MBBS Final Year Medicine Practical Viva - Respiratory System

Complete Question Bank: Basics to Hard

SECTION 1: BASICS / ORIENTATION QUESTIONS

1. What is the normal respiratory rate in an adult?
2. How do you position a patient for respiratory examination?
3. What are the components of a complete respiratory examination? (Inspection, Palpation, Percussion, Auscultation - IPPA)
4. What are the surface markings of the lungs anteriorly and posteriorly?
5. How many lobes does the right lung have? Left lung?
6. Where is the oblique fissure? Where is the horizontal fissure?
7. What is the normal chest shape?
8. What is the AP:lateral diameter ratio of the normal chest?
9. What does SPO2 measure and what is normal?
10. Define tachypnea and bradypnea. At what rate do you call it tachypnea?

SECTION 2: INSPECTION - EASY TO MODERATE

General Inspection

1. What are you looking for when you inspect the patient from the end of the bed?
2. Name the general signs of respiratory distress.
3. What is the use of accessory muscles - which muscles are used?
4. What is paradoxical breathing? When does it occur?
5. What is tracheal tug? What does it indicate?

Chest Shape & Deformity

1. What is barrel chest? What condition causes it and what is the underlying mechanism?
2. What is Harrison's sulcus? What causes it?
3. What is pectus excavatum (funnel chest)? What is pectus carinatum (pigeon chest)?
4. What is kyphoscoliosis? How does it affect respiratory function?
5. What is a flail chest? What causes paradoxical movement?

Breathing Pattern

1. What is Cheyne-Stokes breathing? What causes it?
2. What is Kussmaul's breathing? When do you see it?
3. What is Biot's breathing? Where is the lesion?
4. What is pursed lip breathing? Why do COPD patients do this?
5. Differentiate obstructive vs. restrictive breathing patterns on inspection.

Peripheral Signs (Hands, Face, Neck)

1. What is clubbing? How do you grade it?
2. What are respiratory causes of clubbing?
3. What is the Schamroth sign?
4. What is central cyanosis? Where do you look for it?
5. What is peripheral cyanosis? How do you differentiate central from peripheral?
6. What is nicotine staining? What is its clinical significance?
7. What is asterixis (CO2 flap)? How do you test for it?
8. What is the significance of dilated veins on the chest wall?
9. What does JVP elevation tell you in a respiratory patient?
10. What are the signs of cor pulmonale you look for on general inspection?

SECTION 3: PALPATION - EASY TO MODERATE

1. What is tracheal position? How do you assess it?
2. To which side does the trachea deviate in pleural effusion? In collapse/fibrosis?
3. What is mediastinal shift? Name causes of mediastinal shift toward and away from the lesion.
4. What is chest expansion? How do you measure it? What is normal?
5. How do you assess chest expansion in the upper, middle, and lower zones?
6. What is reduced chest expansion unilaterally? Give causes.
7. What is tactile vocal fremitus (TVF)? How do you elicit it?
8. How do you elicit TVF? What do you ask the patient to say?
9. What is increased TVF? Name conditions.
10. What is decreased TVF? Name conditions.
11. What is subcutaneous emphysema? How does it feel on palpation?
12. What is the apex beat, and what does its displacement tell you in a respiratory patient?
13. What is a parasternal heave? What does it indicate in a respiratory patient?

SECTION 4: PERCUSSION - MODERATE

1. How do you perform percussion correctly? (Technique: middle finger as pleximeter, middle finger of other hand as plexor)
2. What are the normal percussion notes over the chest?
3. What is a dull note? Name causes.
4. What is a stony dull note? What is pathognomonic of it?
5. What is hyper-resonance? Name causes.
6. What is the normal percussion note over the liver? Over the heart?
7. What is the Traube's space and its clinical significance?
8. How do you percuss for diaphragmatic excursion? What is normal?
9. What is the significance of reduced diaphragm excursion?
10. How does percussion help you differentiate consolidation from pleural effusion?
11. What is the shifting dullness of a pleural effusion - wait, this is abdominal. What is the equivalent in the chest? (Describe how fluid shifts on position change)
12. What is a "Wood's sign" or "skodaic resonance"? Where is hyper-resonance heard above a pleural effusion?

