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Question 1

cardinal symptoms for respiratory system?

Answer 1

dyspnoea
chest pain
cough
hamoptysis
sputum production
wheeze

Question 2

what is sarcoidosis and what are some of its symptoms/signs?

Answer 2

multisystem granulomatous disorder
dry cough
progressive dypnoea
chest pain
reduced exercise tolerance
lymphadenopathy
hepatomegaly
splenomegaly
renal stones
erythema nodosum

Question 3

resp causes of clubbing?

Answer 3

lung cancer
cystic fibrosis
COPD?
TB
interstitial lung disease- fibrosing alveolitis

Question 4

sound hear on auscultation in a patient with a pleural rub e.g. due to pleuritis, pneumonia spread, (and pericardial rub e.g. pericarditis)

Answer 4

like footprints on fresh snow, or rusting leaves

Question 5

sound heard on auscultation in a patient with crepitations/crackles e.g. in pneumonia, pulmonary oedema?

Answer 5

like rice krispies- popping sound- as narrow airways forced shut during expiration re-open in inspiration

Question 6

what should you look for when observing a patient’s outstretched hands from the side during a respiratory exam?

Answer 6

a tremor- may be due to beta 2 agonist e.g. salbutamol used in asthma. Short-acting beta 2 agonist= 1st line, 3rd= long acting beta 2 agonist e.g. salmeterol or formoterol.
(ADRs = tachycardia, skeletal muscle tremor, palpitations)

Question 7

what gives a dull percussion note?

Answer 7

pleural effusion- stony dull
consolidation e.g. pneumonia
fibrosis
pleural thickeing

Question 8

what gives a hyperesonant percussion note?

Answer 8

pneumothorax

lung hyperinflation e.g. COPD

Question 9

what gives diminished breath sounds on auscultation?

Answer 9

pleural effusion
pneumothorax
asthma
COPD
pleural thickeing
bronchial obstruction

Question 10

what may produce increased vocal resonance on auscultation?

Answer 10

consolidation e.g. pneumonia

above a pleural effusion

Question 11

in what conditions might a wheeze be heard?

Answer 11

tumour obstructing 1 airway- monophonic

asthma- polyphonic and widespread airflow obstruction

Question 12

what is a wheeze?

Answer 12

a high pitched expiratory sound, like a whistle
occurs due to vibration of intra-thoracic airway wall in at site of airflow limitation. More pronounced in expiration as airways narrower than in inspiration due to compression of small airways to force air out of the lungs, worsening the narrowing.

Question 13

what is stridor?

Answer 13

inspiratory sound due to partial obstruction of upper airways.
Maybe due to something within lumen e.g. oedema from anaphylaxis, laryngospasm, tumour
or extrinsic e.g. goitre, oesophagus, lymphadenopathy

Question 14

why is apex beat felt for on resp examination?

Answer 14

if impalpable, may indicate COPD, pleural effusion

Question 15

differentials for bilateral basal crackles?

Answer 15

pulmonary oedema
interstitial lung disease
bronchiectasis

Question 16

why does TB tend to affect upper lobes of lung?

Answer 16

more air, better O2 supply

Question 17

causes of clear and colourless sputum?

Answer 17

COPD- chronic bronchitis

Question 18

causes of yellow-green sputum?

Answer 18

pulmonary infection- pneumonia, TB

Question 19

causes of red sputum?

Answer 19

haemoptysis- TB, lung cancer, PE, GoodPasture’s syndrome

Question 20

cause of pink and frothy sputum?

Answer 20

pulmonary oedema in L sided heart failure

Question 21

cause of black sputum?

Answer 21

smoke

coal dust

Question 22

what happens to sputum when sent off to laboratory?

Answer 22

microscopy- gram staining
culture
cytology

Question 23

how is peak expiratory flow measured?

Answer 23

maximal forced expiration through a peak flow meter

more effort-dependent than FEV1.0

Question 24

factors affecting peak expiratory flow?

Answer 24

age
gender
height

Question 25

range of peak expiratory flow expected for women?

Answer 25

400-500 L/min for women aged between 15 and 65

Question 26

range of peak expiratory flow expected for men?

Answer 26

520-660 L/min for men aged between 15 and 55

Question 27

what can cause incorrect readings with pulse oximetry?

Answer 27

``` poor perfusion motion excess light skin pigmentation nail varnish dyshaemoglobinaemias e.g. thalassaemia CO poisoning ```

Question 28

what does pulse oximetry measure?

Answer 28

non-invasive assessment of peripheral O2 saturation | and HR

Question 29

difference between vesicular breath sounds and bronchial breathing?

Answer 29

``` vesicular= rustling quality bronchial= heard normally over large airways e.g. trachea, hollow quality, can occur where lung tissue has become firm e.g. pneumonia consolidation, or fibrosis ```

Question 30

characteristic of chest pain resulting from a respiratory cause?

