Respiratory station

Question 1

What conditions is COPD

Answer 1

Chronic bronchitis (cough with sputum for most days for 3 months of 2 years) and emphysema (permanent dilation with destruction of alveolar walls distal to terminal bronchioles)

Question 2

COPD signs

Answer 2

Common on initial inspection = tar staining, sternocleidomastoid hypertrophy, pursed lip breathing. NO CLUBBING. Hyperexpanded chest, and reduced breath sounds

Question 3

COPD causes

Answer 3

SMOKING!, industrial duct exposure, alpha 1 antitrypsin deficiency

Question 4

Investigations COPD

Answer 4

= spirometry = FEV1/FVC <0.7 and FEV1 = <80% of predicted

Question 5

COPD management

Answer 5

Conservative = smoking cessation and exercise, influenza and pneumococcal vaccines, Long term oxygen therapy
Medical = 1st = SABA or SAMA PRN, 2nd if asthmatic features = LABA + ICS
2nd if no asthma = LABA + LAMA
3rd if severe or 2 hosp = LABA + LAMA + ICS

Surgical = lung reduction

Question 6

COPD presentation

Answer 6

Today I examined this gentleman’s respiratory system. The patient was alert sitting in bed and showed signs of pursed lip breathing, sternocleidomastoid hypertrophy and tar staining. He was not clubbed and there was no asterixis. His chest was hyperexpanded with resonant percussion and reduced breath sounds bilaterally with no other added sounds. His JVP was non elevated. These signs are consistent with a diagnosis of chronic obstructive pulmonary disease likely due to cigarette smoke. I would like to perform spirometry and take a history to determine symptom severity and frequency of exacerbations.

Question 7

long term oxygen therapy indications COPD

Answer 7

Non smoker
P02 < 7.3 on room air
Evidence of pulmonary hypertension + PO2 <8kPa
PCO2 does not rise significantly on oxygen

Question 8

lung cancer types

Answer 8

NSCLC
- SCC = smoking
- Adenocarcinoma = most common NSCLC, most common lung cancer in non smokers
SCLC
- Fast growing + Presents with paraneoplastic syndromes

Question 9

Lung ca investigations

Answer 9

CXR +ve
CT thorax
Biopsy
PET CT for staging

Question 10

Pulmonary fibrosis signs

Answer 10

clubbing, reduced expansion, basal and mid zone crackles, JVP non raised, dry cough

Question 11

pulmonary fibrosis signs from causes

Answer 11

MCP swelling (Rheumatoid), Facial rash (SLE), thick skin + bird nose (systemic sclerosis), oral ulcers (Crohn’s), grey skin (amiodarone), kyphosis (ankylosing spondylitis)

Question 12

Pulmonary fibrosis causes

Answer 12

1. Idiopathic Pulmonary Fibrosis.
2. Rheumatoid, SLE, sarcoid, tuberculosis

Question 13

Apical fibrosis

Answer 13

TB, sarcoidosis, ankylosing spond, extrinsic allergic alveolitis

Question 14

Basal fibrosis

Answer 14

IPF, asbestosis, aspiration

Question 15

Pulmonary fibrosis investigations

Answer 15

CXR = opacification in zones as above, honeycombing, groundglass appearance

Question 16

Management of Pulmonary fibrosis

Answer 16

Conservative = stop smoking
Medical = trial of steroids or azathioprine, pirfenidone or nintedanib (anti-fibrotic drugs)
Surgical = single or double lung transplant

Question 17

Respiratory clubbing causes

Answer 17

CF
fibrosis
malignancy
bronchiectasis

Question 18

Horners triad

Answer 18

Ptosis (drooping), Miosis, anhydrosis

Question 19

obstructive respiratory signs

Answer 19

Barrel chest, decreased expansion, hyperresonant, wheeze

Question 20

signs of pleural effusion

Answer 20

tachypnoea, tar staining, dullness to percuss, reduced expansion, reduced vocal fremitus, reduced air entry

Question 21

Lights criteria

Answer 21

Exudate = protein 25-35g/L or effusion/plasma albumin >0.5, or effusion/plasma LDH >0.6 or effusion LDH > 2x ULN

