Respiratory exam

Question 1

CURB-65 for CAP?

Answer 1

• C - confusion (AMT <8/disoriented)
• U - urea >7
• R - RR >30**
• B - BP <90 or/60
• age >65

(RR>30 most prognostic***)

0-1 = mild
2 = admit
>3 = ITU

Question 2

define tachypnoea?

Answer 2

RR >15

Question 3

ΔΔ ↓ RR?

Answer 3

ΔΔ
• opioids
• ↑ CO2
• ↓ thyroid
• ↑ ICP
• hypothalamic lesions

Question 4

what is Cheyne-stokes respiration?

when does it happen?

Answer 4

cyclically increasing rate and depth of breathing
then diminishing resp effort and rate
then apnoea/hypopnoea
(b/c delay in circulation time b/n lungs and chemoreceptors)

ΔΔ
• brainstem stroke
• severe HF
• EOL

Question 5

Hx: patient comes in with panic attack. An ABG is done. what expect to see?

Answer 5

respiratory alkalosis (increased RR)

Question 6

Hx: patient has high RR, is making sighing noise, and has high blood sugar, ABG shows metabolic acidosis?

Answer 6

• Kussmaul (DKA)
ΔΔ
• acute renal failure
• lactic acidosis
• salicylate and methanol poisoning

Question 7

Ex: patient has central cyanosis, a plethoric complexion, and tobacco staining of the nails. The chest is barrel-shaped and hyperinflated, they’re using accessory muscles to breathe, and have a raised JVP. On auscultation, there is a wheeze and reduced A/E. Swollen ankles.
Diagnosis?

Answer 7

COPD
(plethoric due to secondary polycythaemia)
(ankle swelling due to cor pulmonale)

Question 8

Ex: respiratory patient presents with left eye dilated, and posteriorly displaced, with a droopy left lid?

Answer 8

HORNER’s syndrome; lung CA (Pancoast tumour)

unilateral
• miosis
• ptosis
• anhidrosis
• enophthalmos

Question 9

ΔΔ if Horner’s syndrome but anhidrosis on chest as well as face?
ΔΔ if no anhidrosis at all?

Answer 9

ΔΔ
• CNS: stroke, SOL, MS
• if none: lesion after ciliary ganglion: carotid artery dissection/aneurysm/cluster headache

Question 10

Ex: patient has:
- peripherally clubbing, tobacco staining
- fixed and raised JVP, +/- ptosis, cervical lymph enlarged
+/- collapse or effusion Ex

?

Answer 10

lung CA

Question 11

Ex: reduced expansion, dull percussion, reduced breath sounds and vocal resonance localised to lower left lobe?

Answer 11

lobar collapse

Question 12

Ex: reduced expansion, STONY dull percussion, reduced or absent breath sounds and vocal resonance?

Answer 12

pleural effusion

Question 13

• Ex: patient has high HR, hyperinflated chest, and wheeze?

* if agitated + cyanosed + silent chest too?

Answer 13

• asthma

* severe asthma

Question 14

Ex: low BP, confused, feverish, lymph nodes, with reduced expansion, dull percussion and bronchial breath sounds +/- pleural rub, increased vocal resonance?

Answer 14

pneumonia

Question 15

Ex: clubbing, central cyanosis, reduced chest expansion and fine end inspiratory crackles?
(ankle swelling a late sign)

Answer 15

idiopathic pulmonary fibrosis (IPF)

also called “fibrosing alveolitis

Question 16

Ex: pleural friction rub, pleuritic chest pain?
+/- reduced expansion with stony dull percussion
+/- unilateral oedematous warm tender calf

Answer 16

PE

Question 17

Ex: asymmetrical expansion, resonant percussion, absent breath sounds?
if low BP?

Answer 17

pneumothorax

low BP indicates development of “tension” and reduced venous return to the heart, high risk arrest

Question 18

Ex: red discolouration on skin?

Answer 18

erythema nodusum
(sarcoidosis)

Question 19

ΔΔ Ex: clubbing?

Answer 19

• lung CA
• ILD
• CF
• AV shunting

non-thoracic:
• cirrhosis
• coeliac
• UC
• Crohn's

Question 20

ΔΔ shaky hands?

Answer 20

• fine tremor (salbutamol)
• flapping tremor/asterixis (CO2 retention/ventilatory failure, can also get in liver/renal failure, CNS lesion, drugs, or electrolyte imbalance)

Question 21

Ex: ↑JVP?

Answer 21

• right sided HF
• tension pneumothorax
• severe acute asthma
• +/- massive PE
• SVC obstruction (if raised and non-pulsatile)

Question 22

Ex: hyperinflated patient with ↑JVP, ECHO shows right heart dilatation, pulmonary HT, pulmonary arterial vasocontriction?

Answer 22

cor pulmonale

causing COPD

Question 23

ΔΔ Ex: lymphadenopathy?

Answer 23

• rubbery - Hodgkins
• tender - dental sepsis, tonsillitis
• matted/stony hard/fixed to deep structures - mets

Question 24

ΔΔ Ex: tracheal deviation?

Answer 24

• (AWAY) tension pneumothorax
• (TOWARDS) collapse, fibrosis, pneumonectomy
• upper mediastinal mass (retrosternal goitre, lymphoma, lung CA)

Question 25

Ex: bilateral basal medium crackles?

Answer 25

pulmonary oedema

Question 26

ΔΔ Ex: common causes of pleural effusion if:

1) protein < 30g (transudate)
2) protein > 30g (exudate)

Answer 26

transudates:
• LVF
• cirrhosis/ low albumin
• peritoneal dialysis

exudates:
• malignancy
• parapneumonic (pneumonia, lung/subphrenic abscess, or bronchiectasis)

Question 27

Ex: stony dull percussion note, ascites + raised CA-125?

Answer 27

Meigs’ syndrome (ovarian tumour + pleural effusion)