Respiratory Exam

Question 1

3 respiratory diseases asso. with clubbing

Answer 1

Bronchial carcinoma
Bronchiectasis
Pulmonary fibrosis

Question 2

Cough qualities:

• Bovine
• Rattling
• Muffled wheezing
• Barking
• Whooping

Suggestive with what pathologies?

Answer 2

• Bovine: lack of explosive onset > Vocal cord paralysis
• Rattling: Increased bronchial secretions
• Muffled wheezing: Airway obstruction
• Barking = acute upper airway obstruction
• Whooping = pertussis

Question 3

Wheezing during breathing.

Difference in wheezing between inspiration and expiration?

Answer 3

Wheezing = airway narrowing

Wheezing during inspiration/ Stridor = Upper airway obstruction

Wheezing during expiration = Lower airway obstruction

Question 4

Respiratory cause of elevated JVP?

Answer 4

Increased right heart pressure: Pulmonary hypertension

Question 5

Explain changes in breath sounds caused by pneumonia/ area of consolidation?

Answer 5

Bronchial breath sound: High frequency, with silent pause between inspiration and expiration

Pneumonia/ consolidation causes lung cavities to be filled with fluid or solid&raquo_space; Increase sound transduction > Increase upper airway breath sounds

Question 6

Differentiate Biphasic, early inspiratory, mid-inspiratory and pan-inspiratory inspiratory crackles

Answer 6

Biphasic = bronchiectasis (coarse)

Early inspiratory = small airway obstructive diseases (eg. COPD)

Mid inspiratory = pulmonary oedema

Pan-inspiratory = Diffuse fibrosis (fine), pulmonary edema (medium), Pneumonia, lung abscess, TB, COPD secretions (coarse)

Question 7

Differentiate anatomical location related to coarse or fine crackles

Answer 7

Coarse = Large airway/ bronchi 
Fine = Small airway/ Bronchioles

Question 8

Changes in vocal resonance in consolidation and pleural effusion compared to normal?

Answer 8

Normal = muffled sound, dampened by air-filled lung cavities

Consolidation: Inflammatory exudate and fibrosis transduce sound much better = Increase vocal resonance

Pleural effusion: space between auscultation and lung is increased by fluid = Quieter vocal resonance

Question 9

Differentiate causes of tenacious, purulent, and brown sputum

Answer 9

Tenacious - Asthma

Purulent - Bronchial inflammation (infection)

Brown - Intra-alveolar hemorrhage

Question 10

Physical findings:

• Reduced chest wall movement
• Dull percussion note
• Increase bronchial breath sound
• Increased vocal resonance
• Pan-inspiratory or late inspiratory crackles

Dx?

Answer 10

Consolidation

Question 11

Physical findings for Consolidation?

• Chest wall movement
• Percussion
• Vocal resonance
• Breath sound
• Any crackles

Answer 11

• Reduced chest wall movement
• Dull percussion note
• Increase bronchial breath sound **
• Increased vocal resonance **
• Pan-inspiratory or late inspiratory crackles

Question 12

Physical finding

• Reduced chest wall movement
• Chest wall flattening
• Mediastinum and tracheal deviation
• Reduced breath sounds

Dx?

Answer 12

Lung collapse

Question 13

Physical findings for Lung collapse?

Answer 13

• Reduced chest wall movement
• Chest wall flattening
• Mediastinum and tracheal deviation **
• Reduced breath sounds

Question 14

Physical finding

Mediastinal shift 
Reduced chest wall movement 
Stony dullness on percussion 
Reduced vocal fremitus 
Reduced breath sounds 

Dx?

Answer 14

Pleural effusion

Question 15

Physical findings for Pleural effusion

Answer 15

Mediastinal shift
Reduced chest wall movement

Stony dullness on percussion***

Reduced vocal fremitus
Reduced breath sounds

Question 16

Physical findings

• Mediastinum shift
• Hyper-resonance on percussion***
• Reduced breath sounds
• Reduced vocal resonance and vocal fremitus

Dx?

