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MBBS IV - CCT Preparation > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Interpret:

Reduced chest wall movement
Bilateral or focal coarse inspiratory crackles, through inspiration and expiration, may clear temporarily after coughing
Sputum container with purulent or blood stained sputum
Finger clubbing
Percussion normal
+/- cor pulmonale symptoms

Dx and ddx?

A

Bronchiectasis

Ddx:
Pulmonary fibrosis: fine crackles at late inspiratory phase, reduced lung volume

COPD with chronic bronchitis: less coarse crackles and more hyperinflation

Asthma: crackles +/- wheezing, copious tenacious sputum production

Post-TB lung destruction: bronchiectasis, fibrosis and cavitation, focal/ unilateral bronchiectasis

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2
Q

Causes of bronchiectasis

A 
Idiopathic (most)
Post- tuberculosis 
Post-pneumonia 
Childhood measles or pertussis 
Rheumatoid arthritis, SLE 
Pulmonary fibrosis causing traction bronchiectasis

Kartagener’s syndrome
Allergic bronchopneumonia aspergillosis (ABPA)

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3
Q

Interpret:

Bilateral pitting LL edema 
Tachypnea 
Reduced gap between suprasternal notch and cricoid cartilage 
Barrel chest 
Hyper-resonant on percussion 
Decreased breath sounds with long expiratory phase +/- inspiratory crackles 
Low vocal resonance 
Pursed lip breathing

Dx and ddx?

A

COPD

Ddx:
Chronic asthma: shows greater variation in symptoms + reversible airflow obstruction on spirometry

Overlapping asthma and COPD: ACOS

Bronchiectasis: lung crackles across insp. and expiration

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4
Q

Risk factors of COPD

A

Cigarette smoking

Heavy exposure to indoor air pollution

Alpha-1 antitrypsin deficiency

Occupational exposure to dusts or fumes

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5
Q

Interpret:

Tachypnea
Decreased chest movement on affected side
Tracheal deviation +/- apex shift to affected side
Dull percussion to affected sides
Decreased breath sounds on affected areas

Dx?
Causes?
How to distinguish upper or lower lung lobe pathology?

A

Lung collapse

Causes:

  • Endobronchial obstruction or extrinsic compression by neoplasm
  • Foreign body aspiration
  • Infections: endobronchial TB

Tracheal deviation in upper lobe, Apex deviation in lower lobe

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6
Q

How to distinguish pleural effusion and lung collapse in PE?

A

Tracheal or mediastinal shift towards collapse side; shift away from effusion

Dull on percussion for collapse, stony dull for effusion

Decreased breath sounds/ vocal resonance for BOTH

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7
Q

Interpret:

Tachypnea 
Decreased chest movement on left side 
Tracheal deviation to right side 
Stony dull on percussion on left side 
Decreased breath sounds on left side 
Decreased bronchial breath sounds on left side 
Distinct small scar in the back

Dx?
Causes?

A

Pleural effusion

Infection: bacterial, TB or fungal pleurisy, suppurative aspiration pneumonia
Cancer: Malignant effusion or mesothelioma
Bilateral: Hepatic hydrothorax, heart failure, kidney failure

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8
Q

Ddx of pleural effusion

A

Lung collapse/ consolidation
Raised hemidiaphragm
Large lung mass

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9
Q

Interpret:

Tachypneic with O2 supply
Finger clubbing
Normal palpation and percussion
Fine, end-inspiratory crackles at lower zones, bilateral in posterior and lateral aspects

Dx?

A

Idiopathic pulmonary fibrosis

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10
Q

What diseases give clubbing and inspiratory crackles

A

Bronchiectasis if bilateral

Obstructive pneumonia due to lung cancer if localized

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11
Q

Most useful test for diagnosis of idiopathic pulmonary fibrosis?

A

High resolution CT thorax

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12
Q

Conditions that may be mistaken for asthma?

A

Upper airway obstruction: laryngeal stenosis, tumor, vocal cord dysfunction

Lower airway obstructive diseases: bronchiectasis, COPD, bronchiolitis aspergillosis, eosinophilic granulomatous pulmonary angiitis (EPGA)
Left heart failure

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13
Q

Interpret:

Cough with sputum + hemoptysis
History of recurrent lung infections
Dyspnea
Coarse inspiratory crackle over bilateral lower zones
Mild finger clubbing with no cervical lymphadenopathy
Loud P2

Dx?
Tests?

