical lymphadenopathy is a common presenting feature of lymphoma.
In Hodgkin’s disease,, the lymph nodes are typically ‘rubbery’. In dental sepsis and tonsillitis, they are usually tender.
In tuberculosis and metastatic cancer, they are often ‘matted’ together to form a mass; and calcified lymph nodes feel stony hard.
Palpable lymph nodes fixed to deep structures or skin, are usually malignant
What are abnormal chest findings?
Barrel-shaped: lung hyperinflation in patients with severe COPD.
Kyphosis: exaggerated anterior curvature
Scoliosis: exaggerated lateral curvature
Kyphosis and sclerosis may reduce ventilatory capacity and increase the work of breathing.
Pectus carinatum (pigeon chest) - localised prominence of the sternum and adjacent costal cartilages, often accompanied by in drawing of the ribs to form symmetrical horizontal grooves above the costal margin. Most often caused by severe and poorly controlled childhood asthma but can occur in osteomalacia and rickets.
Pectus excavatum (funnel chest) is a developmental deformity with a localised depression of the lower end of the sternum, or less commonly, of the whole length of the sternum. Patients are usually asymmptomatic but concerned about their appearance. In severe cases the heart is displaced to the left and the ventilatory capacity is reduced.
What are common causes of tracheal deviation?
Towards the side of the lung lesion: upper line or lung collapse, upper lobe fibrosis, pneumonectomy
Away from the side of the lung lesion: tension pneumothorax, massive pleural effusion
Upper mediastinal mass: retrosternal goitre, lung cancer, lymphoma
What does reduced chest expansion indicate?
Reduced expansion on one side indicates abnormality on that side e.g. Pleural effusion, lung or lobar collapse, pneumothorax and unilateral fibrosis
Bilateral reduction in chest wall movement is common in severe COPD and diffuse pulmonary fibrosis.
What are the different percussion notes and what are they detected over?
Resonant: Normal lung
Hyperresonant: pneumothorax
Dull: pulmonary consolidation, pulmonary collapse, severe pulmonary fibrosis
Stony dull: pleural effusion, haemothorax
What is vesicular breathing?
Breath sounds heard over the tracheobronchial tree are called bronchial breath sounds and breath sounds heard over the lung tissue are called vesicular breathing. The only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are trachea, right sternoclavicular joints and posterior right interscapular space. These are the sites where bronchial breathing can be normally heard. In all other places there is lung tissue and vesicular breathing is heard.
Vesicular breath sounds are heard across the lung surface. They are lower-pitched, rustling sounds with higher intensity during inspiration. During expiration, sound intensity can quickly fade. Inspiration is normally 2-3 times the length of expiration.
When do diminished vesicular breath sounds occur?
Obesity, pleural effusion, marked pleural thickening, pneumothorax, hyperinflation due to COPD (reduced air flow) and over an area of collapse where the underlying major bronchus is occluded e.g. Due to occluding lung cancer (reduced air flow).
If breath sounds appear reduced, ask patient to cough. If the reduced bronchial breath sounds are due to bronchial obstruction by secretions, they are likely to become more audible after coughing.
When are bronchial breath sounds abnormal?
Bronchial breathing is a high pitched breath sound with a hollow or blowing quality similar to that heard over the trachea and larynx during tidal breathing. The breath sounds are of similar length and intensity in inspiration and expiration with a characteristic pause between the two phases.
Bronchial breath sounds are found when normal lung tissue is repealed by uniformly conducting tissue and the underlying major bronchus is patent so it tends to exclude the possibility of obstructing lung cancer.
Bronchial breathing is heard over pulmonary consolidation (pneumonia), at the top of a pleural effusion and over areas of dense fibrosis
What are crackles and when can they be heard?
Crackles are interrupted non-musical sounds and result from collapse of peripheral airways on expiration. On inspiration, air rapidly enters these distal airways and the alveoli and small bronchi open abruptly, producing the crackling noise.
Early inspiratory crackles suggest small airways disease and can occur in bronchiolitis.
In pulmonary oedema crackles occur in mid/late inspiration and are of medium quality.
Fine late inspiratory crackles, which sound similar to rubbing hair between your fingers, are characteristic of pulmonary fibrosis.
Late coarse inspiratory crackles can be due to bronchial secretions in COPD, pneumonia, lung abscess, tubercular lung cavities (coarse).
Bronchiectasis can cause crackles throughout inspiration and expiration.
What is a wheeze?
Caused by continuous oscillation of opposing airway walls and has a musical quality.
They imply airway narrowing.
They are louder on expiration because airways normally dilate during inspiration and narrow on expiration. Inspiratory wheeze implies severe airway narrowing.
High-pitched wheeze arises from smaller airways and has a whistling quality.
Low-pitched wheeze originates from larger bronchi.
Distinguish wheeze from the harsh rap song rebound of strider.
Wheeze is characteristic of asthma and COPD.
In severe airways obstruction wheeze may be absent because of reduced airflow, producing a ‘silent chest’.
A fixed bronchial obstruction, most commonly due to lung cancer, may cause localised wheeze with a single musical note that does not clear on coughing.
