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Y6 PACES > Respiratory Examination > Flashcards

Respiratory Examination Flashcards

1
Q

VIVA

Please list some causes of upper and lower zone pulmonary fibrosis

A
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2
Q

VIVA

How would you clinically differentiate bronchiectasis and pulmonary fibrosis?

A

Pulmonary fibrosis:
Fine end-inspiratory crackles
Dry cough
Reduced expansion

Bronchiectasis:
Coarse crackles (usually late expiratory)
Wet productive cough
Recurrent chest infections

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3
Q

VIVA

What is the difference between a pneumonectomy and a lobectomy? List some possible indications.

A

Pneumonectomy:
This is removal of a whole lung
Higher morbidity and mortality
FEV1 should be >2L

Lobectomy:
Removal of just one lobe of a lung
More technically challenging
FEV1 should be >1.5L

Possible indications:
Lung cancer (most)
Localised bronchiectasis
Lung abscess
Lung volume reduction surgery in COPD/bullectomy
Aspergilloma
Trauma
Old treatment of TB (generally practice discontinued)

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4
Q

VIVA

How would you differentiate between a transudative and exudative pleural effusion? List some causes of each.

A

In general, an exudate has a high protein content (>30g/L) and a transudate has a low protein content (<30g/L). Light’s criteria can help differentiate the two – any one of three points indicates an exudate:
1. Pleural fluid protein / serum protein = >0.5
2. Pleural fluid LDH / serum LDH = >0.6
3. Pleural fluid LDH = >2/3 the upper limit of normal serum LDH

Transudate causes:
Heart Failure (most)
Hypoalbuminaemia (e.g. in liver cirrhosis, nephrotic syndrome)

Exudate causes:
Infection (e.g. empyema)
Inflammation
Infarction (PE)
Malignancy

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5
Q

VIVA

If a patient presented with kyphoscoliosis, what would you expect their transfer capacity of the lung for carbon monoxide (TLCO) and transfer co-efficient (KCO) to be?

A

TLCOand KCO measure diffusion:
* TLCO = total diffusing capacity of lung. To measure the TLCO, the patient inspires a fixed amount of carbon monoxide in a single breath. The quantity expired again is then calculated to determine how much has diffused into the blood.
* KCO = TLCO/alveolar volume = diffusing capacity of lung per unit volume (i.e. as above but corrected for lung volume)

Restrictive disorders result in incomplete alveolar expansion, but the lung tissue itself is normal. This therefore results in a:
* Reduced TLCO (this is due to the reduction in total ventilation)
* Normal/high KCO (there is normal lung tissue and increased pulmonary capillary blood volume per alveolar volume when lung volumes are reduced causing a normal/high KCO)

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6
Q

Complications of COPD?

A
  • Hypercapnic respiratory failure (PaO2 < 8.0 and PaCO2 > 6.0)
  • Secondary polycythaemia (raised haemoglobin): due to chronic hypoxaemia
  • Cor pulmonale: right heart failure, caused by pulmonary hypertension as a result of chronic hypoxic pulmonary vasoconstriction
  • Bronchiectasis: due to chronic and repeated infections
  • Anxiety and depression
  • Osteoporosis: due to chronic steroid use, smoking, lack of bone-strength exercise and vitamin D deficiency
  • Sleep disturbance
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7
Q

VIVA

What are the stages of digital clubbing?

A

Stage 1: Fluctuant nail bed
Stage 2: Loss of nail angle (Schamroth’s window is obliterated)
Stage 3: Increased curvature of nail
Stage 4: Broadening of distal phalanx

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8
Q

VIVA

What findings would you expect when examining a patient after a pneumonectomy?

A
  • Left/right thoracotomy scar
  • Tracheal displacement to side of removal
  • Reduced expansion on the side of removal
  • Dull percussion note on the side of removal
  • Absent breath sounds on the side of removal (although there may be bronchial breathing in the upper zone due to tracheal deviation)
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9
Q

VIVA

What is Kussmaul’s sign and which conditions could cause it?

A

Normally the JVP falls with inspiration due to negative pressure in the expanding thorax. Kussmaul’s sign is when the JVP rises during inspiration. This is caused by a restriction in the diastolic filling of the right ventricle.

Common causes include:
* Cardiac tamponade/large pericardial effusion
* Constrictive pericarditis
* Restrictive cardiomyopathy
* Severe right-sided heart failure

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10
Q

VIVA

What is pulsus paradoxus and what are the causes?

A
  • Pulsus paradoxus is fall in systolic blood pressure of more than 10mmHg during inspiration
  • Pulsus paradoxus can be caused by cardiac tamponade, or when the right ventricle is distended (e.g. in chronic sleep apnoea and severe obstructive lung disease)
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11
Q

VIVA

What are the causes of bronchiectasis?