Answer 16

Large or tension pneumothorax

Question 17

Key difference in sign between tension pneumothorax and pleural effusion

Answer 17

Tension pneumothorax = Hyper-resonant on percussion

Pleural effusion = fluid-filled = Stony dull on percussion

Question 18

Physical findings:

• Tracheal deviation
• One-sided chest wall flattening with reduced movement
• Dull on percussion
• Bronchial breath sounds +ve
• Crackles

Dx?

Answer 18

Localized pulmonary fibrosis

Question 19

Physical findings for Localized pulmonary fibrosis

Answer 19

• Tracheal deviation
• One-sided chest wall flattening with reduced movement
• Dull on percussion
• Bronchial breath sounds +ve
• Crackles

Question 20

Respiratory cause of wrist tenderness and swelling

Answer 20

Hypertrophic pulmonary osteoarthropathy (HPO):
→ Paraneoplastic periosteal inflammation at distal ends of bones
D/dx: primary CA lung, pleural fibromas, idiopathic

Question 21

Pulmonary cause of wasting of small muscles of hand and finger abduction weakness

Answer 21

compression and infiltration of T1 lower

trunk by Pancoast tumour

Question 22

Scar type and purpose: midline

along sternum

Answer 22

Midline sternotomy

→ CABG
→ Lung transplant

Question 23

Scar type and purpose: long diagonal

posterior scar on thorax

Answer 23

Thoracotomy

→ Pneumonectomy
→ Lobectomy
→ Lung transplant
→ Thoracoplasty

Question 24

Scar type and purpose: three 2-3cm scars around MAL

Answer 24

Video-assisted thoracoscopy (VATs)

→ Bx of lymph nodes
→ Lung reduction surgery
→ Pleurodesis

Question 25

Signs of dyspnoea (2)

Answer 25

Use of accessory respiratory muscles: sternocleidomastoids, platysma, strap muscles of neck In-sucking : in-drawing of intercostal and supraclavicular spaces during inspiration

Question 26

5 characteristic signs of COPD

Answer 26

Use of accessory muscles In-drawing of intercostal and supraclavicular spaces Pursed-lip breathing (positive airway pressure) Lean forward with arms on knees Tracheal tug

Question 27

D/dx mediastinal deviation

Answer 27

→ 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

Question 28

Percussion finding: - Resonant - Hyper-resonant - Dull - Stony dull Causes?

Answer 28

□ 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

Question 29

Differentiate Vesicular and Bronchial breath sounds: | - Origin of sounds

Answer 29

Origin - Vesicular (normal) sounds: Origin: flow vortices in small airway (inspiration), large airway (expiration) - Bronchial breath sounds: Origin: turbulent flow in large airways

Question 30

Differentiate Vesicular and Bronchial breath sounds: | - Quality of sound

Answer 30

Vesicular (normal) sounds: - faint, low-pitched rushing sound - Inspiratory phase longer and louder - Gentle beginning and end - No gap between inspiratory and expiratory phases Bronchial breath sound: - higher-pitched, hollow, blowing quality - Audible gap between inspiratory and expiratory phases***** - Expiratory phase louder and higher pitch

Question 31

Causes of bronchial breath sound

Answer 31

Common - Lung consolidation********* Uncommon - Localized pulmonary fibrosis - Above pleural effusion - Collapsed lung

Question 32

D/dx decreased unilateral breath sound

Answer 32

``` □ COPD, esp emphysema □ Pleural effusion □ Pneumothorax □ Pneumonia □ Large neoplasm □ Collapsed lungs ```

Question 33

Cause of fine, medium and coarse crackles?

Answer 33

Fine crackles indicates airway instability = pulmonary fibrosis Medium crackles indicates disruption of surfactant function = pulmonary oedema Coarse crackles indicates excess bronchial secretions = bronchiectasis

Question 34

Causes of loud, muffled and quiet vocal resonance

Answer 34

Loud - consolidation Muffled - normal Quiet - Pleural effusion