Respiratory Cheat Sheet

Respiratory Consolidation/Lobular Pneumonia General Features from History Sudden onset of malaise Increased WOB Poor lung expansion -> less than 5 cm. Dullness to percussion -> consolidation Unequal/reduce air entry Crepitations Low BP Low saturations Chest pain Dyspnoea Fever Cyanosis Exhaustion if very sick Cough: Pain and dry at first Fever and rigors -> shivers Pleuritic chest pain Dyspnoea Tachypnoea Confusion Physical Examination Findings Reduced expansion on the affected side Increase vocal fremitus on the affect side Dullness but not stony dullness on percussion Bronchial breath sounds Medium, late or pan-inspiratory crackles as the pneumonia resolves. Increased vocal resonance Pericardial rub may be present Atelectasis/Lung Collapse Trachea displaced towards the collapsed side. Reduced expansion on the affected side with flattening of the chest wall on the same side. Dullness on percussion on the affected side. Reduced breath sounds often without bronchial sounds. Pleural Effusions This is when there are fluid collections in the pleural space. Note that the following are NOT considered pleural effusions. Collection of blood -> haemothorax Collection of chyle -> chylothorax Collection of pus -> emphysema Trachea and apex beat displaced on the affected side. Expansion reduced on the affected side Dullness on percussion as there is fluid. Reduced or absent breath sounds. There may be an area of bronchial breathing audible above due to compression of overlying lung. Reduced vocal resonance Pneumothorax Reduced expansion on the affected side. Hyperresonance on percussion. Reduced or absent breath sounds. Possibly subcutaneous emphysema Ipsilateral lung expansion Ipsilateral reduced tactile fremitus Ipsilateral hyperresonance Ipsilateral reduced breath sounds Check for tracheal deviation. Subcutaneous emphysema or skin emphysema Tension Pneumothorax Tachypnoea Cyanosis Hypotension Displaced trachea Displaced apex beat Expansion reduced on the affected side. Hyperresonance over the affected side. Absent breath sounds. Absent vocal resonance Elevated JVP Bronchiectasis Systemic signs: Fever Cachexia Sinusitis Sputum: Voluminous Purulent Foul smelling Blood stained Coarse pain-inspiratory or late inspiratory crackles over the affected area. Signs of severe bronchiectasis: Large amount of septum Large amounts of haemoptysis Clubbing Cyanosis Widespread crackles Signs of airways obstruction Signs of respiratory failure Cor-pulmonale Signs of secondary amyloidosis Bronchial Asthma Wheezing Dry or productive cough Tachypnoea Tachycardia Prolonged expiration Prolonged forced expiratory time Use of accessory respiration muscles Chest hyperinflation: Increase anteroposterior diameter with high shoulders Percussion -> dullness Decreased liver dullness. Inspiration and expiratory wheezing Decreased air entry Tracheal tug Signs of severe asthma: Appearance of exhaustion or fear Inability to speak because of breathlessness Drowsiness due to hypercapnia Cyanosis Tachycardia Pulsus paradoxus Reduced breath sounds Poor lung expansion COPD History Features Heavy smoking of history Reduced breath sounds Previous diagnosis of COPD or emphysema If 2 out 3 of these are present, this is a positive LR of COPD Physical Examination Findings Barrel-shaped chest with increase anteroposterior diameter Pursed lip breathing: Feature of emphysema In expiration through partly closed lips increases the end-expiratory pressure and keeps the airways open -> helps minimise air trapping. Use of accessory muscles of respiration. Drawing in of the lower intercoastal muscles with inspiration. Drowsiness or comas: Signs of increased CO2 levels. Warm peripheries, pounding pulses and flapping tremor/ Signs of CO2 retention. Reduced chest expansion Chest hyperinflation. Hoover’s sign Tracheal tug Hyperresoant percussion Decreased liver dullness of percussion Decreased breath sounds Early inspiratory crackles. Wheeze is usually absent Signs of right