Resp Exam

Question 1

what are peripheral stigmata of respiratory diseases seen in hands?

Answer 1

• clubbing, hypertrophic pulmonary osteoarthropathy
• cyanosis, ie nails blue (o2 sat <85%)
• tar staining
• wasting of intrinsic muscles (T1 nerve innervation by an apical lung cancer)
• swelling [can feel for it] (rheumatological disease- PE, pulmonary fibrosis, HPO)
• thinning, bruising of skin from long-term steroid use (ILD, COPD, asthma)
• Asterixis (CO2 retention, liver failure), fine tremor (B2 agonists)

Question 2

what does low temperature of the hands suggest?

Answer 2

peripheral vasoconstriction / poor perfusion

Question 3

bounding pulse?

Answer 3

CO2 retention

Question 4

pulsus paradoxus ?

Answer 4

in asthma , COPD (in obstructive diseases) and cardiac tamponade

Question 5

raised JVP?

Answer 5

non-pulsatile : SVC obstruction (eg. in lung cancer; also look for face and neck oedema + distended superficial collateral veins on chest wall )
pulsatile: congestive heart failure, pulmonary HTN/fluid overload

Question 6

sure looking at internal/external jugular vein (for JVP)?

Answer 6

• double phase
• not palpable
• collapses/obliterated with finger
• heptaojugular reflex present

Question 7

resp signs in eyes?

Answer 7

• chemosis (conjunctival oedema due to hypercapnia secondary to COPD)
• pallor (anaemia)
• Horner’s syndrome: ptosis mitosis and unilateral anhidrosis (invasion of sympathetic chain by Pancoast’s apical tumour ± ipsilateral hand wasting)

Question 8

tongue?

Answer 8

• central cyanosis (can check under tongue also)
• oral candidiasis from steroid inhaler use (can be on tongue, palate or as angular stomatitis)

also check for dental caries

Question 9

face?

Answer 9

• oedema (SVC obs)
• pink/malar flush (CO2 retention)
• blue (central cyanosis)
• lips pursing (COPD)

Question 10

fine tremor of hands?

Answer 10

SE of B2-agonists eg. salbutamol

Question 11

Flapping tremor of hands?

Answer 11

CO2 retention [eg. in T2RF like COPD]

Question 12

scars on thorax?

Answer 12

• clavicular: pacemaker
• small mid-axillary : chest drain
• horizontal postero-lateral: thoracotomy eg. for lobectomy, pneumonectomy
• central chest: sternotomy, thoracotomy

Question 13

asymmetry in chest?

Answer 13

due to major surgery

• pneumonectomy (eg. for cancer)
• thoracoplasty (rib removed/to treat TB)

Question 14

chest deformities?

Answer 14

• Barrel chest [increased AP diameter] : hyper inflated, eg. emphysema
• kyphoscoliosis [reduced ventilatory capacity + increased work of breathing : eg. ankylosing spondylosis, syringomyelia, ?MSK shite
• pectus excavatum [funnel chest] : developmental defect
• pectus carinatum [pigeon chest] ± Harrison’s sulci : common after childhood resp disease, rickets, etc.

Question 15

right ventricular heave?

Answer 15

secondary to cor pulmonale (eg. due to chronic hypoxic lung ds such as COPD, ILD)

Question 16

how to check for rt. ventricular heave?

Answer 16

heel of hand just next to left sternal border, feeling for parasternal heave

Question 17

trachea deviation?

Answer 17

• away from pneumothorax, large pleural effusions

- towards lobar collapse, pulmonary fibrosis, pneumonectomy

Question 18

resp cause of clubbing?

Answer 18

• bronchial malignancy
• idiopathic pulmonary fibrosis
• suppurative (empyema, lung abscess, bronchiectasis, CF)

Question 19

cardiac cause of clubbing?

Answer 19

• atrial myxoma
• bacterial endocarditis
• cyanotic heart disease

Question 20

abdo cause of clubbing?

Answer 20

• cirrhosis
• Crohn’s
• UC
• CD

Question 21

what common lung disease DOES NOT cause clubbing?

Answer 21

COPD

Question 22

vocal resonance and percussion in pneumothorax?

Answer 22

reduced, hyperprecussion

Question 23

vocal resonance and percussion in consolidation

Answer 23

increased, dull

Question 24

vocal resonance and percussion in effusion

Answer 24

reduced, stony dull

Question 25

percussion of consolidation?

Answer 25

DULL ± bronchial breathing, crepitations (crackles)

Question 26

percussion of effusion?

Answer 26

STONY DULL ± bronchial breathing above the area

Question 27

what are you listening to when auscultating?

Answer 27

whether sounds are: - equal - vesicular/bronchial - added sounds eg. crackles, wheeze, pericardial rubs

Question 28

bronchial breathing?

Answer 28

alveoli collapse

Question 29

wheeze (rhonchi)

Answer 29

always EXPIRATORY

Question 30

stridor

Answer 30

always INSPIRATORY medical emergency eg. due to upper resp Airways obstruction

Question 31

crackles/crepitations?

Answer 31

- coarse [scrunching up crisp packet]: pneumonia, bronchiectasis, fluid overload, pulmonary oedema - fine [velcro sound] : pulmonary fibrosis

Question 32

change in crepitations after coughing?

Answer 32

- change if due to secretions | - no change if due to fibrosis

Question 33

reduced lung expansion?

Answer 33

- lung collapse, pneumonia

Question 34

vocal resonance (99) / whispering pectoriloquy (111) in consolidation

Answer 34

increased

Question 35

vocal resonance (99) / whispering pectoriloquy (111) in pleural effusion, pneumothorax ?

Answer 35

reduced

Question 36

where check for oedema ?

Answer 36

- sacrum - ankles (medial part of shins) to check for cor pulmonale

Question 37

check leg for what?

Answer 37

DVT ! [PE risk] squeeze calves tender? hot? etc. and ERYTHEMA NODOSUM (assess with sarcoid)

Question 38

bronchial breathing associated with?

Answer 38

consolidation

Question 39

increased vocal resonance

Answer 39

- consolidation - lobar collapse - tumour

Question 40

decreased vocal resonance

Answer 40

- pleural effusion | - pneumothorax

Question 41

lymphadenopathy sign of?

Answer 41

- Lung cancer - TB - Sarcoidosis

Question 42

end exam how?

Answer 42

- thank pt + ask to REDRESS - wash hands - summarise would further: - check sputum pot - say would do O2 stats - assess peak flow - full set of bloods, ABG, sputum MC&S, CXR/chest CT, temp, etc.

Question 43

Amiodarone imp resp SE?

Answer 43

causes pulmonary fibrosis | not like IPF which is progressive and eventually kills