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Questions and Answers
Which condition is most likely to cause a chronic cough lasting more than 8 weeks?
What is a typical characteristic of sputum produced in bronchiectasis?
In which scenario would a cough be classified as subacute?
Which medication is known to potentially cause a chronic cough?
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Which condition is NOT typically associated with cough due to respiratory causes?
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What are the potential causes of hoarseness as mentioned?
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Which of the following symptoms is NOT indicative of corpulmonale?
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What is the normal range for respiratory rate in adults?
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Which physical examination technique helps to assess thoracic symmetry?
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During a clinical examination, prominent veins are indicative of which condition?
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What is the term for the breathing pattern characterized by increased respiratory rate?
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Which symptom is associated with Horner’s syndrome during examination?
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What could a deviation of the trachea to the right during palpation suggest?
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What is the most common cause of hemoptysis?
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Which condition is LEAST likely to cause instantaneous dyspnea?
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What is characterized by pink frothy secretions?
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Which condition is NOT considered a pulmonary cause of chest pain?
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Which of the following is classified under chronic dyspnea conditions?
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What might rusty sputum indicate?
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Wheezing is defined as which type of sound?
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Which of the following statements about non-respiratory causes of hemoptysis is true?
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What condition is indicated by tracheal tug with a distance of less than 3-4 finger breadths?
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What does a resonant note below the liver dullness indicate?
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Which type of breath sound is characterized by being louder and longer on the expiration phase with a gap between the phases?
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Which of the following statements about crackles is incorrect?
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What type of added sound is characterized by continuous, musical, polyphonic sounds that are louder on expiration?
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Which condition is often associated with late or pan-inspiratory coarse crackles?
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What does tactile vocal fremitus evaluate during a physical examination?
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Which condition is associated with a decrease in cardiac dullness on examination?
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Study Notes
Respiratory System Symptoms and Signs
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Cough:
- Can be acute (< 3 weeks), subacute (3-8 weeks), or chronic (> 8 weeks).
- Acute cough can be caused by upper or lower respiratory tract infections, exacerbations of underlying chronic lung disease, or pulmonary embolism.
- Subacute cough is often post-infectious or caused by ACE-I medication.
- Chronic cough with a normal chest x-ray is often linked to upper airway cough syndrome, bronchial asthma, or gastroesophageal reflux disease.
- Other respiratory causes of chronic cough include chronic bronchitis, bronchiectasis, lung cancer, interstitial lung disease, lung abscess, obstructive sleep apnea, tracheobronchial foreign body, or nasal polyps.
- Non-respiratory causes include mediastinal compression, heart failure, sinusitis, postnasal drip, GERD, esophageal issues, neurological disorders, medications, or unknown causes.
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Sputum:
- Normal amount is less than 100 ml of mucus per day.
- Normal color is clear and white.
- Large amounts of purulent sputum suggest bronchiectasis (chronic) or lobar pneumonia (acute).
- Foul-smelling purulent sputum may indicate a lung abscess with anaerobic infection.
- Pink frothy sputum can be a sign of pulmonary edema.
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Hemoptysis:
- Blood-stained sputum, ranging from streaks to massive bleeding (>100-600 ml/24 hours).
- Requires thorough investigation.
- Commonest cause is acute infection, but other causes should be ruled out.
- Other causes include pulmonary embolism, lung cancer, pulmonary tuberculosis, bronchiectasis, lung abscess, pulmonary hemorrhage, and non-respiratory causes like heart valve problems or bleeding disorders.
- Rusty sputum (purulent sputum with blood) often indicates lobar pneumonia.
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Dyspnea:
- Feeling of discomfort or awareness of respiratory distress, characterized by increased work of breathing.
- Onset can be instantaneous (pneumothorax, PE), within minutes to hours (airway, parenchymal, vascular, cardiac, metabolic, or hyperventilation), subacute (worsening over days), or chronic (months to years).
- Subacute dyspnea can also be caused by pleural effusion, lobar collapse, acute interstitial pneumonia, superior vena cava obstruction, or pulmonary vasculitis.
- Chronic dyspnea is often associated with COPD, asthma, interstitial lung disease, hypoventilation, anemia, or thyrotoxicosis.
- Severity can be graded I-IV based on the New York Heart Association classification.
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Chest Pain:
- Pulmonary causes include issues with the blood vessels (PE, pulmonary hypertension, cor pulmonale), lung tissue (pneumonia, cancer, sarcoidosis, pleuritis), pleura (pneumothorax, pleural effusion), or psychogenic/psychosomatic causes.
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Wheezing:
- Continuous whistling sound, not specific to asthma and can occur in other respiratory diseases.
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Other Symptoms:
- Runny or blocked nose, sneezing (common cold or allergic rhinitis), nocturnal fever (TB, pneumonia, mesothelioma), nocturnal sweating (TB, lymphoma, lung abscess), hoarseness (laryngitis, vocal cord tumor, recurrent laryngeal nerve palsy), or symptoms of cor pulmonale (abdominal and ankle swelling).
