Test Questions The Thorax and Lungs

Bates’ Guide to Physical Examination and History Taking The Thorax and Lungs Multiple Choice 1. A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: C Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be made worse by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). Realize that in severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these patients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this. 2. A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middleaged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: D Chapter: 08 Page and Header: 318, Table 8–5 Feedback: Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased transmission of high-pitched components of sounds. These higher frequencies are usually filtered out by the multiple air-filled chambers of the alveoli. 3. A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: A Chapter: 08 Page and Header: 314, Table 8–2 Feedback: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds and on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan's syndrome. Read more about this condition. 4. A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: B Chapter: 08 Page and Header: 314, Table 8–2 Feedback: This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance, and during auscultation there are often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this patient's exercise capacity because it may affect his employment and also allows you to follow for progression of his disease. You must offer smoking cessation as an option. 5. A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. What disorder of the chest best describes this disorder? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain Ans: B Chapter: 08 Page and Header: 312, Table 8–1 Feedback: The pain from pericarditis is usually sharp and knifelike and is located over the left side of the chest. Change of position, breathing, and coughing often make the pain worse, whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as systemic lupus and in patients with chronic kidney disease. Patients also experience this after a myocardial infarction. You can read more about Dressler's syndrome. 6. A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent leftsided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthyappearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain Ans: A Chapter: 08 Page and Header: 312, Table 8–1 Feedback: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often radiates to the shoulders, arms, neck, and jaw. It is associated with shortness of breath, nausea, and sweating. The pain is generally relieved by rest or medication after several minutes. This patient needs to be admitted to the hospital for further workup for his accelerating symptoms. 7. A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is “ripping out her heart.” It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's ER for further evaluation. What disorder of the chest best describes her symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain Ans: C Chapter: 08 Page and Header: 312, Table 8–1 Feedback: A dissecting aortic aneurysm is associated with a ripping or tearing sensation that radiates to the neck, back, or abdomen. Because blood supply to the brain and extremities is disrupted, syncope and paraplegia or hemiplegia can occur. Blood pressure will usually be different between the two arms, and the carotid pulses often show an asymmetry. This is because the aneurysm decreases flow distally and causes inequality of flow between sides. 8. A 25-year-old accountant presents to your clinic, complaining of intermittent lower rightsided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married, and his wife has a baby due in 2 months. He denies any smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender. What disorder of the chest best describes his symptoms? A) Pericarditis B) Chest wall pain C) Pleural pain D) Angina pectoralis Ans: C Chapter: 08 Page and Header: 312, Table 8–1 Feedback: This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better. Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease. 9. A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can't do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination the S1 and S2 are distant and an S3 is heard over the apex. What disorder of the chest best describes her symptoms? A) Pneumonia B) Chronic obstructive pulmonary disease (COPD) C) Pleural pain D) Left-sided heart failure Ans: D Chapter: 08 Page and Header: 314, Table 8–2 Feedback: In left-sided heart failure, fluid starts “backing up” into the lungs because the heart is unable to handle the volume. The excess fluid collects in the dependent areas, causing crackles in the bases of the lower lobes. Sitting up allows patients to breathe easier. The two main causes are chronic high blood pressure and coronary artery disease, which lead to myocardial ischemia and decreased contractility of the heart. 10. A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite awhile. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable. What disorder of the thorax best describes your findings? A) Barrel chest B) Funnel chest (pectus excavatum) C) Pigeon chest (pectus carinatum) D) Thoracic kyphoscoliosis Ans: B Chapter: 08 Page and Header: 317, Table 8–4 Feedback: Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary. 11. Which of the following anatomic landmark associations is correct? A) 2nd intercostal space for needle insertion in tension pneumothorax B) T6 for lower margin of endotracheal tube C) Sternal angle marks the 4th rib D) 5th intercostal space for chest tube insertion Ans: A Chapter: 08 Page and Header: 283, Anatomy and Physiology Feedback: The 2nd intercostal space is indeed the correct location for insertion of a needle in tension pneumothorax. The other answers are incorrect. T4 marks the approximate bifurcation of the trachea and therefore marks the inferior limit for an endotracheal tube on chest X-ray. The sternal angle marks the 2nd rib, which helps establish the 2nd interspace for needle insertion as above or locations for cardiac auscultation (aortic and pulmonary areas). Finally, the 4th intercostal space is normally used for chest tube insertion. 