A

Bronchiectasis

High resolution CT thorax
Lung function test
24 hour sputum volume

Find etiologies by:
Gastric reflux study
Sputum for AFB
Serum immunoglobulin levels

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14
Q

Appearance of bronchiectasis on HRCT

A

Signet ring appearance:
internal lumen of affected airways are larger than accompanying arteries

Lack of normal bronchial tapering

Presence of peripheral airways within 1cm of costal pleura

Air-fluid levels in dilated bronchi

Linear clusters of cysts

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15
Q

Causes of hoarseness of voice?

A

→ Common: laryngitis, inhaled corticosteroid
→ Other respiratory: RLN palsy (in Lt CA lung), CA larynx
→ Non-respiratory: hypothyroidism (myxedema of vocal cord)

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16
Q

Causes of dry cough

A

chest infection, asthma, CA lung, LVF, ILD, ACEI side effects

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17
Q

Causes of bovine and whooping cough

A

Bovine cough: lack of usual explosive beginning
→ Indicates vocal cord paralysis

Whooping cough: violent and rapid coughing preceded by a loud ‘whooping’ inhalation
→ Indicates pertussis

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18
Q

Respiratory hand signs

A
  • Clubbing: 80% due to respiratory diseases
  • Hypertrophic pulmonary osteoarthropathy (HPO):
    Paraneoplastic periosteal inflammation at distal ends of bones
    swelling and tenderness over the wrists
    D/dx: primary CA lung, pleural fibromas, idiopathic
  • Tar stains at fingers
  • Wasting and weakness:
    □ Look for wasting of small muscles of hand and finger
    abduction weakness
    □ May be caused by compression and infiltration of T1 lower trunk by Pancoast tumour
  • Asterixis (flapping tremor)
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19
Q

3 causes of asterixis

A

D/dx:
→ Severe CO2 retention
→ Hepatic encephalopathy
→ Azotaemia due to kidney failure

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20
Q

Respiratory neck signs

A

Cervical lymphadenopathy

JVP for cor pulmonale signs

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21
Q

List 4 abnormal chest wall shapes and associated pathologies

A

1) Barrel chest: ↑AP diameter due to hyperinflation of lungs
D/dx:
→ Severe asthmas, emphysema
→ Normal in elderly, thin people (∵small abdomen)

2) Funnel chest (pectus excavatum):
□ Localized depression at lower end of
sternum
□ May occur in congenital syndromes
eg. Marfan syndrome

3) Pigeon chest (pectus carinatum):
□ Outward bowing of sternum and costal cartilage
□ D/dx:
→ Chronic childhood respiratory illness
→ Bony malformation, eg. rickets
→ Congenital syndromes, eg. Marfan syndrome

4) Kyphoscoliosis:
exaggerated forward curvature of spine and lateral bowing of spine
D/dx:
→ Idiopathic (80%)
→ Secondary to poliomyelitis
→ Marfan’s syndrome-associated
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22
Q

Surgeries associated with midline sternotomy

A

Midline sternotomy: midline
along sternum
→ CABG
→ Lung transplant

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23
Q

Surgeries associated with thoracotomy scar

A 
Thoracotomy: long diagonal
posterior scar on thorax
→ Pneumonectomy
→ Lobectomy
→ Lung transplant
→ Thoracoplasty
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24
Q

Surgeries associated with VAT scars

A

Video-assisted thoracoscopy (VATs): three 2-3cm scars
→ Bx of lymph nodes
→ Lung reduction surgery
→ Pleurodesis

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25
Q

Location of chest drain scars

A

At posterior lung base

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26
Q

Define normal and abnormal rates of breathing

A

□ Normal = 16 – 25/min (classically quote 12-16/min)
□ Tachypnoea = >25/min
□ Bradypnoea = <8/min

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27
Q

2 signs of dyspnea

A

Use of accessory respiratory muscles: sternocleidomastoids, platysma, strap muscles of neck
→ Inspiration: elevation of shoulders
→ Expiration: contraction of abdominal muscles

In-sucking: in-drawing of intercostal and supraclavicular spaces during inspiration

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28
Q

Cause of paradoxical breathing

A
  • Abdomen sucks inwards with inspiration
  • Cf normally pouching outward due to
    diaphragmatic descent

> > Diaphragmatic paralysis

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29
Q

5 characteristics signs of COPD

A

□ Use of accessory muscles
→ Indicating ↑work of breathing

□ In-drawing of intercostal and supraclavicular spaces
→ Indicating a more negative intrathoracic pressure

□ Pursed-lip breathing
→ Provides positive airway pressure
→ prevent airway collapse during expiration

