2025 physio sem 2 week 3
Q: Best-practice setup for lung auscultation? (insert photo of patient sitting upright with stethoscope)
A: Quiet room; patient upright, breathing through mouth; warm diaphragm; direct skin contact; compare side-to-side at matched zones; listen to a full insp/exp cycle per spot.
Q: Where to auscultate on the chest wall? (insert photo of standard anterior/posterior stethoscope positions)
A: Anterior: apices above clavicles, 2nd ICS mid-clavicular, 4th–6th ICS. Lateral: mid-axillary at bases. Posterior: apices (C7–T1), between scapulae, bases (T10–T12). Always compare left to right.
Q: What are vesicular breath sounds?
A: Normal peripheral sounds: soft/low-pitched, inspiration longer than expiration, no pause between phases.
Q: What are bronchial breath sounds and when abnormal?
A: Loud, high-pitched with equal insp/exp and a pause; normal over trachea only. Peripherally, they suggest consolidation/collapse.
Q: What does reduced/absent breath sound indicate?
A: Poor air entry from effusion, pneumothorax, severe hyperinflation (COPD), obesity, or mucus plugging.
Q: Describe fine crackles and main causes.
A: End-inspiratory, “Velcro-like” pops (alveoli popping open) → fibrosis, interstitial oedema/early pulmonary oedema.
Q: Describe coarse crackles and main causes.
A: Bubbling, early inspiratory/throughout, clear with cough → secretions (bronchitis, bronchiectasis, pneumonia).
Q: Describe wheeze and what it implies.
A: Continuous musical tone (often expiratory) → airway narrowing (asthma/COPD). Diffuse polyphonic = widespread narrowing.
Q: What is stridor and urgency?
A: High-pitched inspiratory noise from upper airway obstruction → medical emergency.
Q: What is a pleural rub?
A: Harsh grating in insp/exp from inflamed pleura (pleurisy, pneumonia near pleura).
Q: What are transmitted voice tests and what do they show?
A: Bronchophony (loud “99”), whispered pectoriloquy (whisper heard clearly), egophony (“E→A”) = consolidation improves sound transmission.
Q: Auscultation red flags that need urgent review.
A: New stridor, silent chest in severe dyspnoea, rapidly deteriorating SpO₂, altered consciousness.
Q: Technique to differentiate crackles from pleural rub.
A: Ask patient to hold breath; rub persists (pleural), crackles stop (intrapulmonary).
Q: Normal inspiration/expiration ratio and exception.
A: Vesicular I>E; bronchial I=E with a pause (abnormal peripherally).
Q: When do fine vs coarse crackles occur in the breath cycle?
A: Fine: end-inspiration; coarse: early inspiration/throughout and may shift with cough.
Q: What is the silhouette sign? (insert photo of CXR with loss of right heart border)
A: Loss of a normal soft-tissue border on CXR indicates adjacent consolidation at the same anatomical level.
Q: Standard steps before interpreting a chest X-ray. (insert photo of CXR with name/date/side marker)
A: Patient (name/age), Date/time & priors, Orientation/side marker, Projection (PA/AP), Quality (rotation, inspiration, exposure).
Q: How to spot rotation on CXR. (insert photo with clavicular heads vs spinous process)
A: Medial clavicular heads should be equidistant from the spinous process; asymmetry = rotation.
Q: How to assess inspiration on PA CXR. (insert photo counting ribs)
A: See ≥10 posterior ribs (or ~6 anterior) above the right hemidiaphragm; fewer = poor inspiration, mimics cardiomegaly/bibasilar opacities.
Q: What is adequate exposure/penetration?
A: Vertebral bodies are just visible through the cardiac silhouette; too dark = overpenetrated; too white = underpenetrated.
Q: Key differences PA vs AP chest films.
A: AP (portable): heart appears larger, scapulae over lungs, more lordosis; PA is standard, truer heart size.
Q: A safe systematic CXR approach you can use every time.
A: Airway (trachea), Bones/soft tissue, Cardiac/mediastinum, Diaphragm, Effusions/edges (pleura), Fields/fissures/hila/devices.
Q: Normal tracheal position and what deviation means.
