Respiratory

Question 1

Go through the Respiratory Short Case

Answer 1

Sitting over side of bed undressed to waist

Never forget asking to see sputum cup

Trachea

• • deviation = concentrate on upper lobes (deviation toward in UL fibrosis)

Must ask the patient to cough

• • do it after assessing position of the trachea
• • loose, dry, bovine (RLN palsy)

FET/Peak flow

• • normal FET <3sec
• • normal peak flow 600L/min men, 400L/min women

Hoover’s sign

• • paradoxical retraction of lateral costal margin
• • occurs in those with flattened diaphragm (severe COPD)

Question 2

What are the causes of bronchial breath sounds?

Answer 2

Prolonged expiratory phase with blowing quality

Causes

• • lobar pneumonia
• • localised fibrosis or collapse
• • above a pleural effusion
• • large lung cavity

Question 3

What are the causes of reduced breath sounds?

Answer 3

Causes

• • emphysema
• • large lung mass
• • collapse, fibrosis, or pneumonia
• • effusion
• • pneumothorax

Question 4

What are the causes of transudate vs exudate in pleural effusion? How are they defined?

Answer 4

Transudate:

• • Pleural:serum protein <0.5
• • Pleural LDH <2/3 serumULN
• • Pleural:serum LDH <0.6

Transudate

• • cardiac failure
• • liver failure
• • nephrotic syndrome
• • Meig’s syndrome (ovarian fibroma + pleural effusion)
• • hypothyroidism (usually exudate)

Exudate

• • pneumonia
• • neoplasm (lung, metastatic, pleural)
• • granulomatous (TB, sarcoid)
• • pulmonary infarction
• • subphrenic abscess
• • pancreatitis
• • CTD (RA, SLE)
• • drugs (nitrofurantoin, methysergide, bromocriptine, SLE causing drugs, chemotherapy)
• • radiation

Question 5

What are the causes of wheezes? What about crackles?

Answer 5

Wheezes (rhonchi)

• inspiratory: asthma; upper airway extrathoracic obstruction
• expiratory: asthma; COPD
• fixed inspiratory (monophonic = no change with respiration): fixed bronchial obstruction (think carcinoma)

Crackles (crepitations)

• late/pan inspiratory
  
  • fine: fibrosis
  • medium: LVF
  • coarse: bronchiectasis or retained secretions
• early inspiratory
  
  • coarse: COPD

Question 6

What are the findings in Lobectomy/Pneumonectomy?

Answer 6

General Inspection

• • scar (thoracotomy scar
• • asymmetrical chest expansion
• • tracheal deviation to side of lobectomy (if UL)

Percussion

• • dull

Auscultation

• • absent or reduced BS
• • reduced vocal resonance

Question 7

What are the key differentials for pleural fluid analysis of the below:

• pH <7.2
• glucose <3.33mmol/L
• RBC >5000/mL
• Amylase >2000u/L
• decreased complement
• chylous

Answer 7

Question 8

Causes of Bronchiectasis

Answer 8

Congenital

• Cystic Fibrosis
• Primary Ciliary Dyskinesia, including the immotile cilia syndrome (Young’s Syndrome)
• Congenital Hypogammaglobulinemia (especially igA and IgG def)
• Yellow Nail Syndrome

Acquired

• Childhood Infections (e.g. TB, Pneumonia, Measles, Whooping cough)
• Localised disease (e.g. bronchial adenoma, TB, foreign body)
• Allergic bronchopulmonary aspergillosis (proximal brochiectesis)
• RA, Sjogrens
• COPD
• Recurrent Aspiration
• Interstitial lung disease and pneumconiosis
• Idiopathic (up to 50%)

Question 9

Causes of pulmonary fibrosis

Answer 9

Upper lobe predominant (SCHART)

• S = silicosis, sarcoidosis
• C = coal worker’s pneumoconiosis
• H = histiocytosis
• A = ankylosing spondylitis, allergic bronchopulmonary aspergillosis
• R = radiation
• T = tuberculosis

Lower lobe predominant (RASIO)

• R = rheumatoid arthritis
• A = asbestosis
• S = scleroderma
• I = idiopathic interstitial fibrosis
• O = other (drugs e.g. busulfan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone), other collagen vascular diseases, acute allergic alveolitis, acute eosinophilic pneumonitis