Respiratory Examination Flashcards
Symtpoms, signs, conditions and examination
Red flag symptoms associated with cough
Haemoptysis Breathlessness Fever Chest pain Weight loss
What is a wheeze?
Expiratory high pitched whistling produced by air passing through narrowed small airways
How can cancer result in dysphonia?
Damage or compression of the left recurrent laryngeal nerve at the left hilum- prevents the adduction of left vocal course to the midline
Biphasic stridor vs expiratory stridor vs inspiratory stridor
Inspiratory suggests narrowing at the vocal cords
Biphasic suggests tracheal obstruction
Expiratory suggests tracheobronchial obstruction
Causes of stridor
Infection/ inflammation- eg acute epiglottitis Inhalation of foreign body Anaphylaxis Malignancy of the trachea/bronchi Extrinsic compression from lymph nodes
Causes of breathlessness when lying flat (orthopnoea)
Left ventricular failure Respiratory muscle weakness Large pleural effusion Massive ascites Morbid obesity Severe lung disease
What is trepopnoea?
Breathlessness when lying on ones side
Breathlessness that improves at the weekend or on holidays is suggestive of:
Occupational asthma
Definition of COPD
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%
Pleural pain, what is it and causes
Intense, sharp, stabbing pain, intensified by inspiration or coughing
Causes are pneumonia, pneumothorax, PE and rib fractures
Where would a Pancoasts tumour be found? What is the likely type of cancer?
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
Reasons for Kussmaul hyperventilation
Diabetic ketoacidosis, lactic acidosis, methanol or salicylate poisoning, acute renal failure
Questions to ask in history about cough
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
One pack year
20 cigarettes a day for one year
CURB-65 in hospital
Mortality predictor in community acquired pneumonia
Confusion
Urea >7mmol/L
Respiratory rate >30
Blood pressure <60mmHg diastolic or systolic <90
Older than 65
Accessory muscles of respiration
Sternocleidomastoid, platysmus and trapezius
Pulsus paradoxus
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
Erythema nodosum
Acute sarcoidosis and tuberculosis
Respiratory explanations for finger clubbing
Lung malignancy, bronchiectasis, interstitial lung disease, hypertrophic pulmonary osteoarthropathy
What is asterixis?
Course flapping tremor seen with severe ventilatory failure and carbon dioxide retention
Signs of superior vena cava obstruction (often lung malignancy, other causes are lymphoma, thymoma and mediastinal fibrosis)
Distended neck veins
Dilated superficial veins over chest
Plethoric appearance
Pemberton’s sign
How can COPD cause a raised JVP?
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
How is a chest ‘barrel’ shaped?
When the anterio-posterior width is greater than the lateral diameter
What is kyphosis?
Exaggerated anterior curvature of the spine (in the thoracic region)
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)
Causes of Harrison’s sulci
Severe and poorly controlled childhood asthma
Rickets and osteomalacia
Pectus excavatum
Developmental deformity with localised depression of the lower end of the sternum
Usually asymptomatic but patients concerned for appearance
Tracheal tug is a sign of what
Severe hyperinflation
Finger will move inferiorly with each inspiration
Reduced chest expansion on one side indicates
Pleural effusion
Lung or lobar collapse
Pneumothorax
Unilateral fibrosis
What is Tietze’s syndrome?
Idiopathic costochondritis- cartilage swelling at the costosternal junction and chest pain, 2nd ribs are most commonly affected
What percussion note does a pneumothorax produce?
Hyperresonant
Where should the upper border of the liver normally be percussed?
RHS, 5th rib in the mid-clavicular line
How does bronchial breathing sound?
Similar inspiratory and expiratory length phases, high-pitched breath sound with a characteristic pause between phases
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)
Crackles in early inspiration
Small airways disease, such as bronchiolitis
Crackles in mid inspiration
Pulmonary oedema
Crackles at end of inspiration
Pulmonary fibrosis
Pulmonary oedema
Bronchial secretions
Biphasic crackles
Bronchiectasis
What is aegophony?
Increased resonance of sounds when auscultating the lungs- suggestive of consolidation or fibrosis
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
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
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
Investigations for TB
CXR
Sputum (including morning for acid fast bacilli test)
Joint or spinal Xray
Signs of TB on a CXR
Cavitation
Pleural effusion
Mediastinal or hilar lymphadenopathy
Parenchymal infiltrates (mainly in upper lobes)
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
Upper lobe fibrosis
HINT: SCATO
Silicosis Coal miner's pneumoconiosis Ankylosing spondylitis, allergic bronchopulmonary aspergillosis, allergic alveolitis TB Other
Lower lobe fibrosis
HINT: RASHO
Rheumatoid Asbestosis Scleroderma Hamman-Rich syndrome- idiopathic pulmonary fibrosis Other drugs and radiation
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
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
Difference between JVP and carotid pulsation
Double upstroke/ pulsation to JVP
Carotid is palpable
JVP drops during inspiration
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
Describe vesicular breathing
Soft, low pitched sound
Inspiratory longer than expiratory, quieter during inspiration
Causes of pleural effusion
Congestive heart failure (transudative)
Neoplasm (exudative)
Pneumonia (exudative)
PE (trans or ex)
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
Bronchitis definition
Cough with sputum for more than 3 months of the year over two years
Emphysema definition
Pathological diagnosis, needs radiological guidance to diagnose
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
P pulmonale
Hypertrophied right atrium secondary to pulmonary hypertension
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
Long term oxygen therapy criteria
Resting PaO2 <7.3kpa
<8 with evidence of right sided heart failure
Differentials for bronchiectasis
CF COPD Asthma A1AT deficiency Primary ciliary dyskinesia (Kartagener's) Allergic BronchoPulmonary Aspergillosis
Signet ring sign
Bronchiectasis on HRCT
Bronchiolar dilatation
Complications of pneumonia
Pneumoniaa Empyema Pneumothorax Haemoptysis Brain abscess Sinusitis Amyloidosis Cor-pulmonale
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
Treatment of CF
Education Smoking cessation Regular PT Abx Pancreatic enzyme replacement- CREON Immunisation Lung transplant
Lower zone fibrosis
Cryptogenic Asbestosis Rheumatoid Drugs- amiodarone, methotrexate, nitrofurantoin Systemic sclerosis
Upper zone fibrosis
TB
Extrinsic allergic alveolitis
Ankylosing spondylitis
Radiation
Treatment for pulmonary fibrosis
Steroids
Pirfenidone
Diuretics
Long term oxygen therapy
Investigations for TB
Tuberculin skin test
CXR
Microbiology- sputum culture, acid fast bacilli, EMU (early morning urine)
Visual acuity- because of ethambutol
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