A: Midline/slight right at aortic knob; deviates toward collapse, away from tension pneumothorax/large effusion.
Q: Normal diaphragm features. (insert photo of sharp costophrenic angles)
A: Right hemidiaphragm slightly higher; sharp costophrenic angles; stomach bubble under left.
Q: What indicates a pleural effusion on erect film? (insert photo of meniscus sign)
A: Meniscus sign with blunted costophrenic angle; large effusions obscure hemidiaphragm; may cause mediastinal shift away if very large.
Q: How to identify a pneumothorax. (insert photo showing pleural line with no peripheral markings)
A: Visceral pleural line with absent lung markings beyond; in supine, look for deep sulcus sign.
Q: Features of tension pneumothorax on CXR.
A: Large pneumothorax, mediastinal shift away, flattened diaphragm; clinical emergency (don’t wait for CXR if unstable).
Q: CXR signs of consolidation. (insert photo with air bronchograms)
A: Homogeneous alveolar opacity with air bronchograms; no volume loss (fissures static), silhouette sign may be present.
Q: How to distinguish atelectasis (collapse) from consolidation.
A: Volume loss signs: fissure displacement, ipsilateral mediastinal shift, elevated hemidiaphragm, crowded ribs.
Q: Radiographic features of pulmonary oedema. (insert photo of “bat-wing” pattern)
A: Cardiogenic: cardiomegaly, perihilar “bat-wing” opacities, Kerley B lines (interstitial), peribronchial cuffing; may progress to effusions.
Q: CXR markers of hyperinflation. (insert photo showing flattened diaphragms)
A: Low, flat diaphragms, >10 posterior ribs visible, increased retrosternal airspace, narrow cardiac silhouette (often COPD).
Q: What is surgical emphysema on CXR? (insert photo of subcutaneous emphysema)
A: Lucent streaks in the soft tissues of chest/neck wall with outlining of muscle bundles due to subcutaneous air.
Q: Typical RUL collapse signs. (insert photo of RUL triangular opacity + elevated minor fissure)
A: Triangular/apical opacity, elevated minor fissure, upwardly pulled hilum; may see S-sign of Golden with central mass.
Q: Typical RML collapse signs. (insert photo loss of right heart border)
A: Silhouette of right heart border lost on PA; lateral shows wedge opacity over heart.
Q: Typical RLL collapse signs. (insert photo loss of right hemidiaphragm silhouette)
A: Silhouette of right hemidiaphragm lost; triangular basal opacity; fissure displaced downward.
Q: Typical LUL collapse signs. (insert photo “veil” opacity)
A: “Veil”-like hazy opacity over left lung with elevated left hilum and pulled fissures.
Q: Typical LLL collapse signs. (insert lateral photo showing posterior basal triangle)
A: Posterior basal triangular opacity on lateral; loss of left hemidiaphragm silhouette on PA.
Q: Recognising hilar enlargement.
A: Bulky, lobulated hila (lymphadenopathy) vs prominent pulmonary arteries (pulmonary hypertension): compare symmetry, edges, and adjacent signs.
Q: Devices on CXR: safe positions (high-yield). (insert photo with ETT/NG/central line)
A: ETT: tip ~3–5 cm above carina; NG: below diaphragm with subdiaphragmatic course; CVC: tip in SVC; chest drain: side holes within thorax.
Q: What is the air bronchogram and why important?
A: Air-filled bronchi made visible by surrounding alveolar opacity → hallmark of consolidation.
Q: What is the spine sign on lateral CXR?
A: Lower thoracic spine should look darker inferiorly; whiter = lower lobe pneumonia.
Q: Physiotherapy relevance of CXR interpretation.
A: Identifies collapse vs consolidation (airway clearance vs recruitment), effusions (positioning), and device safety before mobilising.
Q: Core spirometry definitions: FEV₁, FVC, FEV₁/FVC. (insert photo of flow-volume loop axes)
A: FEV₁: forced volume in 1 s; FVC: total forced vital capacity; FEV₁/FVC: ratio indicating obstruction when low.
Q: Obstructive pattern: key spirometry findings. (insert photo of scooped expiratory loop)
A: ↓FEV₁/FVC (below LLN or <0.70), ↓FEV₁, often near-normal FVC; scooped expiratory curve.
