Cox & Roper: Clinical Skills

Chapter 05 - Respiratory system

Instructions: Each group of extended matching questions consists of lettered options followed by a list of numbered problems/questions. For each numbered problem/question select the one lettered option that most closely answers the question. You can use the lettered options once, more than once, or not at all.

Topic: Respiratory signs

Options:

1. Clubbing
2. Vocal resonance greater on right than left
3. Left lung base duller than the right
4. Bronchial breath sounds at the right lung base
5. Widespread crackles throughout both lungs especially at the bases
6. Lymphadenopathy in the neck
7. Trachea deviated to the left
8. Right lung base duller than the left
9. Trachea deviated to the right
10. Vocal resonance greater on left than right
11. Bronchial breath sounds at the left lung base
12. A pleural rub

The patients described below have come to see you. Which additional features are they most likely to demonstrate?

1

Scenario 1 a) The patient is a 60 year old man, previous heavy smoker admitted with haemoptysis and two stone weight loss. He is clubbed, looks cachexic and has an enlarged liver. There is no evidence of a pleural effusion. Choose... Clubbing Vocal resonance greater on right than left Left lung base duller than the right Bronchial breath sounds at the right lung base Widespread crackles throughout both lungs especially at the bases Lymphadenopathy in the neck Trachea deviated to the left Right lung base duller than the left Trachea deviated to the right Vocal resonance greater on left than right Bronchial breath sounds at the left lung base A pleural rub Correct. This story is highly suggestive of advanced lung cancer. This is likely to have spread to the nodes of the neck. See pages 110 and 115.Incorrect. This story is highly suggestive of advanced lung cancer. This is likely to have spread to the nodes of the neck. See pages 110 and 115.Your answer has been saved.

2

Scenario 2 a) You see a 20 year old man in the emergency department complaining of severe, sudden-onset breathlessness and left-sided pleuritic chest pain. The trachea is not deviated. The right lung is duller to percussion than the left. Breath sounds are greatly reduced on the left. Choose... Clubbing Vocal resonance greater on right than left Left lung base duller than the right Bronchial breath sounds at the right lung base Widespread crackles throughout both lungs especially at the bases Lymphadenopathy in the neck Trachea deviated to the left Right lung base duller than the left Trachea deviated to the right Vocal resonance greater on left than right Bronchial breath sounds at the left lung base A pleural rub Correct. These features suggest left-sided pneumothorax. Normally, the pathology is on the side of the lung which is duller - pneumothorax is the exception. Pleuritic chest pain is often accompanied by a rub but not usually if the cause is a pneumothorax. Vocal resonance will be reduced in the abnormal left lung. See pages 108 and 119.Incorrect. These features suggest left-sided pneumothorax. Normally, the pathology is on the side of the lung which is duller - pneumothorax is the exception. Pleuritic chest pain is often accompanied by a rub but not usually if the cause is a pneumothorax. Vocal resonance will be reduced in the abnormal left lung. See pages 108 and119.Your answer has been saved.

3

Scenario 3 a) You see an 80 year old lady in clinic complaining of breathlessness. On examination, the left lung is dull all over with virtually absent breath sounds and greatly reduced vocal resonance. Choose... Clubbing Vocal resonance greater on right than left Left lung base duller than the right Bronchial breath sounds at the right lung base Widespread crackles throughout both lungs especially at the bases Lymphadenopathy in the neck Trachea deviated to the left Right lung base duller than the left Trachea deviated to the right Vocal resonance greater on left than right Bronchial breath sounds at the left lung base A pleural rub Correct. These features suggest a massive left-sided pleural effusion. It is likely that this will push the trachea away to the right. You could argue that such a pleural effusion may be due to lung cancer making options a and f reasonable answers. See pages 95 and 113.Incorrect. These features suggest a massive left-sided pleural effusion. It is likely that this will push the trachea away to the right. You could argue that such a pleural effusion may be due to lung cancer making options a and f reasonable answers. See pages 95 and 113.Your answer has been saved.

4

Scenario 4 a) You visit a 55 year old woman at home. She has been chesty for a few days and now become feverish and weak. There is no chest pain. On examination, you find her left base is dull with increased vocal resonance. Choose... Clubbing Vocal resonance greater on right than left Left lung base duller than the right Bronchial breath sounds at the right lung base Widespread crackles throughout both lungs especially at the bases Lymphadenopathy in the neck Trachea deviated to the left Right lung base duller than the left Trachea deviated to the right Vocal resonance greater on left than right Bronchial breath sounds at the left lung base A pleural rub Correct. The symptoms are suggestive of lung infection. The dull left base suggests this is the area affected and the increased vocal resonance suggests there is consolidation. Bronchial breathing is another feature of consolidation. See pages 105 and 114.Incorrect. The symptoms are suggestive of lung infection. The dull left base suggests this is the area affected and the increased vocal resonance suggests there is consolidation. Bronchial breathing is another feature of consolidation. See pages 105 and 114.Your answer has been saved.

5

Scenario 5 a) You see a 70 year old man in clinic. He has never smoked or been prone to chest infections but in the last year has become increasingly breathless. Otherwise he feels well. On examination he is severely clubbed. Choose... Clubbing Vocal resonance greater on right than left Left lung base duller than the right Bronchial breath sounds at the right lung base Widespread crackles throughout both lungs especially at the bases Lymphadenopathy in the neck Trachea deviated to the left Right lung base duller than the left Trachea deviated to the right Vocal resonance greater on left than right Bronchial breath sounds at the left lung base A pleural rub Correct. This sounds like pulmonary fibrosis which commonly causes clubbing as well as widespread crackles. The commonest cause of clubbing is lung cancer but the patient would be likely to be more unwell, chesty and / or a smoker. See pages 85, 106 and 118.Incorrect. This sounds like pulmonary fibrosis which commonly causes clubbing as well as widespread crackles. The commonest cause of clubbing is lung cancer but the patient would be likely to be more unwell, chesty and / or a smoker. See pages 85, 106 and 118.Your answer has been saved.

(c) Oxford University Press, 2007