History Taking
- Detailed information on respiratory symptoms including onset, duration, character, severity, frequency, aggravating and relieving factors, and associated symptoms.
- Past medical history of respiratory disease
- Detailed smoking history
- Drug history, including intravenous drug abuse (lung abscess) and alcohol consumption (aspiration pneumonia)
- Occupational and job history
- Pet history
Clinical Examination (Signs)
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General Appearance:
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Respiratory Distress:
- Assess respiratory rate (normal 14-20 breaths per minute).
- Tachypnea (increased rate of breathing).
- Hyperapnea (increased depth of ventilation).
- Observe use of accessory muscles (sternomastoids, scalene, platysma, strap muscles of the neck, and abdominal muscles).
- Coughing: Characterize the cough.
- Sputum: Observe presence and characteristics.
- Abnormal Sounds: Stridor (croaking noise, loudest on inspiration due to larynx, trachea, or large airway obstruction), wheezing.
- Abnormal Voice: Hoarseness.
- Surroundings: Note presence of sputum containers, oxygen mask, IV lines, respiratory aids, or machines.
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Respiratory Distress:
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General System Examination:
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Hands:
- Clubbing (check for respiratory causes).
- Tar staining.
- Weakness of hand muscles.
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Wrist:
- Pulse rate and character.
- Flapping tremors (asterixis).
- Blood Pressure: Pulsus paradoxus (asthma) or hypotension.
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Hands:
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Neck:
- JVP: Increased in cor pulmonale and superior vena cava obstruction, but non-pulsatile.
- Lymph nodes: Enlarged in lung cancer or metastasis.
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Face:
- Eyes: Horner's syndrome in lung cancer.
- Tongue: Central cyanosis.
- Superior vena cava obstruction: Plethoric and cyanosed face, periorbital edema, injected conjunctivae, and positive Pemberton's sign.
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Chest Examination:
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Inspection:
- Shape: Assess anteroposterior diameter compared to transverse diameter (barrel chest), pectus excavatum, pectus carinatum, kyphoscoliosis, and other abnormalities.
- Symmetry: Assess upper and lower lobes posteriorly for reduced or delayed chest movement during moderate respiration.
- Scars: Examine for scars from surgery, chest drains, cautery marks, or radiotherapy markings.
- Prominent Veins: Note in cases of superior vena cava obstruction.
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Palpation:
- Trachea: Normally central, slight right displacement is possible. Check for gross displacement. Tracheal tug indicates a distance between the sternal notch and cricoid cartilage less than 3-4 fingerbreadths, occurring in chest overexpansion, as in COPD.
- Apex Beat and Mediastinum: Check for displacement.
- Chest Expansion: Assess expansion (should be greater than 5 cm).
- Tactile Vocal Fremitus (TVF): Can be done with the palm of one hand.
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Percussion:
- Perform symmetrically (comparing left to right), posteriorly, anteriorly, and laterally.
- Percuss supraclavicular area and clavicles directly to assess upper lobes.
- Liver dullness: Percuss from the 6th rib midclavicular line downwards, resonant note below this area indicates hyperinflation (COPD, severe asthma).
- Cardiac dullness: May be reduced in a hyperinflated chest.
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Auscultation:
- Use the diaphragm of a stethoscope to comment on the following:
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Breath Sounds (BS):
- Intensity: Normal or decreased (consolidation, collapse, pleural effusion, pneumothorax, lung fibrosis).
- Quality: Vesicular or bronchial in consolidation.
- Vesicular: Louder and longer on inspiration than expiration with no gap between the two phases.
- Bronchial: Louder and longer on expiration with a gap between the two phases.
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Added Sounds:
- Type: Wheezes (musical sounds), crackles (interrupted, non-monophonic sounds), or friction rub.
- Timing: Inspiratory or expiratory.
- Wheezes: High-pitched wheeze occurs in asthma due to acute/chronic airflow limitation, while low-pitched wheeze is found in COPD. Localized monophonic wheezes indicate a fixed airway obstruction in lung cancer.
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Crackles:
- Late/pan-inspiratory coarse crackles in bronchiectasis.
- Late/pan-inspiratory medium crackles in pulmonary edema.
- Late/pan-inspiratory fine crackles in pulmonary fibrosis.
- Friction Rub: Continuous or intermittent grating sound due to thickened or roughened pleural surfaces rubbing together. Indicates pleurisy and may be heard in pneumonia or pulmonary infarction.
- Vocal Resonance: Assess the transmission of sounds.
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Breath Sounds (BS):
- Use the diaphragm of a stethoscope to comment on the following:
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Inspection:
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Description
Test your knowledge on respiratory system symptoms and their signs through this informative quiz. You'll explore cough characteristics, causes of sputum production, and the differentiation between acute, subacute, and chronic conditions. Perfect for medical students or healthcare professionals looking to reinforce their understanding.