Q: Restrictive pattern: key spirometry findings. (insert photo of narrow tall loop)
A: Normal/high FEV₁/FVC with proportionally ↓FVC; confirm with ↓TLC on lung volumes.
Q: Mixed pattern: what does it show?
A: ↓FEV₁/FVC plus ↓FVC; requires lung volumes to separate mixed from severe obstruction with air-trapping.
Q: Standard criteria for bronchodilator reversibility.
A: FEV₁ increase ≥12% and ≥200 mL from baseline after bronchodilator suggests reversible obstruction (e.g., asthma).
Q: Typical spirometry in asthma vs COPD.
A: Asthma: obstructive with reversibility. COPD: obstructive with limited reversibility; may have air-trapping (↑RV).
Q: DLCO: what it measures and patterns.
A: Gas transfer across alveolar-capillary membrane; ↓DLCO in emphysema/interstitial disease, normal/high in asthma.
Q: Flow–volume loop in variable extrathoracic obstruction (e.g., vocal cord). (insert photo showing flattened inspiratory limb)
A: Flattened inspiratory limb, relatively normal expiratory limb.
Q: Flow–volume loop in variable intrathoracic obstruction. (insert photo showing flattened expiratory limb)
A: Flattened expiratory limb, relatively normal inspiratory limb.
Q: Flow–volume loop in fixed large airway obstruction. (insert photo showing box-shaped flattening)
A: Both inspiratory and expiratory limbs flattened.
Q: Quality criteria for acceptable spirometry blows.
A: Good start, ≥6 s exhalation (or plateau), no cough in first second, ≥3 acceptable efforts with best two FEV₁/FVC within 150 mL.
Q: Interpreting spirometry: stepwise logic you can say aloud.
A: (1) Quality ok? (2) Ratio low or normal/high? (3) If low → obstructive; check FEV₁ severity and reversibility. (4) If normal/high with low FVC → restrictive? confirm TLC. (5) Consider DLCO to refine differential.
Q: Simple severity grading in obstruction (clinical shorthand).
A: FEV₁ % predicted: ≥80 mild, 50–79 moderate, 30–49 severe, <30 very severe (use lab reference/LLN where provided).
Q: Bedside spirometry pitfalls to watch for.
A: Poor seal, submaximal effort, early termination, cough, leak around mouthpiece; repeat with coaching.
Q: Peak Expiratory Flow (PEF): when useful.
A: Home monitoring in asthma for variability and action plans; not diagnostic alone.
Q: How does air-trapping appear on lung volumes?
A: ↑RV and ↑RV/TLC (often in COPD) with may-be normal/near normal TLC.
Q: What indicates restriction on lung volumes?
A: ↓TLC with proportionally ↓RV; DLCO helps separate parenchymal vs extrapulmonary causes.
Q: High-yield spirometry pearls for exams.
A: Ratio ↓ = obstruction; Ratio normal/high + low FVC = restriction (confirm TLC); reversible if FEV₁ ↑ ≥12% & ≥200 mL.
Q: Auscultation finding that pairs with consolidation on CXR.
A: Bronchial breath sounds + increased vocal resonance + air bronchograms on CXR.
Q: Auscultation finding that pairs with effusion on CXR.
A: Absent/reduced breath sounds and stony dull percussion; CXR shows meniscus and blunting.
Q: Auscultation finding that pairs with pneumothorax.
A: Absent sounds, hyper-resonant percussion; CXR shows pleural line with no peripheral markings.
Q: Why AP films often “enlarge” the heart.
A: Magnification from source-to-image distance and heart-to-detector distance; don’t over-call cardiomegaly on AP.
Q: What are Kerley B lines? (insert photo of short horizontal lines at lung bases)
A: Short, peripheral septal lines at lung bases from interstitial oedema.
Q: Signs suggesting right heart border silhouette loss.
A: RML pathology (consolidation/collapse) effaces the right cardiac margin on PA film.
Q: Signs suggesting right hemidiaphragm silhouette loss.
A: RLL process; use lateral film for posterior basal triangle.
Q: Why previous CXRs matter.
A: Compare for new vs chronic changes (e.g., stable scarring vs new consolidation), and device migration.
