Respiratory example questions Flashcards
What are the respiratory causes of clubbing?
- Fibrotic lung disease
- Chronic suppurative lung disease (bronchiectasis, chronic lung abscesses)
- Lung cancer (all except small cell)
nb. COPD does not cause clubbing, if a COPD patient has clubbing look for co-existing pathology.
What are the common causes of wheeze?
Obstructive lung diseases, particularly COPD or asthma
What is stridor and what does it indicate?
- It is a high-pitched, monophonic breath sound, usually occuring in inspiration.
- It results from turbulent air flow in the larynx or lower in the bronchial tree and implies obstruction at these (upper airway) levels.
What are the causes of dullness to percussion on respiratory examination?
- Effusion
- Consolidation
- Lobectomy or pneumonectomy
- Raised hemidiaphragm
- Pleural thickening
How do you differentiate consolidation and pleural effusion clinically?
- Both are dull on percussion (though effusion is classically ‘stony dull’).
- In effusion vocal resonance is decreased or absent, in consolidation vocal resonance is increased.
How do you differentiate a transudative from an exudative pleural effusion?
Transudate
- Protein <30g/l: in patients with normal serum protein
Exudate
- Protein >30g/l: in patients with normal serum protein
Light’s criteria
More sensitive for diagnosis of exudative effusions and helpful if fluid protein between 25-35 g/l. Positive if one of these is true:
Pleural:serum protein ratio; >0.5 = exudate
Pleural:serum LDH ratio; >0.6 = exudate
Pleural LDH >2/3 the upper limit of normal serum LDH
What are the causes of fibrosis?
- Usual interstitial pneumonia (UIP)
- Occupational: asbestosis, silicosis, pneumonoconiosis, extrinsic allergic
- Rheumatologival arthritis
- Infection: aspergillosis, TB
- Drugs: amiodarone, methotrexate, bleomycin, cyclophosphamide, nitrofurantoin
- Vasculitis
- Radiation fibrosis
- Recurrent aspiration
- Sarcoid
- Histiocytosis
A patient is brought in following a collapse. He complained of sudden onset shortness of breath and pleuritic chest pain. On examination his trachea is deviated to the left and there is hyperresonance on the right side of his chest. What is the next appropriate management step?
Large bore cannula in right second intercostal space mid-clavicular line.
- This patient has a tension pneumothorax as indicated by the tracheal deviation. It is life threatening and a large cannula should be inserted in the mid clavicular line , second intercostal space. The trachea is deviated away from the side effected. Management must not be delayed for a CXR.
Which of the following has been proven to improve survival in COPD?
a) Long term oxygen therapy
b) Salbutamol inhaler
c) Salbutamol nebulisers
d) Steroids
e) Nil
a) Long term oxygen therapy
- LTOT is the only treatment which has been proven to improve survival as well as provide symptom control. It is thought to work by improvement of pulmonary vasculature haemodynamics.
A 52 year old gentleman presents with unwell with a cough productive of green sputum with occasional blood flecks. He is also complaining of shortness of breath and has a cold sore. On examination he is pyrexial, tachypneoic, tachycardic and there is left basal coarse crackles.
What is the most likely diagnosis?
Pneumonia due to sterptococcus pneumoniae
- This patient is most likely to be suffering from pneumonia secondary to streptococcal pneumoniae. It is the most common cause of community acquired pneumonia and further clues to this being the diagnosis is the evidence of a cold sore and the blood stained sputum
A patient who was previously a coal miner is found on chest xray to have numerous small round opacities with normal lung markings. What is the most likely diagnosis?
Simple pneumoconiosis category 2
- This gentleman is most likely to be suffering from simple pneumoconiosis as he is an ex coal miner. Simple pneumoconiosis is categorised based on its CXR findings. In category 1 there is a few small round opacities. In category 2 there is numerous small round opacities but normal lung markings visible. Category 3 is characterised by very numerous opacities with normally lung markings partially or totally obscured.
Which of the following is not a feature of ARDS (acute respiratory distress syndrome)?
a) Protein rich fluid in alveolar space
b) Refractory hypoxia
c) Bilateral diffuse infiltrates on chesy X-ray
d) No evidence of cardiac failure
e) Protein low fluid in alveolar space
e) Protein low fluid in alveolar space
- ARDS can be caused by numerous conditions including sepsis, pneumonia, smoke inhalation, trauma, acute pancreatitis, eclampsia and fat embolism. It leads to a non cardiogenic pulmonary oedema where there is leakage of protein rich fluid into the alveoli which leads to respiratory failure. There is an acute onset and there is bilateral diffuse infiltrates on chest xray. There should be no evidence of cardiac failure. The hypoxia is normally refractory and high levels of oxygen are required.
