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ISCE prep > Respiratory Examination > Flashcards

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
Q

Pectus carinatum

A

(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)

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26
Q

Causes of Harrison’s sulci

A

Severe and poorly controlled childhood asthma

Rickets and osteomalacia

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27
Q

Pectus excavatum

A

Developmental deformity with localised depression of the lower end of the sternum
Usually asymptomatic but patients concerned for appearance

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28
Q

Tracheal tug is a sign of what

A

Severe hyperinflation

Finger will move inferiorly with each inspiration

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29
Q

Reduced chest expansion on one side indicates

A

Pleural effusion
Lung or lobar collapse
Pneumothorax
Unilateral fibrosis

30
Q

What is Tietze’s syndrome?

A

Idiopathic costochondritis- cartilage swelling at the costosternal junction and chest pain, 2nd ribs are most commonly affected

31
Q

What percussion note does a pneumothorax produce?

A

Hyperresonant

32
Q

Where should the upper border of the liver normally be percussed?

A

RHS, 5th rib in the mid-clavicular line

33
Q

How does bronchial breathing sound?

A

Similar inspiratory and expiratory length phases, high-pitched breath sound with a characteristic pause between phases

34
Q

What is bronchial breathing caused by?

A

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
Q

Crackles in early inspiration

A

Small airways disease, such as bronchiolitis

36
Q

Crackles in mid inspiration

A

Pulmonary oedema

37
Q

Crackles at end of inspiration

A

Pulmonary fibrosis
Pulmonary oedema
Bronchial secretions

38
Q

Biphasic crackles

A

Bronchiectasis

39
Q

What is aegophony?

A

Increased resonance of sounds when auscultating the lungs- suggestive of consolidation or fibrosis

40
Q

Major risk factors for PE

A 
Fracture of hip, pelvis or leg
Hip or knee replacement
Major abdominal or pelvic surgery
Major trauma
Spinal cord injury
Malignancy
41
Q

Organisms that produce atypical pneumoniae

Characteristics

Treatment

A

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
Q

Suspicion of active TB

A

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
Q

Investigations for TB

A

CXR
Sputum (including morning for acid fast bacilli test)
Joint or spinal Xray

44
Q

Signs of TB on a CXR

A

Cavitation
Pleural effusion
Mediastinal or hilar lymphadenopathy
Parenchymal infiltrates (mainly in upper lobes)

45
Q

Management of TB

A

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
Q

Upper lobe fibrosis

HINT: SCATO

A 
Silicosis
Coal miner's pneumoconiosis
Ankylosing spondylitis, allergic bronchopulmonary aspergillosis, allergic alveolitis 
TB
Other
47
Q

Lower lobe fibrosis

HINT: RASHO

A 
Rheumatoid 
Asbestosis 
Scleroderma
Hamman-Rich syndrome- idiopathic pulmonary fibrosis 
Other drugs and radiation
48
Q

Why usually NIV for COPD patients?

A

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
Q

Why do a deep breath in and out from the end of the bed?

A

Short inspiratory phase followed by prolonged expiratory tells you that it is an obstructive diagnosis- asthma or COPD (bronchiectasis or emphysema), bronchiectasis

50
Q

Difference between JVP and carotid pulsation

A

Double upstroke/ pulsation to JVP
Carotid is palpable
JVP drops during inspiration

51
Q

Percussion notes

A

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
Q

Describe vesicular breathing

A

Soft, low pitched sound

Inspiratory longer than expiratory, quieter during inspiration

53
Q

Causes of pleural effusion

A

Congestive heart failure (transudative)
Neoplasm (exudative)
Pneumonia (exudative)
PE (trans or ex)

54
Q

Why listen over the pulmonary area in a respiratory examination?

A

Loud second heart sound and pedal oedema suggestive of pulmonary hypertension- possibly secondary to lung disease

55
Q

Bronchitis definition

A

Cough with sputum for more than 3 months of the year over two years

56
Q

Emphysema definition

A

Pathological diagnosis, needs radiological guidance to diagnose

57
Q

Investigations for COPD

A

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
Q

P pulmonale

A

Hypertrophied right atrium secondary to pulmonary hypertension

59
Q

COPD treatment

A 
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
Q

Long term oxygen therapy criteria

A

Resting PaO2 <7.3kpa

<8 with evidence of right sided heart failure

61
Q

Differentials for bronchiectasis

A 
CF
COPD
Asthma
A1AT deficiency 
Primary ciliary dyskinesia (Kartagener's) 
Allergic BronchoPulmonary Aspergillosis
62
Q

Signet ring sign

A

Bronchiectasis on HRCT

Bronchiolar dilatation

63
Q

Complications of pneumonia

A 
Pneumoniaa
Empyema 
Pneumothorax
Haemoptysis
Brain abscess 
Sinusitis
Amyloidosis
Cor-pulmonale
64
Q

Complications of CF

A

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
Q

Treatment of CF

A 
Education
Smoking cessation
Regular PT
Abx
Pancreatic enzyme replacement- CREON
Immunisation
Lung transplant
66
Q

Lower zone fibrosis

A 
Cryptogenic
Asbestosis
Rheumatoid
Drugs- amiodarone, methotrexate, nitrofurantoin 
Systemic sclerosis
67
Q

Upper zone fibrosis

A

TB
Extrinsic allergic alveolitis
Ankylosing spondylitis
Radiation

68
Q

Treatment for pulmonary fibrosis

A

Steroids
Pirfenidone
Diuretics
Long term oxygen therapy

69
Q

Investigations for TB

A

Tuberculin skin test
CXR
Microbiology- sputum culture, acid fast bacilli, EMU (early morning urine)
Visual acuity- because of ethambutol

70
Q

Treatment for TB

A 
Education
Stop smoking
Segregate 2/52 smear positive
Contact tracing
RIPE- Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
RIPE for 2 months and RI for another 4

ISCE prep (6 decks)

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