□ Lean forward with arms on knees
→ Compresses abdomen + pushes diaphragm upward
→ restore dome shape of diaphragm
→ Improve effectiveness during inspiration

□ Tracheal tug

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30
Q

Causes of unilateral decrease chest wall movement

A

Unilateral:

  • Localized lung fibrosis
  • Consolidation
  • Collapse
  • Pleural effusion
  • Pneumothorax
  • Pain (pleuritic, trauma)
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31
Q

Causes of bilateral reduced chest wall movement

A

COPD

ILD

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32
Q

Describe Hoover’s sign for COPD

A

Hoover’s sign for COPD
□ Hands placed along costal margin with thumbs close to xiphisternum
□ Normal = separation of thumbs
□ COPD = thumbs become closer

In COPD, the lungs become hyperinflated, pressing the diaphragm downward. Therefore, normal inspiratory contraction of diaphragm actually draws the rib cage inward.

33
Q

Differentiate mediastinal deviation causes

A

→ Volume loss lesion if towards side of lesion

  • Lobar collapse
  • Lobar fibrosis
  • Pnuemonectomy

→ Space-occupying lesion if away from side of lesion

  • Pleural effusion
  • Tension pneumothorax
  • Other masses, eg. retrosternal goitre
34
Q

Sites of percussion in respiratory exam

A

□ Bilateral supraclavicular fossa at apex
□ Bilateral clavicle (direct tapping)
□ Bilateral anterior chest for 3 times
→ Move laterally at Lt inferior chest to avoid cardiac dullness
□ Bilateral axilla for 2 times

□ Bilateral posterior chest for 4 times
→ Percuss at apex from behind
→ Percuss between medial border of scapula and spine
→ Ask pt to cross arms in front to hold contralateral shoulder
→ protracts scapula to further expose upper lobe
→ Also percuss at posterior axillae

35
Q

Percussion findings and implications in respiratory exam

A

□ Resonant over normal lung
□ Hyperresonant over hollow structure, eg. bowels,
pneumothorax
□ Dull over solid structure, eg. consolidation, liver, lung
collapse
□ Stony dull over fluid-filled structure eg. pleural effusion

36
Q

Implications of lack of liver and cardiac dullness

A

Hyperinflation of lungs

Emphysema or asthma

37
Q

Sites of auscultation in respiratory exam

A

 Ask pt to take deep breaths in and out through the mouth

 Auscultate bilaterally at the following sites:
□ Supraclavicular fossa (B)
□ Anterior chest for 3 times (D/B)
→ Move laterally at Lt inferior chest to avoid heart
□ Axilla for 2 times (D/B)
□ Posterior chest for 4 times (D/B)

38
Q

Define causes of vesicular vs bronchial breath sounds

A

Vesicular (normal) sounds:
□ Origin: flow vortices in small airway (inspiration),
large airway (expiration)

Bronchial breath sounds:
□ Origin: turbulent flow in large airways

39
Q

Define difference in characteristics between vesicular vs bronchial breath sounds

A

Vesicular (normal) sounds: faint, low-pitched rushing sound
→ Gentle beginning and end
→ Inspiratory phase longer and louder12 (E:I ≈ 1:3)
→ No gap between inspiratory and expiratory phases

Bronchial sounds:
higher-pitched, hollow, blowing quality
→ Inspiratory phase shorter/equal and softer (E:I ≈ 1-3:1)
→ Expiratory phase louder and higher pitch
→ Audible gap between inspiratory and expiratory phases

40
Q

All bronchial breath sounds are abnormal.

T or F

A

→ Normal when heard over manubrium or posterior central chest, Normally muffled by alveoli (high pitch)
→ NOT heard over peripheral chest

→ Abnormal when heard over peripheral chest
Indicates ↑sound transmission in alveoli

41
Q

Causes of bronchial breath sounds

A

Common
- Lung consolidation

Uncommon

  • Localized pulmonary fibrosis
  • Above pleural effusion
  • Collapsed lung
42
Q

Causes of unilateral decreased breath sounds

A 
Unilateral ↓breath sounds indicate bronchial
obstruction
□ COPD, esp emphysema
□ Pleural effusion
□ Pneumothorax
□ Pneumonia
□ Large neoplasm
□ Collapsed lungs
43
Q

Wheezing

  • Timing
  • Characteristic
  • Pitch
  • D/dx
A

Timing:
Most commonly expiratory
Inspiratory or biphasic wheezes indicate severe narrowing