A 25 year old female presents with dry cough, fever and shortness of breath. She has also been suffering from night sweats and malaise. She has also noticed bruise like lesions on her shins. She is found to have an elevated ESR and a CXR reveals bilateral hilar lymphadenopathy, a pleural effusion and evidence of reticulo nodular shadowing in the upper lobes.
What is the most likely diagnosis?
Sarcoidosis
- The finding of respiratory symptoms, erythema nodosum and bilateral hilar lymphadenopathy is very suggestive of sarcoidosis. As well as bilateral hilar lymphadeonpathy, sarcoidosis can lead to interstitial lung disease which often leads to fibrosis and reticulo nodular shadowing in the upper lobes.
A 22 year old female who has previously suffered from panic attacks presents with acute shortness of breath, palpitations, perioral tingling and paraesthesia in hands and chest tightness. Given the most likely diagnosis, what would you expect to observe on blood gas?
Low CO2
- This patient is most likely suffering from hyperventilation. The clue to the diagnosis is the previous panic attacks. The ABGs are likely to show low CO2 which would account for the perioral tingling and paraesthesia.
What percentage increase in FEV1 post bronchodilator, is required for the diagnosis of asthma?
> 12%
A 42 year old with Rheumatoid arthritis presents with increasing dyspnoea and a non productive cough. A CXR reveals diffuse reticular opacities and pulmonary functions tests reveal a restrictive pattern. What is the most likely diagnosis?
Interstitial lung disease
- Rheumatoid arthritis can effect the lungs. It can lead to pulmonary fibrosis with interstitial lung damage. It is thought to occur in 2 to 5%. Pulmonary fibrosis can also occur secondary to DMARDs such as methotrexate. Caplans syndrome is the association of rheumatoid nodules with pneumoconiosis. BOOP does not present in this fashion. COPD and asthma lead to obstructive pattern on pulmonary function tests.
A 66 year old male is brought in with severe pneumonia. He is in type 1 respiratory failure with an O2 level of 6.9 kPa. He is normally fit and well and is only on antihypertensives. He states he does not want to be on a “life support machine”. He requires intubation. What should be done next?
Intubate
- In this case this patient has a very good premorbid state. He is only on antihypertensives. Although the wish not to be put on a “life support machine” may be a previous decision made by the patient it is difficult to assess this in this situation. He is hypoxic and is likely confused and agitated. He may have misconceptions about ventilation and these may have never been formally discussed and thus this patient is not making an informed decision. Therefore the doctor responsible for care must make the decision. In this patient he is likely to respond very well to ventilation and survive. Although it is appropriate to discuss the decision with the family, it is unfair for this to be their decision.
Which of the following is not a poor prognostic factor for pneumonia?
a) Respiratory rate of 28
b) Confusion
c) Age 72
d) Systolic BP 88mmHg
e) Urea of 7.2mmol/L
a) Respiratory rate of 28
- According to CURB 65 a RR of 30 or more is associated with poor prognosis. The other options all indicate a poor prognosis and the CURB 65 score is used to guide treatment because of this.
A 52 year old presents with normally well controlled asthma presents with, shortness of breath, wheeze and nocturnal cough. He has noticed coughing up blood on several occasions. He also complains of feeling generally unwell with a headache and fever. Bloods reveal an elevated eosinophil count and IgE. A CXR reveals new infiltrates. Which of the following will confirm the diagnosis?
a) Lung biopsy
b) High resolution CT
c) Serology for aspergillus precipitins
d) Autoantibodies
e) Pulmonary function tests
c) Serology for aspergillus precipitins
- This patient presents with features of deteriorating asthma with haemoptysis, general malaise and headache. This is inkeeping with allergic bronchopulmonary aspergillosis. There is evidence of eosinophilia, increased IgE and infiltrates CXR therefore either skin test for aspergillus or serology showing elevated precipitins to aspergillus will be useful in confirming the diagnosis.
In regards to cryptogenic fibrosis alveolitis, which of the following is not true?
a) Reduced elastic recoil
b) Reduced FEV1
c) Reduced FVC
d) Normal to high FEV1/FVC
e) Poor lung compliance
a) Reduced elastic recoil
- CFA leads to a fibrotic ppicture on pulmonary functions tests and thus there is poor lung compliance as the lungs are stiff and increased elastic recoil. The other features are in keeping with a fibrotic picture.
A 55 year old gentleman presents to his GP with haemoptysis. He had a previous history of tuberculosis. He has a cough and feels fevered at times. A chest xray reveals a cavitating lesion in the left upper lobe. Bloods reveal an elevated aspergillus precipitins.
What is the most likely diagnosis?
Aspergilloma
- The most likely diagnosis is aspergilloma. It often presents with haemoptysis and a cavitating lesion occurs where there has been previous cavitating lung disease such as tuberculosis and therefore most commonly found in upper lobes. Fever and cough are less common. Chronic necrotising aspergillosis is rare, the patient is normally immunocompromised and it presents like an indolent pneumonia and haemoptysis is less common.