A
  • Genetic: CF, Young’s syndrome, Kartagener’s syndrome, yellow nail syndrome, α1-antitrypsin deficiency
  • Mechanical: malignancy, foreign body
  • Childhood infection: pertussis, measles, TB, pneumonia
  • Immunological: allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, HIV, leukaemia, autoimmune
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12
Q

VIVA

What are the indications for a pneumonectomy/lobectomy?

A

Lung malignancy
Localised bronchiectasis
Aspergilloma
Large bullectomy
TB (historically – practice discontinued)

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13
Q

VIVA

What are the causes of upper and lower zone pulmonary fibrosis?

A

Upper zone fibrosis = CARTEx
Coal
Ankylosing spondylitis
Radiation
TB
Extrinsic allergic alveolitis

Lower zone fibrosis = CAID (more common)
Connective tissue disorders (scleroderma, rheumatoid)
Asbestos
Idiopathic pulmonary fibrosis
Drugs (nitrofurantoin, amiodarone, methotrexate, cyclophosphamide, sulfasalazine)

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14
Q

VIVA

How would you categorise the severity of COPD?

A

The severity of COPD is categorised by the percentage of predicted value of the patient’s forced expiratory volume in 1 second (FEV1), measured by spirometry:
* Mild = FEV1 >80%
* Moderate = FEV1 50-80%
* Severe = FEV1 30-50%
* Very severe = FEV1 <30%

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15
Q

A patient presents with breathlessness and a fever. You hear coarse crepitations in the left lower zone of their chest. What are the different types of crepitations and what may they signify?

A

Coarse crepitations: bronchiectasis, consolidation/infection
Fine inspiratory crepitations: pulmonary oedema
Fine end-inspiratory crepitations (like Velcro): pulmonary fibrosis

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16
Q

What are the most common organisms to cause community acquired pneumonia?

A

– Streptococcus pneumoniae (pneumococcus)
– Haemophilus influenzae
– Atypicals (e.g. mycoplasma, legionella)
– Viral (influenza, RSA, adenovirus)
– If immunocompromised (e.g. malnourished, alcoholic, diabetic, on long-term steroids), also: Staphylococcus aureus, coliforms, TB, PCP
– If severely immunosuppressed (e.g. HIV with CD4 <200, transplant recipient), also: pneumocystis carinii, cryptococcus, CMV, varicella zoster virus, influenza, fungal infections

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17
Q

What are the clinical signs of cardiac tamponade?

A

Beck’s triad consists of jugular vein distention, quiet heart sounds and hypotension

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18
Q

What are some of the causes of abnormal breathing noises?

A
  • Speech abnormalities (e.g. in recurrent laryngeal nerve palsy)
  • Stridor (large airway obstruction e.g. mediastinal masses, bronchial carcinoma, retrosternal thyroid)
  • Wheeze
  • Cough (dry/productive/bovine)
  • Prolonged expiratory phase (asthma, COPD)
  • Clicks (bronchiectasis)
  • Gurgling (airway secretions)
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19
Q

What are the causes of digital clubbing?

A

Respiratory: idiopathic pulmonary fibrosis, lung cancer, suppurative lung disease (e.g. bronchiectasis, cystic fibrosis), sarcoidosis/TB
Cardiovascular: cyanotic congenital heart disease, infective endocarditis
Abdominal: inflammatory bowel disease, liver cirrhosis
Others: pregnancy, acromegaly, thyroid acropachy, familial clubbing

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20
Q

What is the difference between hypoxia and hypoxaemia?

A

Hypoxaemia = low blood oxygen
Hypoxia = deficiency of oxygen supply to the tissues of the body

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21
Q

What is long-term oxygen therapy (LTOT)? What are the indications?

A

LTOT is oxygen therapy that is delivered for at least 15 hours daily. It is usually considered in chronic hypoxaemia when PaO2<7.3kPa (or <8kPa in presence of pulmonary hypertension or secondary polycythaemia)

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22
Q

What is ambulatory oxygen therapy? What are the indications?

A

Ambulatory oxygen therapy is oxygen that used during exercise or activity. It may be used for patients who develop hypoxaemia on exercise but are not hypoxemic at rest.

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23
Q

What are the different inhaler devices available?

A

Metered dose inhalers (MDIs): deliver aerosol; a spacer can be used with these
– Breath actuated inhalers (BAIs): automatically release a spray of medicine when the patient inhales
– Dry powder inhalers (DPIs): release a dry powder instead of a spray

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24
Q

What is type 1 and type 2 respiratory failure?

