Respiratory Clinic Extended Matching Questions Formative Self Assessment

An 18-year-old presents with polyphonic expiratory wheezes through the entire chest. The percussion note is mostly resonant – hyperresonant in the apex of each lungs. The respiratory rate is 28 and the heart rate is 110. Patient is a university student studying politics. Non-smoker, never smoked.

55-year-old factory worker presents with unequal pupils and what he describes as a 3rd cranial nerve lesion (he has Googled his symptoms). He is a smoker with a 28 pack-year history. His chest has normal expansion and his crico-sternal distance is 4 cm. His liver is not palpable even on deep inspiration. There is resonance to percussion and a fixed monophonic wheeze heard loudest posterior in his mid-back.

An 18-year-old woman presents with a progressive worsening of difficulty in breathing – her breathing has become progressively worse over a period of three months. She is concerned that her other care providers have not been able to diagnose her and as her symptoms are progressive; she is anxious to receive some answers. On examination you are able to detect a raised JVP, and cannon waves are seen. Her trachea is midline and her cricosternal distance is 3 cm; chest expands equally with bilateral equal vesicular breath sounds with no added sounds. She has a systolic murmur heard best at the 4th intercostal space at the left side of her sternum. Here liver is 15 cm and palpable below the costal margin with a slight pulsatile sensation emanating although it.

A 55-year-old female presents with shortness of breath, dullness to percussion and an absence of breath sounds to the right- and left-lower lobes. There is no fever present. She has previously been diagnosed with ovarian cancer. The respiratory rate is 19. She works in a pet shop; non-smoker, never smoked.

A 64-year-old morbidly obese female presents with reduced oxygen saturations. On examination you note that her breath sounds are quiet across all lung fields apart from the right-lower lobe where breath sounds are absent. This are area is also associated with a dullness to percussion. You note some inspiratory crackles at the junction between the presence and absence of breath sounds. Her trachea is deviated towards the right hand side of her chest.

A 31-year-old male presents to you after the collapse of a rugby scrum. He is short of breath, his respiratory rate is 36 and his heart rate is 140. His blood pressure is 86/71 mmHg. There is reduced expansion of his left chest. You also note that there is an absence of breath sounds on his left chest and the percussion note is hyop-resonant (Dull). His trachea is midline. He is a non-smoker, never smoked, he works as a mechanic.

An 18-year-old with pectus excavatem presents with shortness of breath and reduced exercise tolerance. Breath sounds are vesicular in nature although you appreciate a quieting of the breath sounds on right of the upper chest. The percussion sounds are also more resonant on the right apex. The remainder of the chest examination is unremarkable. Patient works in retail, selling fashion. Smokes approximately 7 cigarettes a day; has done since 15 years of age.

A 47-year-old woman previously treated for community acquired lobar pneumonia returns to see you with chest pain. The pain is worse on inspiration; you appreciate that she stops breathing in when she feels the pain ‘catch’. On examination you note that she has a resonant percussion note and breath sounds are equal bilaterally and vesicular in nature. There is a friction rub present on the right chest which is associated with the location of the pain experienced.

A 43-year-old train driver present with chest pain which she says is worse when she breathes in. There is no haemoptysis although her heart rate is 120 and the respiratory rate is 23 at rest. Breath sounds are equal bilaterally with no added sounds. She currently smokes with a 15 pack-years record.

A 73-year-old lady with metastatic breast cancer presents in a moribund state. You are able to appreciate coarse crackles from your end-of-bed assessment. She is dehydrated, her JVP is not visible and heart rate is 90. Her blood pressure is 104/72 mmHg and this is usual for her. Her heart sounds are S1+S2+0. Her lung bases are dull to percussion bilaterally and coarse crackles are audible, although you can hear breath sounds throughout her lung fields they are notably loudest at the base. Chest expansion is overall reduced. There is viscous mucus present in her mouth.

A 78-year-old male with a previous diagnosis or squamous cell carcinoma of the right main bronchus presents with a distended neck veins and a facial plethora. His pyjamas look tight around his neck. There are a number of distended blood vessels on his chest. There is an area of dullness to percussion in the upper area of the man’s right chest and there is an absence of breath sounds in this same area. There are coarse crackles noted throughout his lungs on both inspiration and expirations.

A 53-year-old woman who works in an electronics factory presents with recurrent chest infections. At the time of presentation she has what she describes as a “bad chest”. She is coughing up sputum which is green in colour and has a viscous appearance. On examination you find that she has a slightly elevated JVP, there is a reduced cricosternal distance, with reduced chest expansion. The anterior posterior diameter of her chest is increased and her liver is palpable below the costal margin with a span of 10 cm. Her chest is notability hyperresonant in the apices; breath sounds are vesicular with the occasional course crackle.

56-year-old non-smoker presents with a dry non-productive cough. He does not take any medications and works at a garden centre. His chest has a normal percussion note and there are wide-spread fine crackles heard throughout his lung fields on inspiration.

A 58-year-old male presents with dullness to percussion over the right middle lobe. There are bronchiole breath sounds present in the same location. Coarse crackles are also present in the right chest. The respiratory rate is 23. He works as a school teacher, teaching English. Non-smoker, stopped smoking 20 years ago.