Respiratory

Question 1

Age Related Tachypnea (4)

Answer 1

1. Younger than two months: >60 bpm
2. Two-12 months: >50 bpm
3. 1-5 years old: >40 bpm
4. 5 years an older: >20 bpm

Question 2

Respiratory Inspection (2)

Answer 2

1. Retractions are suprasternal and severe in high obstruction
2. Retractions are infrasternal and less evere in low obstructions

Question 3

Percussion Sounds (6)

Answer 3

1. Flatness: Over Thigh
2. Dullness: Over liver
3. Resonance: Over lung
4. Hyperresonance: none normally present
5. Tympany: Gastric air bubble or puffed out
   cheek
6. Omit the area under the scapula

Question 4

Tactile fremitus vibrations (2)

Answer 4

1. Vibration increases over area of lung consolidation

2. Vibrations decrease or are absent when bronchus is obstructed or occupied by fluid

Question 5

Normal Lung Sounds (3)

Answer 5

1. Soft and nonmusical
2. Heard on inspiration and early expiration (longer inspiratory, shorter expiratory)
3. Will be diminished by those factors that affect sound generation—hypoventilation or narrowed airway or sound transmission such as lung destruction, pleural effusion or pneumothorax

Question 6

Tracheal Breath Sounds (4)

Answer 6

1. Hollow and non-musical
2. Heard clearly in both phases of respiratory cycle
3. Heard best at suprasternal notch or lateral neck (trachea)
4. Represents intrapulmonary sound but can be disturbed if upper airway patency is altered

Question 7

Vesicular Breath Sounds (5)

Answer 7

1. Soft and non-musical
2. Heard on inspiration and early expiration
3. Diminished by factors affecting sound generations such as hypoventilation and airway narrowing
4. Diminished by factors affecting sound transmission such as pleural effusion
5. Rules out clinically significant airway obstruction

Question 8

intrapulmonary factors that affect sound transmission (4)

Answer 8

1. Pneumothorax
2. Hemothorax
3. Intrapulmonary masses
4. Lung consolidation

Question 9

extrapulmonary factors that affect sound transmission (4)

Answer 9

1. Obesity
2. Chest deformities
3. Abdominal distention due to ascites
4. Parenchymal destruction

Question 10

Bronchial Breath Sounds (3)

Answer 10

1. Soft and non-musical
2. Heard on both phases of respiratory cycle (mimics tracheal sounds)
   - Equal inspiratory and expiratory phase
3. Indicates patent airway surrounded by consolidated lung tissue - pneumonia or fibrosis

Question 11

Stridor (4)

Answer 11

1. High pitched and musical
2. Best heard over upper airway or at a distance without a stethoscope
3. Indicates upper airway obstruction
4. Associated with extrahoracic lesions (laryngomalacia, vocal cord lesion) or intrathroacic lesions (tracheomalacia, bronchomalacia, extrinsic compression) when heard on expiration

Question 12

Paradoxical Vocal-Cord Motion (2)

Answer 12

Vocal cord dysfunction…can occur with stridor

1. Inappropriate adduction of the vocal cord
2. Resultant airflow limitation at the level of the larynx, accompanied by stridorous breathing

Question 13

Wheeze (4)

Answer 13

1. Musical and high pitched
2. May be heard on inspiration, expiration or both
   - Usually is initially expiratory; worry when it’s on both
3. Suggests airway narrowing or blockage (foreign body tumor) when it is localized
4. Associated with generalized airway narrowing and airflow limitation when widespread (COPD, Asthma)

Question 14

What can cause monophanic (homophanic) wheezing? (7)

Answer 14

Large airway obstruction…

1. Inhaled foreign body
2. Endobronchial tuberculosis
3. Bronchial adenoma
4. Enlarged mediastinal nodes
5. Achalasia
6. Malignant mediastinal tumors
7. In patients with monophonic localized
   wheezing, mass lesion needs to be considered

Question 15

What can cause polyphonic (heterophonous) wheezing? (what it is and 3 causes)

Answer 15

Small airway obstruction, and expiratory wheezing is predominantly present

1. Asthma
2. Bronchiolitis
3. Transient Earlier wheezing

Question 16

Transient Earlier Wheezing (3)

