Respiratory System

Question 1

Ddx for peripheral cyanosis

Answer 1

PVD
Raynaud’s
CCF or with central cyanosis

Question 2

What signs and indications might you see in the hands?

Answer 2

Peripheral cyanosis
Temperature - central cyanosis warm, peripheral cold
Dilated veins - Hypercapnia
Tar staining - smoking or coal worker
1sr webbing space wasting - T1 lesion (eg pancoast tumour)

Question 3

Ddx finger clubbing

Answer 3

Malignancy (bronchogenic carcinoma , mesothelioma)
Interstitial lung disease
Suppurative lung disease (bronchiectasis, abscess, empyema, cystic fibrosis)

Question 4

Ddx koilonychia

Answer 4

Iron deficiency anaemia - cause shortness of breath

Question 5

What do you look for in the wrist?

Answer 5

Flapping tremor - resp failure (CO2 retention), hepatic/ renal failure

Fine physiological tremor - beta2 agonist Rx

Respiratory rate - count over 15 seconds while pretending to take pulse

Radial pulse - rate (tachycardia) and volume (bounding Hypercapnia)

Question 6

Face, eyes and mouth

Answer 6

Cushingoid (moon face, plethora, acne, hirsute) - long term steroid Rx (eg for cyptogenic fibrosing alveolitis)

Conjunctival pallor - anaemia

Horner’s (ptosis, Miosis) - pancoast tumour

Central cyanosis - hypoxia lung disease, cardiac shunt, abnormal Hb

Candida - steroid inhalers, immunocompromised pt

Question 7

Ddx raised JVP

Answer 7

RHF, PE, superior vena cava obstruction

Question 8

How and why might the trachea position differ?

Answer 8

Deviate towards collapse, away from tension / big effusion

Reduced cricosternal distance in hyperinflated lungs (COPD)

Question 9

Inspection of the chest

Answer 9

AP diameter - hyperinflation (COPD)

Scars - thoracotomy (lobectomy) or old chest drain sites

Deformity of chest/ spine - pectus excavatum, pectus carinatum (asthma), scoliosis

Intercostal in drawing (Hoover’s sign) - hyperinflation (COPD)

Question 10

What are you looking for on palpation

Answer 10

Symmetry

Apex beat - mediastinal shift (collapse, tension, big effusion)

RV heave - right ventricular hyper trophy (possible cor pulmonale)

Question 11

What sounds do you listen for?

Answer 11

Wheeze - obstruction (asthma and COPD)

Crepitations - fluid in air spaces (secretions, pus, oedema)

Nb. If hear crepitations ask pt to cough - normal crepitations should clear

Question 12

Describe how vocal resonance might differ in different presentations

Answer 12

Increase in consolidation

Decrease in collapse, effusion or pneumothorax

If heard - get them to whisper and check only in areas of increased VR or bronchial breathing

Question 13

Concluding remarks

Answer 13

See sputum pot (if not already)
Obs chart (BP, temp, SaO2)
Investigations - peak flow, CXR, ABG, PFTs

Question 14

Describe signs in a pt with consolidation

Answer 14

Percussion not - dull
Breath sounds - bronchial or decreased
Vocal resonance - increased

Question 15

Signs in pt with collapse

Answer 15

Mediastinal shift - towards
Percussion not - dull
Breath sounds - decreased or absent
Vocal resonance - decreased or absent

Question 16

Signs in pt with effusion

Answer 16

Mediastinal shift - away if big
Percussion not - stony dull
Breath sounds - decreased or absent
Vocal resonance - decreased or absent

Question 17

Signs in pt with pneumothorax

Answer 17

Mediastinal shift - away if tension
Percussion note - (hyper) resonant
Breath sounds - decreased or absent
Vocal resonance - decreased or absent

Question 18

Signs in pneumonectomy

Answer 18

Mediastinal shift - towards
Percussion not - dull
Breath sounds - absent
Vocal resonance - absent

Question 19

Ddx lobectomy/ pneumonectomy

Answer 19

Bronchogenic cancer (25% of non SCLC is respectable)
Bronchiectasis
Trauma
TB

Question 20

Ddx raised hemidiaphragm

Answer 20

Due to phrenic nerve palsy -

Thoracic surgery, trauma, malignancy

Question 21

Signs of hyperinflation

Answer 21

Reduced cricosternal distance +- tracheal tug

Increased AP diameter
Intercostal indrawing (Hoovers sign)
Apex beat not palpable
Hyper-resonant percussion note

Question 22

Ddx interstitial lung disease (pulmonary fibrosis)

Answer 22

1. Idiopathic - crypto genie fibrosing alveolitis
2. Due to Inhaled antigen (EAA) - bird fanciers lung, farmers lung
3. Due to inhaled irritant - asbestosis, silicosis, coal workers pneumoconiosis
4. Associated with systemic disease - SLE, RA, sarcoid, systemic sclerosis
5. Drug induced - methotrexate, Amiodorone, bleomycin, nitrofurantoin

Question 23

Ddx Horners syndrome

Answer 23

1. Central lesion - stroke, tumour, MS, syringobulbia
2. T1 root lesions - spondylosis, neurofibroma
3. Brachial plexus lesion - pancoast tumour, cervical rib, trauma/birth injury (Klumpke’s)
4. Neck lesion - tumour, carotid artery aneurysm, sympathectomy
5. With cluster headaches

Question 24

Features of bronchial breathing

Answer 24

Loud and blowing
Length of inspiration = expiration
Audible gap between inspiration and expiration
Reproducible by placing stethoscope over own trachea

Question 25

Ddx bibasal crepitations

Answer 25

Fine - pulmonary oedema, interstitial lung disease Coarse - Bronchiectasis, cystic fibrosis, bibasal pneumonia

Question 26

Ddx pleural effusion - transudate

Answer 26

(Protein

Question 27

Ddx pleural effusion - exudate

Answer 27

(Protein > 30g/l) 1. Infection (pneumonia, TB) 2. Infarction (PE) 3. Inflammation (RA, SLE) 4. Malignancy (bronchogenic, mesothelioma)

Question 28

What are you examining for at the end of the bed and what are their significance?

Answer 28

Appearance (unwell/ distressed/ dyspnoeic/ in pain) Accessory muscle use, purse lipped breathing (airway obstruction - COPD) Nutritional status / cachexia (COPD, malignancy) Oxygen, fluids, medication (inhalers & nebulisers) Look inside sputum pot if available (describe colour, purulence, presence of blood)