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Respiratory Examination Flashcards

Symtpoms, signs, conditions and examination

1
Q

Red flag symptoms associated with cough

A 
Haemoptysis
Breathlessness 
Fever 
Chest pain 
Weight loss
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2
Q

What is a wheeze?

A

Expiratory high pitched whistling produced by air passing through narrowed small airways

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3
Q

How can cancer result in dysphonia?

A

Damage or compression of the left recurrent laryngeal nerve at the left hilum- prevents the adduction of left vocal course to the midline

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4
Q

Biphasic stridor vs expiratory stridor vs inspiratory stridor

A

Inspiratory suggests narrowing at the vocal cords
Biphasic suggests tracheal obstruction
Expiratory suggests tracheobronchial obstruction

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5
Q

Causes of stridor

A 
Infection/ inflammation- eg acute epiglottitis 
Inhalation of foreign body
Anaphylaxis 
Malignancy of the trachea/bronchi
Extrinsic compression from lymph nodes
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6
Q

Causes of breathlessness when lying flat (orthopnoea)

A 
Left ventricular failure
Respiratory muscle weakness
Large pleural effusion
Massive ascites
Morbid obesity 
Severe lung disease
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7
Q

What is trepopnoea?

A

Breathlessness when lying on ones side

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8
Q

Breathlessness that improves at the weekend or on holidays is suggestive of:

A

Occupational asthma

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9
Q

Definition of COPD

A

Characterised by airflow obstruction that is progressive and not fully reversible
Defined by a reduced post-bronchodilator forced expiratory volume in 1 second/ forced vital capacity (FEV1)/FVC of <70%

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10
Q

Pleural pain, what is it and causes

A

Intense, sharp, stabbing pain, intensified by inspiration or coughing
Causes are pneumonia, pneumothorax, PE and rib fractures

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11
Q

Where would a Pancoasts tumour be found? What is the likely type of cancer?

A

In the apex of the right or left lung- often spread to nearby tissue such as ribs or vertebrae
Most commonly small cell lung cancer

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12
Q

Reasons for Kussmaul hyperventilation

A

Diabetic ketoacidosis, lactic acidosis, methanol or salicylate poisoning, acute renal failure

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13
Q

Questions to ask in history about cough

A

When in the day and duration- lying down at night-GORD, disrupting sleep- asthma and cough on rising in the morning- rhinosinusitis and post-nasal drip

Wheeze, precipitating factors
Sputum- colour and quantity
Haemoptysis- volume and nature of the blood
Breathlessness- distance they can walk 
Chest pain- SOCRATES
Past history of respiratory illness
DHx
FHx- CF, atopy, COPD
SHx, pets, living conditions, smoking
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14
Q

One pack year

A

20 cigarettes a day for one year

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15
Q

CURB-65 in hospital

A

Mortality predictor in community acquired pneumonia
Confusion
Urea >7mmol/L
Respiratory rate >30
Blood pressure <60mmHg diastolic or systolic <90
Older than 65

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16
Q

Accessory muscles of respiration

A

Sternocleidomastoid, platysmus and trapezius

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17
Q

Pulsus paradoxus

A

Abnormally large decrease in stroke volume during inspiration
Causes: Massive PE, pericardial tamponade, constrictive pericarditis, COPD or asthma exacerbation, obstructive sleep apnoea, large pleural effusion, pectus excavatum

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18
Q

Erythema nodosum

A

Acute sarcoidosis and tuberculosis

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19
Q

Respiratory explanations for finger clubbing

A

Lung malignancy, bronchiectasis, interstitial lung disease, hypertrophic pulmonary osteoarthropathy

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20
Q

What is asterixis?

A

Course flapping tremor seen with severe ventilatory failure and carbon dioxide retention

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21
Q

Signs of superior vena cava obstruction (often lung malignancy, other causes are lymphoma, thymoma and mediastinal fibrosis)

A

Distended neck veins
Dilated superficial veins over chest
Plethoric appearance
Pemberton’s sign

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22
Q

How can COPD cause a raised JVP?