A

– Type 1 respiratory failure = 1 gas abnormal (low pO2)
– Type 2 respiratory failure = 2 gasses abnormal (low pO2, high CO2)

– Patients with COPD are at risk of type 2 respiratory failure as they may rely on hypoxic pulmonary vasoconstriction to improve their V/Q ratios to improve gas exchange. Hence, it is important to use controlled oxygen therapy to avoid over-oxygenation.

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25
Q

What is cor pulmonale?

A

Cor pulmonale is right-sided heart failure due to a primary respiratory disorder resulting in pulmonary hypertension.

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26
Q

Which antibiotics may be considered for an exacerbation of bronchiectasis in a patient with multiple sputum cultures growing pseudomonas?

A

Antibiotics should be tailored to the patient’s previous sputum cultures. It is not uncommon for patients with bronchiectasis or CF to be colonised with pseudomonas. Examples of antibiotics with antipseudomonal activity include: ciprofloxacin, tazocin, ceftazidime, meropenem.

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27
Q

What is Kartagener’s syndrome?

A

Kartagener’s syndrome is an autosomal recessive ciliary disorder. It results in the triad of situs inversus, chronic sinusitis, and bronchiectasis.

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28
Q

What are the FEV1 cut offs for when pneumonectomy and lobectomy are appropriate?

A

FEV1 > 2L for pneumonectomy
FEV1 >1.5L for lobectomy

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29
Q

For patients with FEV1 below the cut off, which other scan may be appropriate to gain more information?

A

Ventilation-perfusion scanning may be considered to determine split lung function (lung with tumour may not be contributing to total FEV1)

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30
Q

What can be seen from the end of the bed in a respiratory examination?

A
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31
Q

Cause of dilated veins in the hands?

A

Hypercapnia

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32
Q

Causes of 1st web space wasting?

A

T1 lesion (Pancoast tumour)

33
Q

Neck examination in resp?

A
34
Q

Mediastinal shift, percussion note, breath sounds and vocal resonance in: consolidation

A
35
Q

Mediastinal shift, percussion note, breath sounds and vocal resonance in: collapse

A
36
Q

Mediastinal shift, percussion note, breath sounds and vocal resonance in: effusion

A
37
Q

Mediastinal shift, percussion note, breath sounds and vocal resonance in: pneumothorax

A
38
Q

Mediastinal shift, percussion note, breath sounds and vocal resonance in: pneumonectomy

A
39
Q

Lobectomy/pneumonectomy findings?

A
40
Q

Causes/findings of raised hemidiaphragm?

A
41
Q

Signs of hyperinflation? (5)

A
42
Q

DDx for interstitial lung disease (pulmonary fibrosis)

A
43
Q

Features of bronchial breathing?

A
44
Q

DDx of Horner’s syndrome

A
45
Q

DDx of pleural effusion

A
46
Q

DDx for lymphadenopathy

A
47
Q

Lymph node groups of the head and neck

A
48
Q

Typical descriptions of lymphadenopathy

A
49
Q

Recommended sequence of lymph node palpation (head and neck)

A
50
Q

Features of finger clubbing

A
51
Q

∆∆ Finger clubbing

A
52
Q

∆∆ Pitting oedema

A
53
Q

∆∆ non-pitting oedema

A
54
Q

∆∆ unilateral/localised leg swelling

A
55
Q

Lobectomy vs pneumonectomy

A
56
Q

DDx lateral thoracotomy scar

A

lobectomy, pneumonectomy, open biopsy, lung volume reduction, bullectomy (COPD), pleurectomy (recurrent pleural disease), thoracoplasty (TB)

57
Q

Indications for lung transplant

A
58
Q

Contraindications for lung transplant

A
59
Q

Complications for lung transplant

A
60
Q

Examination findings in lung transplant

A
61
Q

Causes of interstitial lung disease

A
62
Q

Symptoms in ILD

A
63
Q

Investigations in ILD

A
64
Q

Management of ILD

A
65
Q

Causes of bronchiectasis

A
66
Q

Symptoms in bronchiectasis

A

SOB(OE), productive cough, recurrent infection, weight loss, clubbing, coarse crackles

67
Q

Investigations in bronchiectasis

A
68
Q

Management of bronchiectasis

A
69
Q

Diagnostic criteria for asthma

A
70
Q

Stepwise management of asthma

A
71
Q

COPD staging

A
72
Q

Management of COPD

A
73
Q

Acute COPD management

A
74
Q

Transudative vs exudative pleural effusion

Mechanism, Aetiology, Biochemsitry

A
75
Q

Examination findings in pleural effusion

A
76
Q

Investigations for pleural effusion

A

CXR followed by USS for volume estimation and guide aspiration

77
Q

Management of pleural effusion

A
78
Q

Pneumothorax management pathway

A

Y6 PACES (21 decks)

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