heart failure may occur In the late course of the disease. Hepatomegaly JVP Poor lung expansion. Prolonged expiration. PINK PUFFER – EMPHYSEMA BLUE PUFFER – CHRONIC BRONCHITIS Noncyanotic Productive cough Cachectic Overweight Pursed lip breathing Peripheral edema Slightly reduced PaO2. PaO2 is markedly reduced CO2 normal? Increase hypercapnia Chronic Bronchitis Definition Daily production of septum for 3 months a year for at least 2 consecutive years. Features Loose cough and sputum Mucoid or mucopurulent Especially in the morning shortly after waking up and lessening as the day progresses. Cyanosis In later stages of disease Blue bloaters. Edema from RVF Hyperinflated chest with reduced chest expansion. Increased resonance on percussion. Reduced breath sounds with end-expiratory high- or low-pitched wheeze and early inspiratory crackles. Signs of RVF Interstitial Lung Disease Remember the 3 Cs: Cough -> dry Clubbing Crackles Dyspnoea Cyanosis Reduced chest expansion Fine late inspiratory crackles heard over the affected lobes. Signs of connective tissue disease: RA SLE Erythematosus Scleroderma Sjogren’s syndrome Polymyositis Dermatomyositis Mediastinal compression Causes Due to pathological masses such as: Lung carcinomas (90% of the time). Lymphomas Thymomas Dermatoid cyst Large retrosternal goitre Rarely aortic aneurysm Features SVC obstruction: Plethoric Cyanosed Peripheral edema Exophthalmos Elevated JVP -> raised but NOT pulsatile Enlarged thyroid Supraclavicular lymphadenopathy Positive Pemberton’s sin Dilated collateral vessels on the chest Other features of lung carcinomas. Tracheal compression: Stridor Respiratory distress RLN involvement: Voice hoarseness Horner’s syndrome: Ptosis Myosis Anhidrosis Paralysis of the phrenic nerve: Dullness to percussion on the affected side -> does not change with deep inspiration -> abnormal tidal percussion. Absent breath sounds -> suggest paralysed diaphragm due to RLN involvement. Lung Carcinomas Respiratory and chest signs Haemoptysis Clubbing Lobar collapse or volume loss Pneumonia Pleural effusion Fixed inspiratory wheeze Tender ribs: Secondary tumor deposits in the ribs. Mediastinal compression with nerve involvement: RLN -> voice hoarseness Phrenic -> diaphragmatic paralysis Supraclavicular or axillary lymph node involvement Pulmonary embolism Respiratory distress Reduced chest expansion Reduce breath sounds Dull ness of percussion Split of the S2. Low grade fever Cough Haemoptysis Sudden pleuritic chest pain Rarely abdominal pain. If large PE: Presyncope or syncope JVD Circulatory collapse Kussmaul sign: Distension of the jugular veins during inspiration to elevation of venous pressure. Can be seen in patients with constrictive pericarditis, restrictive cardiomyopathy, right ventricular infraction and tricuspid stenosis. Lung Tumours Apical/Pancoast Tumor Horner syndrome: Ptosis Myosis Anhidrosis C8 and T1 nerve root lesion -> RLN -> voice hoarseness Distal metastasis Brain, live and bone are the most affected sites. Non-metastatic extrapulmonary manifestations General Features Anorexia Weight loss Cachexia Fever Endocrine PTH -> hypercalcemia Squamous cell carcinoma ADH -> hyponatremia Small cell carcinomas ATCH -> Cushing’s like features Small cell carcinomas Carcinoid syndrome: Gonadotrophs -> gynecomastia -> usually squamous cell Squamous cell carcinomas -> insulin like peptide -> hypoglycaemia Neurological manifestations Peripheral neuropathy Polymyositis Cortical degeneration Subacute cerebellar degeneration Eaton-Lambert Syndrome: Progressive muscle weakness Retinal blindness Seen in small cell carcinomas Haematological Features Migrating venous thrombophlebitis Disseminated intravascular coagulation a Anaemia Skin features Acanthosis Dermatomyositis -> rare Renal features Nephrotic syndrome due to membranous glomerulonephritis -> rare Sarcoidosis Features Lungs: Usually no signs, even though 80% pf patients have lung involvement. In severe disease there might be signs of ILD