A

Chronic hypoxia leads to bronchoarterial vasoconstriction, this increases the pulmonary blood pressure and causes right sided heart dilatation
This causes peripheral oedema with elevated JVP

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23
Q

How is a chest ‘barrel’ shaped?

A

When the anterio-posterior width is greater than the lateral diameter

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24
Q

What is kyphosis?

A

Exaggerated anterior curvature of the spine (in the thoracic region)

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25
Pectus carinatum
(pigeon chest) Localised prominence of the sternum and adjacent costal cartilages, often accompanied by Harrison's sulci (indrawing of the ribs to create symmetrical horizontal grooves- occurs when the bony thorax is still pliable pre-pubertally)
26
Causes of Harrison's sulci
Severe and poorly controlled childhood asthma | Rickets and osteomalacia
27
Pectus excavatum
Developmental deformity with localised depression of the lower end of the sternum Usually asymptomatic but patients concerned for appearance
28
Tracheal tug is a sign of what
Severe hyperinflation | Finger will move inferiorly with each inspiration
29
Reduced chest expansion on one side indicates
Pleural effusion Lung or lobar collapse Pneumothorax Unilateral fibrosis
30
What is Tietze's syndrome?
Idiopathic costochondritis- cartilage swelling at the costosternal junction and chest pain, 2nd ribs are most commonly affected
31
What percussion note does a pneumothorax produce?
Hyperresonant
32
Where should the upper border of the liver normally be percussed?
RHS, 5th rib in the mid-clavicular line
33
How does bronchial breathing sound?
Similar inspiratory and expiratory length phases, high-pitched breath sound with a characteristic pause between phases
34
What is bronchial breathing caused by?
Normal lung tissue replaced by uniformly structured conducting tissue, with patent underlying major bronchus- heard over pulmonary consolidation, above pleural effusion and over dense fibrosis (helps rule out obstructive lung disease)
35
Crackles in early inspiration
Small airways disease, such as bronchiolitis
36
Crackles in mid inspiration
Pulmonary oedema
37
Crackles at end of inspiration
Pulmonary fibrosis Pulmonary oedema Bronchial secretions
38
Biphasic crackles
Bronchiectasis
39
What is aegophony?
Increased resonance of sounds when auscultating the lungs- suggestive of consolidation or fibrosis
40
Major risk factors for PE
``` Fracture of hip, pelvis or leg Hip or knee replacement Major abdominal or pelvic surgery Major trauma Spinal cord injury Malignancy ```
41
Organisms that produce atypical pneumoniae Characteristics Treatment
Legionella pneumophilia Chlamydia pneumoniae Mycoplasma pneumoniae Generally characterised by constitutional symptoms predominating over respiratory symptoms- low grade fever, malaise, lethargy, cough, headache 1st line macrolides and supportive care
42
Suspicion of active TB
High risk group (living with active TB, born outside of the UK, immunosuppression, co-morbid) Weight loss, fever, malaise, night sweats, anorexia Pulmonary involvement- Cough, breathlessness, haemoptysis Extrapulmonary- lymphadenopathy, osteodynia or arthralgia, skin lesions (erythema nodosum), meningitis symptoms
43
Investigations for TB
CXR Sputum (including morning for acid fast bacilli test) Joint or spinal Xray
44
Signs of TB on a CXR
Cavitation Pleural effusion Mediastinal or hilar lymphadenopathy Parenchymal infiltrates (mainly in upper lobes)
45
Management of TB
Referral to specialist management team Usually 2 months of Rifampicin, Isoniazid, Pyrazinamide and Ethambutol Followed by a further 4 months of Rifampicin and Isoniazid 4 MDT team approach
46
Upper lobe fibrosis | HINT: SCATO