Question 22

exudate examples

Answer 22

malignancy, PE, infection

Question 23

Transudate examples

Answer 23

cirrhosis, heart failure, renal failure

Question 24

signs of old TB

Answer 24

scars for lobectomy or pneumectomy, apical fibrosis with tracheal traction, crackles and bronchial breathing, dullness on percussion, reduced expansion, no clubbing or asterixis

Question 25

TB management

Answer 25

rifampicin, isoniazid, pyrazinamide, ethambutol

Question 26

TB management side effects

Answer 26

Rifampicin = orange secretions,
isoniazid = peripheral neuropathy (give pyridoxine),
pyrazinamide = hepatitis,
ethambutol = visual disturbances

Question 27

Old tb presentation

Answer 27

Today I examined this gentlemen’s respiratory system. He was alert and comfortable at rest. He was not short of breath, not clubbed and there was no asterixis. He had a right sided thoracotomy scar with the underlying rib removed. This was associated with reduced lung expansion on that side, with reduced breath sounds and dullness to percussion. Auscultation of the remainder of the chest was normal. These signs are consistent with right upper lobectomy which would point to a diagnosis of previous tuberculosis or bronchial carcinoma. I would like to take a full history and perform spirometry.

Question 28

CF signs

Answer 28

clubbing, pseudomonas prophylaxis inhaler, creon, gastrotomy, port-a-cath for IV access, wet cough

Question 29

CF complications

Answer 29

infection, diabetes, infertility, digestive issues

Question 30

CF management

Answer 30

Conservative = postural drainage, active cycle breathing, nutrition
Medical = creon, immunisations, RhDnase, prophylactic Abx
Surgical = lung transplant

Question 31

CF presentation

Answer 31

I examined this gentleman’s respiratory system. On inspection he had a gastrostomy port and there was Creon by the bedside. He was clubbed, but comfortable at rest, and had a slightly wet cough. There was a Portacath in his right axilla. He had equal air entry bilaterally with no additional sounds and the chest was resonant throughout. These signs are consistent with a diagnosis of cystic fibrosis. I would like to take a full history and perform spirometry.

Question 32

normal respiratory exam presentation

Answer 32

Today I performed a respiratory examination of X year old Y.
On general inspection the patient was comfortable at rest and did not have monitoring attached.
On closer inspection of the hands and arms, the patient did not exhibit any stigmata of respiratory disease such as cyanosis or clubbing.
There were no asterixis or fine tremor noted.
Pulse was regular at Z bpm, and RR was W bpm.
On closer inspection of face and chest, no anaemia, central cyanosis or Horner’s were identified.
JVP was non raised, trachea was not deviated and apex beat was non displaced.
On both the anterior and posterior chest wall, expansion was equal bilaterally and percussion was resonant. Vesicular sounds were audible and vocal resonance was normal throughout.
There was no cervical lymphadenopathy and no pitting oedema. Calves were soft non tender.
In conclusion this was a normal respiratory examination. To complete my examination, I would like to take full history and perform a cardiovascular examination.
I would like to take a full set of observations, take bloods, including FBC, U&Es and LFTs for baseline and request a peak flow reading, as well as a chest x ray if indicated.

Question 33

Apical fibrosis (BREASTS CLAP)

Answer 33

Berylliosis
Radiation
Extrinsic allergic alveolitis
Allergic bronchopulmonary aspergillosis
Sarcoidosis
TB
Silicosis

Coal workers pneumoconiosis
Langerhans cell histiocytosis
Ankylosing spondylitis
Psoriasis (very rare)

Question 34

Basal Fibrosis

Answer 34

Idiopathic pulmonary fibrosis
Rheumatological disease (not ank)
connective tissue disease e.g. SLE
Drugs (methotrexate)
Asbestosis
Aspiration

Question 35

complications of interstitial lung disease?

Answer 35

• Respiratory failure
• Chest infection
• Pulmonary hypertension
• Cor pulmonale
• Carcinoma of the lung

Question 36

most common pathogens in acute infective exacerbations of COPD?

Answer 36

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

Question 37

what is bronchiectasis?

Answer 37

Abnormal bronchial wall dilatation, destruction, and transmural inflammation.