Answer 30

pleuritic= worse on inspiration

Question 31

what do I want once completed respiratory examination

Answer 31

examine any sputum perform peak flow temperature

Question 32

what chest deformities may be visible in respiratory disease?

Answer 32

barrel chest- AP diameter increased, tracheal descent, reduced chest expansion, seen in chronic hyperinflation e.g. COPD, asthma pigeon chest- pectus carinatum- lung hyperinflation whilst bony thorax still devloping e.g. in chronic childhood asthma funnel chest- pectus excavatum- assoc with Marfan's syndrome and scoliosis, developmental defect involving local sternum depression. kyphosis- increase AP thoracic spine curvature scoliosis- lateral curvature ALL can cause restrictive lung defect- FEV1.0/FVC ratio >70%

Question 33

what may cause trachea/mediastinal shift towards pathology?**

Answer 33

lobe collapse/spontaneous pneumothorax | fibrosis

Question 34

what may cause trachea/mediastinal shift away from pathology?

Answer 34

pleural effusion | tension pneumothorax

Question 35

what do you want to ask a patient specifically about if thinking asthma?

Answer 35

precipitants= cold air, exercise, smoking, allergens e.g. fur from pets at home, emotion diurnal variation in symptoms- cough worse at night? stopping them from sleeping, nights per wk?, performance at school reduced? dyspnoea on a morning? dyspnoea- what does it stop you from doing? exercise tolerance? acid reflux? PMH: other atopic disease e.g. eczema, hayfever FH: atopic disease? SH: home- pets? carpet? nonsmoker?- unlikely to be COPD job e.g. paint sprayer, animal handler

Question 36

how can asthma and COPD be distinguished between with spirometry?

Answer 36

>/15% in FEV1.0 with bronchodilators (beta 2 agonists) in asthma as reversible, <15% improvement in COPD as irreversible.

Question 37

Differential diagnoses for asthma?

Answer 37

COPD- irreversible- spirometry, almost all patients smokers or have smoked in past, symptoms all the time as chronic, not related to precipitating factors and time of day, tend to be older patients. large airway obstruction e.g. foreign body, tumour pulmonary oedema malginancy SVC obstruction- but wheeze/dyspnoea not episodic pneumothorax PE bronchiectasis interstitial lung disease- dry cough pulmonary fibrosis gastro-oesophageal reflux- nocturnal cough in children consider bronchiolitis, cystic fibrosis- persistent cough and infections, foreign body obstructing large airway, recurrent childhood infections.

Question 38

typical symptoms of asthma?

Answer 38

dry cough- worse at night dyspnoea- worse on a morning wheeze chest tightness

Question 39

describe what asthma is to a patient, and how it comes about

Answer 39

from time to time, the small airways known as bronchi, which carry air to and from the lungs, become narrowed producing the symptoms experienced. These airways are more sensitive than normal to certain things such as cold air and pet fur. Normally, air taken in through large airway= trachea, down into lungs via smaller airways, and then oxygen from air can pass into you blood by crossing small air sacs in the lungs, and so can get to all the different parts of the body requiring oxygen. Inflammation of the bronchi occurs and when you come into contact with something that irritates your lungs – known as a trigger – your airways become narrow, the muscles around them tighten, and there is an increase in the production of sticky mucus (phlegm), which makes air entry into the lungs more difficult, so you may feel breathless. Mucus production may cause you to cough, but dry cough?* as mucous plugging?- body trying to get rid of it but can't? and limit airflow, so breathless. wheeze- due to restriction of air flow to and from lungs. The cause isn't known, but people are more likely to get asthma if others in their family have it, or other atopic conditions e.g. eczema and hayfever- body more sensitive than other people's to substances e.g. pollen.

Question 40

how is asthma investigated?

Answer 40

spirometry | peak flow

Question 41

tment of asthma?

Answer 41

reliever and preventor medication- must take preventor even if not experiencing symptoms to protect airways from being damaged?*

Question 42

key management aim in COPD patient?

Answer 42

smoking cessation want to reduce risk of exacerbations and admission to hospital, improve QOL and ability to cope with symptoms e.g. dyspnoea- try and improve exercise tolerance e.g via pulmonary rehabilitation- 6wk programme.

Question 43

how is it important to quantify dyspnoea/pain?

Answer 43

what does it stop you from doing? is your ability to do daily activities affected? how does this make you feel (consider psychosocial aspect)?

Question 44

pharmacologic management of asthma?

