Respiratory examination quiz part 2

Features of clubbing include; an AP diameter of the finger at the nail bed: at the DIP joint > 1; fluctuation of the nail bed; beaking of the fingernail; rounding of the nail plate; flattening of the angle between the nail plate and proximal nail skin fold; and shiny smooth skin over the cuticle. (Link)

The most common pulmonary cause of clubbing is lung cancer. Less common causes are idiopathic pulmonary fibrosis, sarcoidosis, empyema, lung abscess and bronchiectasis. It is uncommon in COPD and TB. (Link)

Normal chest expansion is > 5 cm. It is generally reduced in chest hyperexpansion and fibrosis and locally reduced due to many underlying causes. (Link)

Inspiration is louder and longer than expiration with normal vesicular breath sounds. Bronchial breath sounds have a tubular quality and a more pronounced expiratory phase. Egophony is the change of the pronounced sound of ‘eee’ to ‘aaye’. Coarse crackles are gurgling in quality and imply fluid in small airways. (Link)

Causes of pulmonary fibrosis that can affect any area of the lung include: radiation, smoke inhalation, ARDS, methotrexate, hydralazine, nitrofurantoin, amiodarone, busulphan, cyclophosphamide, methysergide and paraquat. Coal miners pneumoconiosis usually affects the upper lobes. (Link)

The likelihood ratios for COPD are: Barrel chest and loss of cardiac dullness to percussion – 10; rhonchi – 6; hyperresonance – 4.8; FET > 9 – 4.8; FET < 6 – 0.45; pulsus paradoxus –  3.7; decreased breath sounds – 3.7. (Link)

Pancoast’s syndrome is an apical tumour with local extension and is usually a squamous cell carcinoma. The C8, T1, T2 nerves are often involved with pain along their nerve roots. Destruction of 1st and 2nd ribs may also occur. (Link)

The positive LRs for CAP are: egophony – 6; bronchial breath sounds – 3.5, dullness to percussion – 3; T > 37.8 C – 3; RR > 25/min. – 2.5; crackles – 2.5, decreased breath sounds – 2.4. (Link)

Decreased breath sounds are about 75% sensitive whilst increased percussion note is only 10% sensitive. Small pneumothoraces (< 15%) may have no obvious clinical signs. Tracheal deviation occurs in < 25% of cases of tension pneumothorax, so is an insensitive feature. (Link)

Hypercalcaemia and hypoglycaemia are most commonly caused by squamous cell tumours. Eaton Lambert syndrome, hyponatraemia, carcinoid and ectopic ACTH are most common in small cell tumours. Hypertrophic pulmonary osteoarthropathy (HPO) is usually due to adenocarcinoma. (Link)

SVC syndrome may have features of voice hoarseness, however true stridor or dysphagia are rare.
Upper body oedema is common, especially of the face, neck, periorbital tissue and tongue. The neck veins are usually distended and there is facial plethora or telangiectasia. Elevation of the arms (Pemberton’s sign) causes worsening facial suffusion. (Link)

The clinical sensitivity of cyanosis is approximately 50% at a paO2 of 80mmHg, 75% at 70mmHg and 100 at 60mmHg. (Link)

The normal anterior-posterior to transverse ratio in and adult is 1:2. (Link)

The normal AP:transverse chest ratio is 1:1 from birth until 2 years of age. It is 1:1.4 by 6 years of age and 1:2 by adulthood. (Link)

The inspiratory crackles of pulmonary fibrosis tend to be later in onset and of longer duration than the crackles of pulmonary oedema. Bronchial breath sounds may be normal over the central region of the chest and the apex of the right lung. Wheezes and rhonchi have a duration of > 250 milliseconds. Wheezes are higher pitched than rhonchi. (Link)