Respiratory

Question 1

Differentials from age?

Answer 1

Young - asthma, CF
Old - COPD, interstitial lung disease, malignancy

Question 2

General inspection signs? (5,4)

Answer 2

General - Age group, cyanosis, pallor, oedema, cachexia
Breathing - SoB, cough, wheeze, stridor

Question 3

Objects/equipment of relevance?

Answer 3

O2 delivery devices, sputum pot, ECG leads, medications, catheters, IV access
Cigarettes/vaping
Medical charts

Question 4

Hands clinical signs?

Answer 4

Colour - cyanosis
Tar staining
Skin changes (thinning/bruising = long-term steroids)
Joint swelling/deformity (RA-associated resp issues)
Clubbing

Question 5

Clubbing implications?

Answer 5

Interstitial lung disease
Bronchiectasis
Cystic fibrosis
Lung cancer

Question 6

Fine tremor implication?

Answer 6

Overuse of beta-2-agonist therapy (salbutamol)

Question 7

Asterixis (flapping tremor) implication?

Answer 7

CO2 retention (type 2 resp failure)

Uraemia, hepatic encephalopathy

Question 8

Hand temperature signs?

Answer 8

Cool = poor peripheral perfusion
Excessively warm + sweaty = CO2 retention

Question 9

2 main pulse abnormalities in resp exam?

Answer 9

Bounding pulse - underlying CO2 retention
Pulsus paradoxus - severe acute asthma, severe exacerbation of COPD, late cardiac tamponade (so quite unlikely in exam!)

Question 10

Asymmetries in respiratory rate inspiration/expiration?

Answer 10

EXPIRATORY phase prolonged relative to inspiration in asthma and COPD

Question 11

Respiratory causes of raised JVP?

Answer 11

VENOUS HYPERTENSION = pulmonary hypertension causing right-sided heart failure due to COPD or interstitial lung disease

Question 12

Plethoric complexion/congested red-faced appearance, respiratory causes?

Answer 12

Polycythaemia (e.g. in COPD)
CO2 retention (type 2 resp failure)

Question 13

Respiratory eye signs?

Answer 13

Conjunctival pallor
Ptosis, mitosis, enophthalmos = HORNER’S indicating sympathetic trunk damage due to lung cancer affecting lung apex (Pancoast tumour)

Question 14

4 main chest scars + location + indication?

Answer 14

Median sternotomy (thorax midline - cardiac valve replacement, coronary artery bypass grafts)
Axillary thoracotomy (4th/5th ICS in axilla between posterior pec major + anterior lat dorsi - chest drain insertion)
Posterolateral thoracotomy (between scapula + mid-spinal line, extends to axillary line - lobectomy, pneumonectomy, oesophageal surgery)
Infraclavicular (infraclavicular region either side - pacemaker insertion)

Question 15

Radiotherapy-associated skin changes?

Answer 15

Dry skin, scale, thickened skin, depigmentation, telangiectasia

Question 16

Chest wall deformities + implications?

Answer 16

Asymmetry - pneumonectomy, thoracoplasty
Pectus excavatum/carinatum
Hyperexpansion (barrel chest) - asthma, COPD (chronic lung disease)

Question 17

Causes of tracheal deviation + direction?

Answer 17

Deviates AWAY - tension pneumothorax, large pleural effusion
Deviates TOWARD - lobar collapse, pneumonectomy

Question 18

Decreased (<3 fingers) cricosternal distance = ?

Answer 18

Lung hyperinflation e.g. asthma, COPD

Question 19

Respiratory causes of displaced apex beat?

Answer 19

Right ventricular hypertrophy (pulmonary hypertension, COPD, interstitial lung disease)
Large pleural effusion
Tension pneumothorax

Question 20

Respiratory causes of reduced chest expansion?

Answer 20

Symmetrical - pulmonary fibrosis reducing lung elasticity (overall chest expansion reduced)
Asymmetrical - pneumothorax, pneumonia and pleural effusion

Question 21

Types of percussion note + implication?

Answer 21

Resonant - normal
Dullness - increased tissue density (cardiac dullness, consolidation, tumour, lobar collapse)
Stony dullness - pleural effusion
Hyper-resonance - decreased tissue density (pneumothorax)

Question 22

Tactile vocal fremitus + vocal resonance abnormalities?

Answer 22

Increased vibration OR volume = increased tissue density (consolidation, tumour, lobar collapse)
Decreased vibration OR volume = presence of fluid/air outside the lung (pleural effusion, pneumothorax)

Question 23

Various breath sounds + implications?

Answer 23

Vesicular breathing - normal
Bronchial breathing - harsh-sounding (consolidation), insp/exp are equal with a pause in between

Quiet breath sounds = reduced air entry (e.g. pleural effusion, pneumothorax)

Wheeze (asthma, COPD, bronchiectasis), stridor (subglottic stenosis), coarse crackles (popping, sounds like rice crispies = pneumonia, bronchiectasis, pulmonary oedema), fine end-inspiratory crackles (velcro = pulmonary fibrosis)

Question 24

Respiratory causes of lymphadenopathy?

Answer 24

Lung cancer + mets
TB
Sarcoid

Question 25

Sacral/pedal oedema cause?

Answer 25

Congestive heart failure

Question 26

Further assessments and investigations for respiratory examination?

Answer 26

At the bedside - full set of obs (inc. O2 sats, temp, BP), sputum sample, peak flow assessment, ABG if indicated
Imaging - CXR (?CT ok for fibrosis)
Cardiovascular examination and full history