12. A 55–year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture? A) Bronchitis B) Costochondritis C) Pericarditis D) Angina pectoris Ans: D Chapter: 08 Page and Header: 290, The Health History Feedback: The clenched fist of Levine's sign, while not completely specific for ischemic pain, should definitely cause you to consider this etiology. Bronchitis is usually painless and pericarditis can produce a sharp pain which worsens with inspiration. This is called pleuritic pain and can be associated with pneumonia and other chest diseases. Costochondritis is a parasternal pain, usually well localized. It is exquisitely tender. 13. A 62-year-old smoker complains of “coughing up small amounts of blood,” so you consider hemoptysis. Which of the following should you also consider? A) Intestinal bleeding B) Hematoma of the nasal septum C) Epistaxis D) Bruising of the tongue Ans: C Chapter: 08 Page and Header: 290, The Health History Feedback: When you suspect hemoptysis, you must consider other etiologies for bleeding. Commonly, epistaxis can mimic this as well as bleeding from the gastrointestinal tract. The other answers, although they involve bleeding, are contained or distant from the pharynx. 14. Which of the following occurs in respiratory distress? A) Speaking in sentences of 10–20 words B) Skin between the ribs moves inward with inspiration C) Neck muscles are relaxed D) Patient torso leans posteriorly Ans: B Chapter: 08 Page and Header: 297, Examination of the Posterior Chest Feedback: This description is consistent with retractions that occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing, in which the patient exhales against his lips, which are pressed together. 15. Which of the following is consistent with good percussion technique? A) Allow all of the fingers to touch the chest while performing percussion. B) Maintain a stiff wrist and hand. C) Leave the plexor finger on the pleximeter after each strike. D) Strike the pleximeter over the distal inter-phalangeal joint. Ans: D Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Percussion takes practice to master. Most struggle initially with keeping the wrist and hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off the chest wall. These can dampen the sound you are trying to obtain. The ideal target for the plexor is the distal interphalangeal joint. 16. Which of the following percussion notes would you obtain over the gastric bubble? A) Resonance B) Tympany C) Hyperresonance D) Flatness Ans: B Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD may have hyperresonance over his chest, while a normal person would have resonance. Dullness is heard over a normal liver, and flatness is heard if one percusses a large muscle. 17. Which of the following conditions would produce a hyperresonant percussion note? A) Large pneumothorax B) Lobar pneumonia C) Pleural effusion D) Empyema Ans: A Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid. 18. Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration? A) Bronchovesicular B) Vesicular C) Bronchial D) Tracheal Ans: C Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: These sounds are consistent with bronchial breath sounds. Be alert for these, as they may occur elsewhere and indicate a pneumonia or other pathology. The current explanation for this phenomenon is that the sound from the trachea is carried very well to the chest wall by fluid. This same explanation explains “ee” to “aa” changes, whispered pectoriloquy, bronchophony, and other circumstances in which high-frequency sounds, normally blocked by the air-filled alveoli, could be transmitted to the chest wall. 19. A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these? A) Asthma B) COPD C) Bronchiectasis D) Heart failure Ans: D Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: The timing of crackles within inspiration provides important clues. These late inspiratory crackles that appeared suddenly would be most consistent with heart failure. COPD and asthma usually produce early inspiratory crackles. Bronchiectasis, as seen in cystic fibrosis, classically produces mid-inspiratory crackles, but this is not always reliable. Interestingly, endexpiratory crackles can be heard in asthma on occasion. 20. When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology? A) Bronchitis B) Simple asthma C) Cystic fibrosis D) Heart failure Ans: A Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not be associated with findings that cleared with a cough. 21. A patient with longstanding COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. Which of the following would be reasonable to do next? A) Percuss the lower border of the liver B) Measure the span of the liver C) Order a hepatitis panel D) Obtain an ultrasound of the liver Ans: B Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: In this patient, measuring the span of the liver saved the patient an involved workup, because it was normal. His history of COPD is consistent with flattening of the diaphragms, which pushed the liver edge down while the actual size of the liver remained the same. Percussing the lower border of the liver alone caused this referral, because it was assumed that the liver was enlarged. 22. You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area. What would your next step be? A) B) C) D) Call a medevac helicopter Drive him to the city (4 hours away) Press on his sternum and spine simultaneously Examine him for tenderness over the injured area Ans: C Chapter: 08 Page and Header: 309, Special Techniques Feedback: The area involved in the injury will of course be tender. If you press in an area remote to the injury, but over the same bone which may be involved, you can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs. Fortunately, this maneuver did not reproduce pain remotely, and your uncle simply sat on the sidelines for the rest of the game.