``` Silicosis Coal miner's pneumoconiosis Ankylosing spondylitis, allergic bronchopulmonary aspergillosis, allergic alveolitis TB Other ```
47
Lower lobe fibrosis | HINT: RASHO
``` Rheumatoid Asbestosis Scleroderma Hamman-Rich syndrome- idiopathic pulmonary fibrosis Other drugs and radiation ```
48
Why usually NIV for COPD patients?
Often need help removing carbon dioxide as well as providing inspiratory pressure, so non-invasive ventilation provides help for expiration too unlike CPAP which only provides positive inspiratory pressure
49
Why do a deep breath in and out from the end of the bed?
Short inspiratory phase followed by prolonged expiratory tells you that it is an obstructive diagnosis- asthma or COPD (bronchiectasis or emphysema), bronchiectasis
50
Difference between JVP and carotid pulsation
Double upstroke/ pulsation to JVP Carotid is palpable JVP drops during inspiration
51
Percussion notes
Resonant- normal Dull- consolidated lung, collapsed, abscess or neoplasm Stony dull- pleural effusion Hyper-resonant- generalised- hyperinflation or localised- pneumothorax or large emphysematous bulla
52
Describe vesicular breathing
Soft, low pitched sound | Inspiratory longer than expiratory, quieter during inspiration
53
Causes of pleural effusion
Congestive heart failure (transudative) Neoplasm (exudative) Pneumonia (exudative) PE (trans or ex)
54
Why listen over the pulmonary area in a respiratory examination?
Loud second heart sound and pedal oedema suggestive of pulmonary hypertension- possibly secondary to lung disease
55
Bronchitis definition
Cough with sputum for more than 3 months of the year over two years
56
Emphysema definition
Pathological diagnosis, needs radiological guidance to diagnose
57
Investigations for COPD
Obs- pulse oximetry ABG FBC- infective exacerbation CXR- features of pulmonary hypertension- P pulmonale ECG Spirometry- looking for an obstructive picture- FEV1/FVC <0.70
58
P pulmonale
Hypertrophied right atrium secondary to pulmonary hypertension
59
COPD treatment
``` Education Smoking cessation Pulmonary cessation and specialist nurse contact Inhaled bronchodilators/ ICS Steroids and abx for acute exacerbations Long term oxygen therapy consideration Flu and pneumococcal vaccination ```
60
Long term oxygen therapy criteria
Resting PaO2 <7.3kpa | <8 with evidence of right sided heart failure
61
Differentials for bronchiectasis
``` CF COPD Asthma A1AT deficiency Primary ciliary dyskinesia (Kartagener's) Allergic BronchoPulmonary Aspergillosis ```
62
Signet ring sign
Bronchiectasis on HRCT | Bronchiolar dilatation
63
Complications of pneumonia
``` Pneumoniaa Empyema Pneumothorax Haemoptysis Brain abscess Sinusitis Amyloidosis Cor-pulmonale ```
64
Complications of CF
Respiratory- chronic cough, ABPA, sinusitis Infertility- failure of the vas deferens to form Intestinal- DM, ileal obstruction, pancreatic failure, malabsorption (vit ADEK), steatorrhea, osteoporosis, gallstones
65
Treatment of CF
``` Education Smoking cessation Regular PT Abx Pancreatic enzyme replacement- CREON Immunisation Lung transplant ```
66
Lower zone fibrosis
``` Cryptogenic Asbestosis Rheumatoid Drugs- amiodarone, methotrexate, nitrofurantoin Systemic sclerosis ```
67
Upper zone fibrosis
TB Extrinsic allergic alveolitis Ankylosing spondylitis Radiation
68
Treatment for pulmonary fibrosis
Steroids Pirfenidone Diuretics Long term oxygen therapy
69
Investigations for TB
Tuberculin skin test CXR Microbiology- sputum culture, acid fast bacilli, EMU (early morning urine) Visual acuity- because of ethambutol
70
Treatment for TB
``` Education Stop smoking Segregate 2/52 smear positive Contact tracing RIPE- Rifampicin, Isoniazid, Pyrazinamide, Ethambutol RIPE for 2 months and RI for another 4 ```

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