Respiratory

Question 1

3 causes of dry cough

Answer 1

1. Post-nasal drip
2. Asthma/ COPD +/- wheeze
3. Reflux

Question 2

What does the following coughs suggestive of:
1. Purulent sputum
2. Foul-smelling, dark coloured sputum
3. Pink frothy sputum
4. Hemoptysis

Answer 2

1. Purulent sputum - bronchiectasis/ lobar pneumonia
2. Foul-smelling, dark coloured sputum - lung abscess with anaerobic organism
3. Pink frothy sputum - from the trachea, occur with pulmonary edema
4. Hemoptysis - pneumonia, malignancy, TB, bronchiectasis, pulmonary infarction

Question 3

Severity of dyspnoea (Class I-IV)

Answer 3

• Class I—dyspnoea on heavy exertion
• Class II—dyspnoea on moderate exertion
• Class III—dyspnoea on minimal exertion
• Class IV—dyspnoea at rest

Question 4

Duration of onset of dyspnoea for PE/ pneumothorax?

Answer 4

It comes suddenly

Question 5

What significant hx to ask in the past medical hx for respiratory presentation? (2)

Answer 5

1. Any previous infection - pneumonia, tuberculosis, exacerbation of chronic bronchitis
2. Any previous abnormal imaging - CT/ CXR

Question 6

Drug classes that can potentially cause Dyspnoea (4)

Answer 6

1. OCP - PE
2. Cytotoxic agents - ILD
3. Beta-blockers/ aspirin - bronchospasm
4. ACEi - cough

Question 7

What occupational history should be explored in patient with dyspnoea?

Answer 7

1. Possible exposure to dusts in mines and factories (e.g. asbestos, coal, silica, iron oxide, tin oxide, cotton, beryllium, titanium oxide, silver, nitrogen dioxide or anhydrides) and if ventilators/ equipments provided to reduce the workplace exposure
2. Work or household exposure to animals, including birds (e.g. Q fever or psittacosis)
3. Exposure to mouldy hay, humidifiers or air-conditioners, which may also result in lung disease (e.g. hypersensitivity pneumonitis)
4. Exposure to spray painting and wood dusts, which may provoke occupational asthma that typically resolves on weekends or on holidays

Question 8

Significant family hx conditions for dyspnoea (4)

Answer 8

1. Emphysema
2. A1-antitrypsin deficiency
3. Asthma
4. Cystic fibrosis

Question 9

4 signs to look for in hand examination

Answer 9

1. Clubbing - carcinoma of lung, chronic lung suppuration and interstitial lung disease
2. Cigarette staining
3. Wasting of muscle - Compression and infiltration by a peripheral lung tumour of a lower trunk of the brachial plexus
4. Palm crease pallor - Anaemia

Question 10

3 types of sputum

Answer 10

Purulent, Mucoid, mucopurulent

Question 11

Causes of hoarseness

Answer 11

1. Laryngitis
2. Vocal cord tumour
3. Recurrent laryngeal nerve palsy (e.g. from an apical lung cancer) 4. 4. Gastro-oesophageal reflux.

Question 12

1. Tracheal tug
2. Forced expiratory time test

Answer 12

1. Tracheal tug - the finger resting on the trachea feels it move inferiorly with each inspiration - sign of over expanded lung
2. Forced expiratory time test -maximum inspiration, then exhale forcefully:
   * Normal is 3 seconds or less.
   * A forced expiratory time of 9 seconds or more is strongly suggestive of chronic obstructive pulmonary disease in a smoker.

Question 13

Inspection of chest wall (5)

Answer 13

1. General deformities - kyphosis, scoliosis
2. Scars - thoracic operation, chest drains from pneumothorax / pleural effusion
3. Erythema/ thickening from radiotherapy of lung/lymphoma
4. Subcutaneous emphysema
5. Prominent veins: sign of SVC obstruction

Question 14

Unilateral reduction of chest wall expansion cause (5)

Answer 14

1. Pulmonary fibrosis
2. Consolidation
3. Collapse
4. Pleural effusion
5. pneumothorax

Question 15

Bilateral reduction of chest wall movement cause (3)

Answer 15

1. Diffuse gross abnormality
2. COPD
3. ILD

Question 16

Two things which are highly suggestive of COPD

Answer 16

1. Cigarette smoking - more than 10 pack years
2. Positive Hoover’s sign

Question 17

Percussion findings - associated pathology
1. Dull note
2. Stony dull note
3. Resonant note
4. Hyper-resonant note

Answer 17

1. Dull note - solid structure -> liver, consolidation
2. Stony dull note - Fluid-filled area -> pleural effusion
3. Resonant note - Normal lung
4. Hyper-resonant note - Hollow structure -> bowel/ pneumothorax/ hyper inflated lungs. If percussion below the right rib (mid-clavicular line) is resonant -> consider hyper-inflated lungs as it should be dull due to liver