Answer 44

short acting beta 2 agonist e.g. salbutamol, terbutaline inhaled corticosteroid e.g. beclometasone long acting beta 2 agonist e.g. salmeterol, may be in combination inhaler with inhaled corticosteroid e.g. symbicort= formoterol and budesonide? add on therapies= xanthines, muscarinic antagonists e.g. tiotropium bromide, LRAs oral corticosteroid- prednisolone also want to tell patients to avoid triggers, comply with therapy, educate them and parents about symptoms of acute attacks.

Question 45

main symptoms of COPD?

Answer 45

progressive disease, cough with clear and colourless sputum- as damaged airways make more mucus than normal exertional dyspnoea- can't get enough air into lungs through obstructed airways, progressively worsens possibly wheeze- obstructed airways, walls vibrate, aways compressed in expiration- worsens narrowing

Question 46

what is copd, explain to patient

Answer 46

term to describe 2 conditions: chronic bronchitis and emphysema. persistent condition, will have for life but management, especially smoking cessation, will control symptoms, and stopping smoking can improve function of airways. chronic bronchitis= inflammation of bronchi= lung airways emphysema= damage to smaller airways and air sacs (alveoli) in lung which allow O2 from air to get into our blood. COPD= persistent, air flow obstructed to and from lungs, affecting lungs. cause= usually smoking= smoke irritates airways, causes damage, promoting inflammatory response. degree of genetic risk- lack an important protein for keeping appropriate structure of smaller airways and air sac for air movement. at risk of chest infections- mucus build up good for bacteria, can worsen symptoms= exacerbation, so report to dr and can treat with antibiotics. also of heart failure= heart unable to work as well so can't pump blood around body as effectively as normal as lung tissue damage with COPD puts an increased strain on the heart as heart has to pump blood through the damaged lungs- breathlessness may worsen and may find swelling of ankles. Treatment= ACEIs and beta blockers, possibly aldosterone antagonsit diuretic. and resp failure

Question 47

tments for COPD?

Answer 47

STOP SMOKING- can't reverse airway narrowing but prevents disease worsening, stops airway function from decreasing as fast as it would with smoking, reduces symptoms. No treatment is CURATIVE. inhalers= short acting bronchodilators to relax smooth muscle of airways to open them up, long-acting if symptoms remain problematic. steroid inhaler- reduce inflammation, can help prevent symptoms flaring up. Only used with long term bronchodilator. And may increase dose of usual tments. mucolytics= make sputum less thick and easier to cough up, must take regularly, can help reduce flare ups as less risk of infection as less mucus for bacteria. may give steroid tablets e.g. prednisolone, and antibiotics for flare ups. home O2 if severe regular exercise lose weight

Question 48

differentials for COPD?

Answer 48

asthma- trigger factors, diurnal variation, history of atopy, non smoker bronchiectasis- LOTS of sputum, intermittent hamoptysis TB- night sweats, hamoptysis, FH, contacts, weight loss malignancy- weight loss, fatigue, chest pain intersitial lung disease congestive heart failure- with pulmonary oedema- dyspnoea wakes you up, have to sleep with more pillows to stop feeling breathless? ankle swelling? raised JVP? anaemia

Question 49

4 differentials for sudden onset chest pain?

Answer 49

trauma MI pneumothorax aortic dissection- causes radial-radial delay

Question 50

pathology in PE which causes type 1 respiratory failure?

Answer 50

ventilation/perfusion mismatch- as embolus obstructs flow of blood, blood is away, which means that actually too much blood is reaching alveoli for the ventilation available, and it is this which causes the problem= hypoxia= pO2<8.0 kPa.

Question 51

what might you seen on inspection of a patient with a pneumothorax?

Answer 51

reduced chest expansion on affected side trachea deviation away from affected side (if tension pneumothorax- these are more common and more dangerous as air can only travel 1 way in pleural sac, so air accumulates*) trachea deviated towards affected side in spontaneous pneumothorax.

Question 52

what might you hear on auscultation of a patient with a pneumothorax?

Answer 52

diminshed/absent breath sounds on affected side

Question 53

characteristic signs of patient with interstitial lung disease?

Answer 53

bilateral fine inspiratory crackles/crepitations | clubbing

Question 54

signs in a severe acute asthmatic attack?

Answer 54

pulse >110bpm RR>25 breaths/min PEFR between 33 and 50% of that predicted or best unable to complete sentences

Question 55

signs in life threatening asthma attack?

Answer 55

paCo2 increasing/high, PEFR<33% of that predicted or best

Question 56

Tment of severe acute asthmatic attack?

Answer 56

high dose O2 nebulised salbutamol and ipratropium bromide with O2 oral prednisolone or IV hydrocortisone do CXR to exclude pneumothorax

Question 57

what may cause reduced vocal resonance on auscultation?

Answer 57

pleural effusion