SECTION 5: AUSCULTATION - MODERATE

Normal Breath Sounds

1. What are vesicular breath sounds? Where are they heard normally?
2. What are bronchial breath sounds? Where are they heard normally?
3. What is bronchovesicular breathing? Where is it heard?
4. What are the characteristics of bronchial breath sounds? (Harsh, tubular, high-pitched, equal I:E ratio, pause between inspiration and expiration)
5. What is the physiological basis of vesicular breath sounds?
6. Why are bronchial breath sounds heard over consolidation?

Added / Adventitious Sounds

1. What are the types of added sounds on auscultation?
2. What are crackles (crepitations)? Differentiate fine vs. coarse crackles.
3. What are fine crackles? Name causes.
4. What are coarse crackles? Name causes.
5. Are crackles in pulmonary edema fine or coarse? At what phase of respiration?
6. What are wheezes? What is the mechanism?
7. What is the difference between polyphonic and monophonic wheeze?
8. What does an end-expiratory wheeze suggest?
9. What is stridor? How do you differentiate it from wheeze?
10. Is stridor inspiratory or expiratory? What are the causes?
11. What is a pleural rub? Describe its character. What are its causes?

Vocal Resonance

1. What is vocal resonance? How do you test it?
2. What is bronchophony?
3. What is whispering pectoriloquy? What does it indicate?
4. What is aegophony (egophony)? What does it indicate? (Nasal, bleating quality of "E" to "A" change)
5. What is the significance of increased vocal resonance?

SECTION 6: CLINICAL EXAMINATION FINDINGS BY CONDITION

(Moderate to Hard - Classic Examiner Questions)

Pleural Effusion

1. Describe the complete examination findings in a right-sided pleural effusion.
2. Why is there stony dullness in pleural effusion?
3. Why is there reduced/absent breath sounds in pleural effusion?
4. Why is TVF reduced in pleural effusion?
5. What is the Ellis-Damoiseau (S-shaped) line? What does it represent?
6. Why is the trachea deviated away from a large pleural effusion?
7. What is the difference between transudate and exudate? (Light's criteria)
8. Name transudative and exudative causes of pleural effusion.
9. What are the signs at the upper level of the effusion? (Aegophony, skodaic resonance)
10. How do you differentiate free fluid from encysted fluid clinically?

Pneumothorax

1. Describe the complete examination findings in a left-sided pneumothorax.
2. Why is there hyper-resonance in pneumothorax?
3. What is tension pneumothorax? What are the clinical signs?
4. Why does the trachea shift away in tension pneumothorax?
5. How would you differentiate a large bulla from pneumothorax clinically?

Consolidation (Lobar Pneumonia)

1. Describe the complete examination findings in right upper lobe consolidation.
2. Why are bronchial breath sounds heard over consolidation?
3. Why is TVF/vocal resonance increased in consolidation?
4. Why is there dullness on percussion over consolidation?
5. What are the signs of resolution in consolidation?
6. What is an air bronchogram? (Briefly - for CXR correlation)

Collapse / Atelectasis

1. Describe the examination findings in right lower lobe collapse.
2. How do you differentiate collapse from consolidation on examination?
3. In collapse, in which direction does the trachea deviate?
4. What are the causes of lobar collapse?

Bronchial Asthma

1. Describe the examination findings in a patient in an acute asthma attack.
2. What is a silent chest in asthma? What does it indicate?
3. What is pulsus paradoxus? How do you measure it? In asthma, what value is significant?
4. What is the PEFR and its significance?
5. What are the signs of severe and life-threatening asthma?

COPD / Emphysema

1. Describe the examination findings in a patient with emphysema.
2. What is the pink puffer (Type A COPD)? What is the blue bloater (Type B COPD)?
3. Why is there reduced cardiac dullness in emphysema?
4. Why is the diaphragm low and flat in emphysema?
5. What are the signs of COPD on general examination?
6. What is the Hoover sign in COPD?