Q: Common reasons a CXR looks “white” at bases on AP portable.
A: Poor inspiration, under-penetration, supine position causing dependent atelectasis.
Q: “Bat-wing” pattern differentials besides cardiogenic oedema.
A: ARDS (usually normal heart size), pulmonary haemorrhage; correlate with clinical and echo.
Q: What is a meniscus sign vs straight fluid level?
A: Meniscus on erect film; straight level on lateral decubitus indicates free-flowing fluid.
Q: Typical CXR signs of emphysema.
A: Hyperinflation, flattened diaphragms, decreased vascular markings peripherally, bullae.
Q: When to suspect bronchiectasis clinically/radiologically.
A: Coarse crackles, chronic sputum; CXR may show tram-tracks/ring shadows; HRCT confirms airway dilation.
Q: What does a veiled hemithorax suggest on CXR?
A: Whole-lung collapse or massive effusion—use mediastinal shift and diaphragm level to differentiate.
Q: Why correlate auscultation with work of breathing.
A: Sounds alone can mislead; accessory use, paradoxical movements, SpO₂ trend refine severity and urgency.
Q: Practical check before interpreting “haziness” as pneumonia.
A: Ensure adequate inspiration/exposure and no rotation; compare priors; correlate fever/WBC/crackles.
Q: Obstruction severity vs symptoms during physio.
A: Severe obstruction (low FEV₁) → slow recovery from activity; pace, PLB, pauses for breathing control.
Q: Why DLCO matters for rehab.
A: Low DLCO predicts desaturation on exertion; anticipate need for O₂ titration and close monitoring.
Q: High-yield auscultation + spirometry pairing for asthma.
A: Polyphonic wheeze, obstructive spirometry with significant reversibility.
Q: High-yield pairing for COPD.
A: Distant/reduced sounds, hyperinflation signs on CXR, obstructive spirometry with limited reversibility, possible ↓DLCO.
Q: High-yield pairing for fibrosis.
A: Fine end-inspiratory crackles, restrictive spirometry, ↓DLCO, reticular/volume-loss changes on imaging.
Q: Bedside red flags in the breathless patient during assessment.
A: SpO₂ drop, silent chest/stridor, hypotension, ALOC → stop, sit upright, escalate (MET) per criteria.
Q: Why air bronchograms argue for pneumonia over atelectasis.
A: In atelectasis bronchi may also collapse; open air-filled bronchi inside opacity = alveolar filling (pneumonia).
Q: Portable CXR pitfall with lines/tubes.
A: ETT too high/low (target 3–5 cm above carina), NG coiled in oesophagus, CVC tip not in SVC—confirm before mobilising.
Q: What to document after interpreting imaging for physio plan.
A: Key findings (e.g., RLL collapse), implications (PD position), safety checks (O₂/lines), and treatment plan (ACBT, huffing, mobilisation).
Q: What is the deep sulcus sign and when seen? (insert supine CXR)
A: Abnormally lucent costophrenic angle on supine films → suggests pneumothorax.
Q: How to distinguish pleural effusion vs consolidation on percussion.
A: Stony dull in effusion vs dull in consolidation; breath sounds reduced/absent over effusion.
Q: Spirometry: when to suspect suboptimal effort.
A: Variable attempts, truncated end, cough artifacts; check for repeatability within 150 mL.
Q: Lung volumes: differentiating intrinsic vs extrinsic restriction.
A: Intrinsic (ILD): ↓TLC, ↓DLCO. Extrinsic (obesity/chest wall/neuromuscular): ↓TLC with normal DLCO.
Q: What indicates air-trapping on flow–volume loop?
A: Notched/scooped expiratory limb with low end-expiratory flow; often seen in COPD with ↑RV.
Q: Why spirometry alone can’t diagnose restrictive disease.
A: It suggests restriction (low FVC with normal/high ratio) but needs lung volumes (TLC) to confirm.
Q: Physiotherapist’s immediate actions after spotting new lobar collapse on CXR.
A: Notify team, start positioning/postural drainage for the lobe, initiate airway clearance (ACBT/huff), mobilise as safe.
Q: When not to percussion in suspected collapse.