Answer 16

1. Usually disappear in early toddlerhood
2. Patients frequently see rattle as a wheeze
3. Rattles get misdiagnosed in young children as wheeze

Question 17

Rhonchus (6)

Answer 17

1. Musical and similar to snoring
2. Lower in pitch than a wheeze
3. May be heard on inspiration, expiration, or both
   - Coarser breath sounds at the end of inspiration that clear with coughing; sound is a variation of a wheeze
4. Associated with fluid films and abnormal airway collapsibility
5. Often clears with coughing →suggests large airway involvement
6. Can occur with mucosal thickening or edema or bronchospasms

Question 18

Fine Crackles (7)

Answer 18

1. Nonmusical
2. Short and explosive
3. Heard on mid to late inspiration and occasionally on expiration
4. Unaffected by cough
5. Gravity dependent
6. Not transmitted to mouth
7. Can be present in pneumonia and interstitial lung disease

Question 19

Coarse Crackles (7)

Answer 19

1. Non-musical, short and explosive
2. Heard on early inspiratory and throughout expiration
3. Affected by cough
   - Changes or disappears with cough
4. Transmitted to mouth
5. Indicates intermittent airway opening
6. May be related to sections – bronchitis
7. Difficult to hear in young children

Question 20

Pleural Fiction Rub (6)

Answer 20

1. Non-musical and explosive
2. Biphasic (hallmark rule)
   - Expiratory sequence of sound mirrors the inspiratory sequence
3. Typically heard over basal regions
4. Associated with pleural inflammation or pleural tumors
5. Wave form is similar to crackle but longer in duration and lower in frequency
6. Heard in inflammatory diseases or malignant pleural disease

Question 21

Squawk (3)

Answer 21

1. Mixed with a short musical component similar to a short wheeze
2. Accompanied or preceded by crackles
3. Distal airways are affected—interstitial lung disease if not acutely ill or pneumonia in patients who are acutely ill.

Question 22

What is barking or brassy cough associated with? (3)

Answer 22

1. Croup
2. Tracheomalacia
3. Habit cough

Question 23

What is honking cough associated with?

Answer 23

Psychogenic cough

Question 24

What is paroxysmal (+/- inspiratory whoop) cough associated with? (2)

Answer 24

1. Pertussis

2. Parapertussis

Question 25

What is staccato cough associated with?

Answer 25

Chlamydia in infant

Question 26

What is cough productive of casts cough associated with? (2)

Answer 26

1. Plastic bronchitis | 2. Asthma

Question 27

What is chronic wet cough in am only associated with?

Answer 27

suppurative lung disease

Question 28

Croup (6)

Answer 28

1. History is consistent for URI with or without low grade fever and runny nose 2. Barking cough usually starts late in the evening after the child has been asleep; the child may not look very sick but will have a barking cough 3. Child can be progressively worse each night, usually worse by the 2nd or 3rd night. 4. Can have mild croup with just expiratory stridor 5. Can have severe croup with expiratory and inspiratory stridor 6. Steeple sign on lateral neck film

Question 29

Pulsus Paradoxus

Answer 29

Associated with asthma; drop in systolic BP of 10mmHg or more with inspiration

Question 30

Spirometry Asthma Diagnostic

Answer 30

1. Degree of respiratory compromise 2. Peak expiratory flow rate over 6 but likely is not practical assess under 8 year 3. 30% to 50% of predicted or patient’s personal best—severe obstruction

Question 31

Asthma blood gases in severe obstruction (2)

Answer 31

1. PCO2 is decreased initial and then may elevate as a sign of muscle fatigue 2. Hypoxia or hypercapnia lead to acidosis

Question 32

Pertussis (5)

Answer 32

1. Can occur even if infant is fully immunized 2. Cough can persist for up to 6 months after acute illness * **3. Infants may not have characteristic whoop but do have paroxysmal coughs w/ turning red or blue (croupy barking cough that is paroxysmal) * May vomit after cough 4. Incubation period: 7-10 Days 5. Three phases: catarrhal, paroxysmal, convalescent

Question 33

Viral Pneumonia Clinical Presentation (7)

Answer 33

1. Gradual 2. Associated with preceding upper airway symptoms (rhinorrhea, congestion) 3. Diffuse and bilateral findings 4. Non-toxic appearance 5. Wheezing is more frequent 6. Rhinorrhea 7. Myalgia