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Clinical Cases
Breath Sounds Tutorial
Answer Sheet: Case 1
A 70-year-old woman is brought into the A&E by ambulance. She is complaining of increasing breathlessness over the last 5 days, and a cough productive of purulent green sputum. She is a long-standing smoker of 50 pack
years. She is able to mobilise around the house but struggles on the stairs.
1. What clinical sings might you find on examination of this patient?
a) Tachypnoea
b) Use of accessory muscles of respriration
c) Hyperinflation
d) Reduced corticosternal distance (<3cm)
e) Reduced chest expansion
f) Resonant or hyper-resonant percussion note
g) Quiet breath sounds
h) Wheeze
i) Cyanosis
j) Signs of Cor Pulmonale
2. What type of breath sound is it?
a) Polyphonic Wheeze
3. Name the acid-base abnormality?
a) Respiratory Acidosis
PaO2 is too low on 100% oxygen. It should be roughly around 90kPa. This indicates hypoxia.
PaCO2 is >6 kPa, indicating hypercapnia
pH <7.35 indicates acidosis.
4. What could have exacerbated this acid-base abnormality since arrival in A&E?
a) High-flow Oxygen
b) Administration of opiate analgesia/sedative medication
5. List at least 2 specific investigations that you would perform to assess this patient
a) Blood culture
b) Sputum culture
Clinical Cases
Breath Sounds Tutorial
Answer Sheet: Case 1
c) CXR to exclude pneumothorax and infection,
d) FBC, U&E, CRP
e) ECG
6. Suggest 4 management steps you would instigate for this patient
a) Controlled oxygen therapy - start at 24-28%. Aim for PaO2 > 8 kPa with a rise in PaCO2 <1.5
kPa
b) Nebulized bronchodilators - Salbutamol and Ipratropium
c) Steroids - IV Hydrocortisone or Oral Prednisolone
d) Antibiotics - if evidence of infection
e) Physiotherapy to aid sputum expectoration
7. If her blood gas continues to deteriorate further, name one additional treatment
to consider
a) Nasal intermittent positive pressure ventilation (NIPPV) - if respiratory rate >30 or
pH<7.35
b) Mechanical ventilation - if pH<7.26 and PaCO2 is rising
c) Respiratory stimulant - Doxapram
Clinical Cases
Breath Sounds Tutorial
Answer Sheet: Case 2
A 45-year-old man presents to his GP complaining of feeling unwell for 7 days,
cough productive of green sputum with an occasional reddish tinge, and rightsided chest pain. He has been feeling hot and cold. He has smoked 15 cigarettes a
day for 30 years.
1.
Calculate the number of pack years
a) No of pack years = (15 x 30)/20 = 22.5
2.
What clinical signs might you find on examination of his chest?
a) Reduced/Diminished chest expansion
b) Dull percussion note
c) Increased tactile vocal fremitus/vocal resonance
d) Bronchial breathing
e) Pleural rub
f) Coarse crackles
3. What is this sound and what does it indicate?
a) Bronchial breathing
b) Consolidation (Pneumonia)
4.
What investigations would you request for this patient?
a) Chest XR
b) Arterial blood gas if oxygen saturation <92%
c) FBC, U&E, LFT, CRP, atypical serology
d) Blood cultures
a) Sputum microscopy and culture
5. How would you assess the severity of pneumonia?
a) Correct Answer: CURB - 65
C - confusion (abbreviated mental test <8)
U - urea >7mmol/L
R - respiratory rate >30/min
B - BP <90 mmHg systolic
>65 years old
Clinical Cases
6.
Breath Sounds Tutorial
Answer Sheet: Case 2
What would be your management plan?
a) CURB-65 = 0
b) Treat at home for mild community acquired pneumonia with oral Amoxicillin 500mg-1g tds
c) Analgesia for pleuritic pain - Paracetamol
d) Follow-up at 6 weeks with Chest XR
Clinical Cases
Breath Sounds Tutorial
Answer Sheet: Case 3
A 65-year-old woman has suddenly become very short of breath. In the last hour,
she has had a CT guided biopsy of a mass in the right lung.
Temp = 36.4°C SaO2 = 75% on 15L O2 HR = 120bpm
BP = 100/60 mmHg
1. What other clinical sings would you expect on examination of this patient?
a) Respiratory distress
b) Distended neck veins
c) Trachea deviated away from the side of pneumothorax
d) Hyper-resonant percussion note on the affected side
e) Reduced air entry/breath sounds on the affected side
2. What is the diagnosis?
Tension Pneumothorax
3. Was the chest X-ray essential for this diagnosis?
No. In tension pneumothorax, the mediastinum is shifted away from the affected side, causing
compression of the great veins and impaired venous return. This is a medical EMERGENCY and can lead to cardiorespiratory arrest unless addressed immediately. There is no
time for any further investigation.
4. What is the single most appropriate course of action?
The patient should be given a high concentration of oxygen and a large-bore cannula should
be inserted into the 2nd intercostal space in the midclavicular line on the side of the suspected
tension pneumothorax. Air should be removed until the patient is no longer compromised. A
chest drain can then be inserted into the pleural space.