Fibrosis

1. Describe the examination findings in pulmonary fibrosis.
2. What type of crackles are heard in fibrosis? At which phase?
3. Why is there reduced chest expansion bilaterally in fibrosis?
4. Name causes of pulmonary fibrosis (upper zone vs. lower zone causes).

SECTION 7: HARD / ADVANCED VIVA QUESTIONS

Mechanisms and Pathophysiology

1. Explain the mechanism of bronchial breath sounds over consolidation vs. over a cavity.
2. Why is TVF increased in consolidation but decreased in pleural effusion, even though both are dull on percussion?
3. What is the mechanism of clubbing? (Megakaryocyte and platelet emboli theory, PDGF, VEGF)
4. What is the mechanism of central cyanosis? At what SpO2 does it become visible?
5. Explain the mechanism of paradoxical breathing in flail chest.
6. What is the mechanism of CO2 retention in Type II respiratory failure?
7. What is hypoxic pulmonary vasoconstriction (HPV)? What is its clinical relevance?

Differentiation Questions

1. Differentiate pleural effusion vs. collapse on complete clinical examination (table format).
2. Differentiate consolidation vs. pleural effusion on examination.
3. Differentiate pneumothorax vs. bullous emphysema.
4. How do you differentiate cardiac wheeze (cardiac asthma) from bronchial asthma?
5. How do you differentiate upper airway obstruction from lower airway obstruction?
6. Differentiate Type I vs. Type II respiratory failure. How would you suspect each clinically?

CXR Correlation

1. What is the CXR finding in right-sided pleural effusion? (Homogeneous opacity, meniscus sign, loss of costophrenic angle)
2. What is the CXR finding in tension pneumothorax?
3. What is a meniscus sign on CXR?
4. What are the features of consolidation on CXR?
5. What is the sail sign? What is the golden S sign?
6. What does a bilateral perihilar bat's wing opacity suggest?
7. What are the CXR features of COPD?

Investigations and Correlation

1. What is spirometry? What patterns do you see in obstructive vs. restrictive disease?
2. What is the FEV1/FVC ratio in COPD vs. asthma vs. interstitial lung disease?
3. What does ABG show in Type I vs. Type II respiratory failure?
4. What are the indications for pleural fluid analysis?
5. What is the significance of a lymphocytic exudative pleural effusion?
6. What are Light's criteria?
7. What is the significance of ADA in pleural fluid? (Adenosine deaminase - raises suspicion of TB)
8. What is a Kerley B line on CXR and what does it indicate?

Clinical Scenario Questions

1. A patient has left-sided stony dull note, absent breath sounds, absent TVF, and the trachea is shifted to the right. What is the diagnosis? What investigations will you order?
2. A patient has right-sided hyper-resonance, absent breath sounds, and the trachea is shifted to the left with hypotension and distended neck veins. Diagnosis and immediate management?
3. A patient has bilateral fine inspiratory crackles at the bases, not clearing with cough, clubbing, and cyanosis. What is the most likely diagnosis? What does spirometry show?
4. A patient with COPD presents with worsening dyspnea, increased sputum, and purulent sputum. What is the diagnosis? How do you manage?
5. A patient has a deviated trachea toward the right, reduced right chest expansion, dull percussion right lower zone, absent breath sounds but increased TVF. What is the diagnosis?

QUICK REFERENCE TABLE: Classical Findings

TIPS FOR PRESENTING A RESPIRATORY CASE

• Start with general examination: "On general examination, the patient is conscious, oriented, and in mild/moderate/severe respiratory distress..."
• Note SpO2, RR, use of accessory muscles before IPPA
• Always state the side before giving findings: "On the right side..."
• When you find dullness + absent breath sounds, immediately think: Is it effusion or collapse? Use TVF and tracheal position to differentiate
• Always correlate with history and CXR when the examiner asks