Respiratory

Question 1

Where can the middle lobe of the lung be examined?

Answer 1

Axilla and back

Question 2

What angle should the patient be sitting at?

Answer 2

45 degrees

Question 3

What should you look for in general inspection?

Answer 3

Colour of patient (are they cyanosed), 
obvious signs of weight loss, 
breathlessness (are they propped up?), 
any wasting of accessory muscles of breathing (COPD), pursing of lips, 
expiratory time. 

Check surroundings for oxygen, inhalers, nebulisers, drips, sputum pots, medications, masks etc.

Question 4

Respiratory causes of clubbing?

Answer 4

Empyema, bronchiectesis, non-small cell carcinoma, lung fibrosis, CF, abscesses, suppurative diseases.

Question 5

Summarise what you are looking for in the hands?

Answer 5

Clubbing, cyanosis, tar staining, Duypetren’s contracture, asterixis, tremor (B2 agonists).

Question 6

Check BP? Yes/no?

Answer 6

Yes, or say you would

Question 7

Summarise what looking for in head/face?

Answer 7

Cyanosis (under side of tongue)
Check for lesions
Check eyes (anaemia, jaundice, xanthelasma) Horner’s sign
Arcus
Angular stomatits (anaemia)
Glossitis (sign of iron deficiency/pernicious anaemia)
Smell of breath (ketones)
Dental state
Thrush and leukoplakia
GENERAL SWELLING - SVC OBSTRUCTION AS RESULT OF LUNG CANCER

Question 8

What is Horner’s sign?

Answer 8

Constricted pupils, droopy eyelid and reduced sweating. All on same side of face.
No sympathetic so pupil is always constricted
Common symptom of an upper lung tumour.

Question 9

Summarise what looking for in neck?

Answer 9

Feel for inflamed lymph nodes - submandibular/submental LNs, then backwards to LNs anterior to SCM muscle, then along towards the clavicle up the back of the neck all the way up to the occipital nodes. Don’t forget to check lymph nodes in axilla.

Question 10

Check JVP in respiratory exam?

Answer 10

Apparently not but say you would. Often raised in cor pulmonale.

Question 11

Name neck lymph nodes?

Answer 11

Submental, submandibular, pretracheal, preauricular, upper, middle and lower cervical, postauricular, posterior triangle, supraclavicular.

Question 12

Where else should you check lymph nodes?

Answer 12

Axilla

Question 13

Where should you definitely look for scars?

Answer 13

On the back! And the axilla

Question 14

What should you do before you check for tracheal deviation?

Answer 14

Tell patient it will feel a bit uncomfortable

Question 15

How to check for tracheal deviation?

Answer 15

Put second and fourth fingers on heads of the two clavicles, leaving middle finger to feel the trachea.

Question 16

Reasons for a displaced trachea?

Answer 16

Tension pneumothorax - shifts trachea away from side of pneumothorax.
Collapsed lobe of lung - shifts trachea towards side of collapse.

Question 17

When is the JVP raised?

Answer 17

In right sided heart failure/states of fluid overload.

Question 18

Define cor pulmonale?

Answer 18

Chronic hypoxia in COPD leads to pulmonary arterial vasoconstriction, pulmonary hypertension, right heart dilatation and peripheral oedema with elevation of the JVP.

Question 19

Another state in which JVP is raised?

Answer 19

When intrathoracic pressure is raised i.e. tension pneumothorax or acute asthma.

Question 20

What is the JVP like in SVC obstruction?

Answer 20

Raised and non-pulsatile, and abdomino-jugular reflex is absent.

Question 21

What is normal respiratory rate?

Answer 21

12-13

Question 22

How to check for chest expansion?

Answer 22

Ask patient to take a deep breath out then lay hands flat on upper part of the chest and ask them to take deep breaths - should feel both sides moving in and out equally.
For lower part extend hands around the sides of the chest.

Question 23

Other thing in palpation?

Answer 23

Palpate apex beat.

Question 24

Where do you percuss the clavicle?

Answer 24

Medial third.

Question 25

What should you do when percussing the posterior chest?

Answer 25

Ask patient to fold arms across the front of the chest, moving the scapulae laterally. Do not percuss in the midline due to spine and musculature.

Question 26

How should the patient be breathing for auscultation?

Answer 26

With an open mouth

Question 27

what are normal breath sounds called?

Answer 27

Vesicular

Question 28

what are the three types of abnormal breath sounds?

Answer 28

Wheeze, creps, friction rubs

Question 29

Define wheeze?

Answer 29

• whistley, noisy breathing – caused by the narrowing of airways. Due to small airway obstruction, such as COPD or asthma.
• Usually only heard on expiration.
• If only heard on inspiration, this is called stridor. Stridor is a very bad prognostic sign (cancer).
• Monophonic wheeze is also very bad because this is caused by a single blockage of a single airway.
• Pitch and duration of wheeze is related to the severity of the pathology, NOT LOUDNESS.

Question 30

Define crepitations?

Answer 30

• Like a rustling crisp packet – occur mainly in LV failure (where the sound is caused by air bubbling through fluid) and lung fibrosis (where the sound is causes by the ‘popping open’ of the alveoli).
• Nearly always inspiratory. Can also occur in COPD, bronchiectasis and resolving pneumonia.
• Fine, medium or coarse.

Question 31

Define friction rub?

Answer 31

• Squelching squeaky sound, like walking in fresh snow.
• This is the sound of the two layers of pleura rubbing together as the lungs expand and contract.
• Main causes = pneumonia, pulmonary infarct and malignancy. Usually these causes lead to inflammation, which causes the actual rub.
• Often very localised, and patient often complains of pain in the region of the sound – in which case they have pleurisy.
• In contrast to crackles, rub tends to be only heard on expiration.

Question 32

What else do you auscultate for?

Answer 32

Vocal resonance/vocal fremitus

Question 33

How to listen for vocal resonance?

Answer 33

Listen over different areas and get patient to say ‘99’

Question 34

What do you hear in vocal resonance if there is consolidation?

Answer 34

99 is very clear

Question 35

Decreased vocal resonance = ?

Answer 35

Empyema

Question 36

End pieces for resp exam?

Answer 36

Check sputum, function tests such as FEV1 (spirometry) and PEFR