Characteristics:
musical quality due to continuous oscillation of airway walls

Pitch:
Higher pitch from smaller bronchi
Lower pitch (aka rhonchi) from larger bronchi

D/dx:
□ Asthma (often high-pitched)
□ COPD (often low-pitched)

44
Q

Define different timings of crackles and implied underlying conditions

A

□ Early inspiratory indicates small airway obstructive diseases (eg. COPD)

□ Mid-inspiratory indicates pulmonary oedema

□ Late or pan-inspiratory indicates alveolar diseases
→ Pulmonary fibrosis (fine)
→ Pulmonary oedema (medium)
→ Pneumonia, lung abscess, TB, COPD secretions (coarse)

□ Biphasic indicates bronchiectasis (coarse)

45
Q

Explain physiology of fine crackles

A

Fine crackles indicates airway instability
→ Expiration → small airways collapse
→ Inspiration → air rapidly enters distal airways → pops open

D/dx: pulmonary fibrosis

46
Q

Physiology of medium crackles

A

Medium crackles indicates disruption of surfactant function

→ D/dx: pulmonary oedema (due to LV failure)

47
Q

Physiology of coarse crackles

A

Coarse crackles indicates excess bronchial secretions
→ Inspiration → air bubbles through secretions → gurgling sounds
→ Disappear upon coughing

D/dx: bronchiectasis, other causes of retained bronchial secretions

48
Q

Causes of pleural friction rub

A 
pleurisy
□ Pulmonary embolism
□ Pneumonia
□ Pleural malignancy
□ Spontaneous pneumothorax
□ Pleurodynia: pain due to rib cage/diaphragm pathologies
49
Q

Define different vocal resonance and underlying pathologies

A

1) Normal lung:
→ Transmits low-pitched sound with a booming quality
→ High-pitched sound becomes attenuated
2) Consolidated lung:
→ Transmit high frequency with a bleating quality
→ Aegophony: ‘ee’ becomes ‘aa’

□ Normal areas: sound inaudible and muffled
□ Consolidation: clearly audible (pectoriloquy)
□ Pleural effusion: even more muffled

50
Q

D/dx for cor pulmonale

A
  • Idiopathic
  • COPD
  • ILD
  • Pulmonary thromboembolism
  • Marked obesity
  • Sleep apnoea
  • Severe kyphoscoliosis
51
Q

Signs of cor pulmonale

A

□ JVP for RH failure → may indicate cor pulmonale

□ Auscultation for P2 > A2 → suspect pulmonary hypertension

52
Q

Cause of Pemberton’s sign

A

Pemberton’s sign:
□ Ask pt to lift arms over head and wait for 1min
□ Development of facial plethora, cyanosis, inspiratory stridor, non-pulsatile ↑JVP

→ indicates SVC obstruction

53
Q

Interpret:

Flattened chest and deep supraclavicular fossa on left side
Reduced chest wall movement on left side
Tracheal deviation to the left side
Dull percussion over clavicles
Decreased breath sounds on left side with localized fine crackles

Dx?

3 causes?

A

Apical fibrosis

Old pulmonary TB
Ankylosing spondylitis
Post-radiation pulmonary fibrosis (e.g. lung cancer)

54
Q

Conditions that give clubbing with inspiratory crackles

A

Bronchiectasis - bibasilar

Obstructive pneumonia e.g. due to lung cancer - localized

55
Q

What systemic features would you look for in pulmonary fibrosis

A

Autoimmune diseases such as RA

56
Q

Interpret:

Cachexic
Tachypnea 
Central trachea 
Decreased chest movement on right side 
Dull percussion on right lower chest 
Decreased breath sounds on right lower zone 
Vocal resonance reduced over lower zone

dx?
ddx?

A

Pleural effusion

RLL collapse/ consolidation
Raised hemidiaphragm
Large lung mass

57
Q

4 different types of sputum and associated pulmonary conditions

A

Very tenacious in asthma

Purulent (creamy or yellow) in URTI or pneumonia

Brown/ Red for intra-alveolar haemorrhage

True mucoid with greyish fragments +/- blood stains- Bronchiectasis

58
Q

Characteristic signs of COPD

A 
□ Use of accessory muscles
□ In-drawing of intercostal and supraclavicular spaces
□ Pursed-lip breathing
□ Lean forward with arms on knees
□ Tracheal tug
59
Q

Unilateral decrease chest wall movement

A

Unilateral:

  • Localized lung fibrosis
  • Consolidation
  • Collapse
  • Pleural effusion
  • Pneumothorax
60
Q

