EMQ: 9
Respiratory Conditions
a)
Left sided pleural effusion
b)
Right sided pleural effusion
c)
Left sided pneumothorax
d)
Right sided pneumothorax
e)
Right apical collapse
f)
Right apical consolidation
g)
Fibrosing alveolitis
h) Bronchiectasis
i)
Pulmonary embolus
j)
Chronic bronchitis
1) A 56-year-old male presenting with cough and
fever. On examination he is febrile, no clubbing, trachea midline, respiratory
movements decreased at right apex, vocal fremitus increased at the right apex,
percussion note dull at the right apex.
Bronchial breathing at the right apex with fine
inspiratory crepitations localised to the right apex. Vocal resonance
increased at the right apex.
Answer: f) right apical consolidation
Cough and fever would suggest an infective disorder of
the respiratory tract.
The trachea being in the midline means there is no
mediastinal shift.
Decreased respiratory movements at the right apex suggest
that there is an underlying lesion affecting the pleura or parenchyma.
Increased vocal fremitus indicates increased conduction
of sound from the underlying bronchus due to consolidation of the parenchyma
or the bronchus being drawn towards the chest wall. This is the same as
increased vocal resonance.
Dull percussion note would suggest consolidation,
collapse or fibrosis (not pneumonectomy as this has not been mentioned in the
history nor has a scar been mentioned)
As the trachea is in the midline collapse and fibrosis
are not likely
This leaves consolidation and with the localised
crepitations suggests the patient has an apical pneumonia.
2) A 63-year-old male presents with dyspnoea. On
examination he is afebrile, the trachea is deviated to the left, respiratory
movements are decreased at the right base, vocal fremitus is decreased at the
right base. Percussion note is stony dull at the right base, breath sounds are
diminished at the right base, vocal resonance is decreased at the right base
and there is aegophony at the upper limit of the area of dullness.
Answer: b) right sided pleural effusion
Dyspnoea may be due to any lesion of the respiratory
system or systemic disease.
The deviation of the trachea to the left means either
pathology in the right side pushing the mediastinum to the left or pathology
on the left side pulling the mediastinum to the left.
Decreased respiratory movements on the right means the
pathology is on the right side.
Stony dullness at the right base indicates an effusion
and this will explain all the signs that have been discussed so far.
Decreased breath sounds and decreased vocal resonance are
in keeping with this diagnosis.
Aegophony may be heard at the upper border of an
effusion.
3) A 62-year-old female with progressive breathlessness.
On examination she has clubbing and there are fine late inspiratory
crepitations at both lung bases
Answer: g) fibrosing alveolitis
Progressive breathlessness may be due to any progressive
lesion in the reparatory system or systemic disease.
Clubbing narrows the causes down considerably (classified
as lesions of the bronchi, alveoli, lung parenchyma, pulmonary vasculature
pleura see ACES for PACES page 254)
Fine inspiratory crepitations at the bases may be due to
fibrosing alveolitis or left ventricular failure.
(ACES for PACES page 265)
In the context of progressive breathlessness and clubbing
the diagnosis would be fibrosing alveolitis
4) A 26-year-old male presents with sudden onset chest
pain and breathlessness. On examination his trachea is deviated to the right,
respiratory movements are decreased on the left hand side. Percussion note is
hyper-resonant on the left hand side. Breath sounds are decreased on the left
hand side.
Answer: c) left sided pneumothorax
Breathlessness may be due to any lesion in the
respiratory tract. However chest pain in relation to the respiratory system is
usually due to lesions in the pleura or chest wall (ACES
for PACES page 247-248). This rapidly narrows down the
possibilities.
Tracheal deviation to the right would suggest a lesion on
the left pushing to the right or a lesion on the left pulling the mediastinum
to the left.
Decreased movement on the left indicates that the lesion
is in the left hand side.
Hyper-resonant percussion note is noted in either a
pneumothorax or emphysema. With the foregoing clinical features the most
likely lesion is a left sided pneumothorax. Decreased breath sounds on the
left are in keeping with this diagnosis.
5) A 40-year-old male with a chronic productive cough and
recurrent respiratory infections. He gives a history of whooping cough in
childhood.
On examination he is clubbed, there are coarse
crepitations at both bases of the lings. The crepitations change when the
patient is asked to cough.
Answer: h) bronchiectasis
A productive cough is due to increased production of
sputum and this may be due to lesions in the bronchi, alveoli, lung parenchyma
or external factors see ACES for PACES page 247
The history of whooping cough in childhood would point to
bronchiectasis see ACES for PACES page 239
Clubbing and coarse crepitations at the lung bases
especially if the crepitations change with coughing would suggest
bronchiectasis see ACES for PACES pages 264-265.
Revision Tip
Read up lesions of the respiratory system
ACES for PACES
pages 237-245
This will give you a good idea of the conditions that are
likely to occur in relation to the respiratory system
Revise the section on examination of the respiratory
system and the likely findings on examination
chapter 11 ACES for PACES