A: If rib fractures, metastases, severe osteoporosis, or anticoagulated; use breathing/positioning strategies instead.
Q: What is peribronchial cuffing?
A: Thickened bronchial walls appearing as donut or tram-track opacities from interstitial oedema.
Q: Reading a CXR quickly under time pressure—3 killer checks.
A: Trachea/mediastinum, pleural edges (PTX/effusions), lung fields for asymmetry/air bronchograms; then circle back with full ABCDEF.
Q: How to leverage priors in rehab planning.
A: Stable chronic changes → baseline; new changes dictate short-term targets (clear secretions, re-expand lobe, titrate O₂).
Q: Why egophony implies peripheral consolidation not effusion.
A: Fluid-filled alveoli transmit high-frequency sounds better; pleural fluid alone typically dampens voice sounds.
Q: Clinical pairing: Viral wheeze vs bacterial pneumonia.
A: Viral/asthma = wheeze, hyperinflation possible; pneumonia = crackles + fever + air bronchograms.
Q: Best patient instruction during auscultation to avoid artifact.
A: “Open your mouth, take slow deep breaths; if dizzy, pause.”
Q: Spirometry: bronchodilator testing—practical point.
A: Record pre values; give standard dose; wait 10–15 min (short-acting), retest; ensure consistent technique.
Q: CXR: recognising cardiomegaly.
A: On PA film, cardiothoracic ratio > 0.5; avoid judging on AP.
Q: When to request lateral decubitus CXR.
A: To confirm small effusions and whether fluid is free-flowing (layers out).
Q: COPD + infection pattern across tools.
A: CXR: hyperinflation ± patchy consolidation; Ausc: wheeze + coarse crackles; Spirometry: obstructive with limited reversibility.
Q: Interstitial lung disease pattern across tools.
A: CXR: reticular pattern + volume loss; Ausc: fine crackles; Spirometry: restrictive; DLCO low.
Q: Asthma pattern across tools.
A: CXR often normal/hyperinflated; Ausc: polyphonic wheeze; Spirometry: obstructive with reversibility.
Q: Pneumonia pattern across tools.
A: CXR: consolidation with air bronchograms; Ausc: bronchial sounds/crackles; Spirometry: may be near-normal or restrictive from pain.
Q: Mechanical ventilation tube depth quick check.
A: ETT tip should move ~2 cm with neck flex/extend; aim 3–5 cm above carina in neutral.
Q: Why an effusion can cause mediastinal shift away.
A: Mass effect of large fluid volume; collapse typically shifts toward side of volume loss.
Q: Why deep sulcus sign matters in supine trauma.
A: Air accumulates anterior/inferior, not apex; missing PTX risks tension during positive-pressure ventilation.
Q: When to suspect upper airway obstruction from spirometry alone.
A: Flattened loop (inspiratory/extrathoracic; expiratory/intrathoracic; both/fixed) + discordant symptoms vs asthma.
Q: Post-bronchodilator: improved FEV₁ but persistent symptoms—next step.
A: Assess technique/adherence, triggers, consider peak flow diary, escalate per guideline.
Q: Auscultation artifact to avoid misreading as crackles.
A: Hair rubbing on diaphragm, patient moving, stethoscope tubing knocking.
Q: Teaching point: Consolidation increases which bedside findings?
A: Bronchial sounds, vocal resonance, dull percussion, possible egophony.
Q: Teaching point: Effusion changes which bedside findings?
A: Stony dull percussion, reduced/absent sounds, reduced vocal resonance, reduced expansion.
Q: Teaching point: Pneumothorax bedside pattern.
A: Hyper-resonant, absent sounds, reduced expansion; trachea may deviate away if tension.
Q: When to pause mobilisation due to oxygenation.
A: SpO₂ <88–90% despite O₂, or rapid downward trend with symptoms; recover, adjust O₂, retry if safe.
Q: High-yield “what next” after spotting lower-lobe consolidation.
A: Consider segmental postural drainage (if secretions), ACBT, early mobilisation, analgesia to enable deep breaths.
Q: Quick recap: Obstruction vs Restriction in one line.
A: Obstruction = low ratio; Restriction = low FVC with normal/high ratio (confirm low TLC).