Bilateral decrease chest wall movement

A

Bilateral:

  • COPD
  • ILD
61
Q

Explain Hoover’s sign for COPD

A 
Hoover’s sign for COPD
□ Hands placed along costal margin with thumbs close to
xiphisternum
□ Normal = separation of thumbs
□ COPD = thumbs become closer
62
Q

List volume loss lesions and space-occupying lesions

A

→ Volume loss lesion if towards side of lesion

  • Lobar collapse
  • Lobar fibrosis
  • Pnuemonectomy

→ Space-occupying lesion if away from side of lesion

  • Pleural effusion
  • Tension pneumothorax
  • Other masses, eg. retrosternal goitre
63
Q

Test for use of accessory respiratory muscles

A

Use of accessory respiratory muscles:
□ Place fingers in supraclavicular fossa → feel for contraction of scalene muscles
□ Place fingers on SCM muscle → feel for contraction of SCM

64
Q

4 different percussion qualities and underlying causes

A

□ Resonant over normal lung
□ Hyperresonant over hollow structure, eg. bowels,
pneumothorax
□ Dull over solid structure, eg. consolidation, liver, lung
collapse
□ Stony dull over fluid-filled structure eg. pleural effusion

65
Q

What causes loss of liver and cardiac dullness

A

Emphysema or Asthma can cause hyperinflation&raquo_space; decrease liver and cardiac dullness

66
Q

Causes of bronchial breath sounds

A 
Common
- Lung consolidation
Uncommon
- Localized pulmonary fibrosis
- Above pleural effusion
- Collapsed lung
67
Q

Differences between bronchial and vesicular breath sounds

A

Vesicular (normal) sounds:
Characteristics: faint, low-pitched rushing sound
→ Gentle beginning and end
→ Inspiratory phase longer and louder12 (E:I ≈ 1:3)
→ No gap between inspiratory and expiratory phases

Bronchial breath sounds:
Characteristics: higher-pitched, hollow, blowing quality
→ Inspiratory phase shorter/equal and softer (E:I ≈ 1-3:1)
→ Expiratory phase louder and higher pitch
→ Audible gap between inspiratory and expiratory phases

68
Q

Causes of unilateral decrease in breath sounds

A 
Unilateral ↓breath sounds indicate bronchial
obstruction
□ COPD, esp emphysema
□ Pleural effusion
□ Pneumothorax
□ Pneumonia
□ Large neoplasm
□ Collapsed lungs
69
Q

Causes of wheezing

A

→ Polyphonic wheeze indicates diffuse airway narrowing (asthma, COPD)
→ Monophonic wheeze (that is not cleared by coughing) indicates fixed bronchial obstruction

D/dx: acute or chronic airway obstruction (bronchospasm + mucosal oedema + excessive secretions)
□ Asthma (often high-pitched)
□ COPD (often low-pitched)

70
Q

Difference between stridor, rhonchi, rales, crepitations

A
  • Stridor = inspiratory wheezing sound
  • Rhonchi = low-pitched wheezes
  • Rales = low-pitched crackles
  • Crepitations = high-pitched crackles
71
Q

Causes of early inspiratory crackles

A

small airway obstructive diseases (eg. COPD)

72
Q

Causes of mid inspiratory crackles

A

pulmonary oedema

73
Q

Causes of pan/ late inspiratory crackles

A

→ Pulmonary fibrosis (fine)
→ Pulmonary oedema (medium)
→ Pneumonia, lung abscess, TB, COPD secretions (coarse)

74
Q

Cause of biphasic crackles

A

Biphasic indicates bronchiectasis (coarse)

75
Q

Cause of fine, medium and coarse crackles

A 
Fine = pulmonary fibrosis
Medium = pulmonary edema 
Coarse = Bronchiectasis
76
Q

Causes of increased or decreased vocal resonance

A

Consolidation = increase vocal resonance

Pleural effusion = decrease vocal resonance

77
Q

D/dx of cor pulmonale

A
  • Idiopathic
  • COPD
  • ILD
  • Pulmonary thromboembolism
  • Marked obesity
  • Sleep apnoea
  • Severe kyphoscoliosis
78
Q

5 additional exams after respiratory exam

A

Heart:
□ JVP for RH failure → may indicate cor pulmonale
□ Auscultation for loud P2 → suspect pulmonary hypertension

Liver:
□ Drooping due to emphysema
□ Enlargement due to CA lung metastasis

Pemberton’s sign: SVC obstruction due to CA compression

MBBS IV - CCT Preparation (10 decks)

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