CLIN Resp Exam - Week 2 Flashcards
fResp Exam Intro
- HH
- Greet pt
- Introduce yourself
- Identify pt
- Explanation of examination & confidentiality
- Discuss exposure – to the waist (w gown for female pts)
- Obtain consent
- Clarification – ask give the pt the opportunity to ask any questions
- Position – sitting & later lying at 45 degrees/lying at 45 degrees
- Privacy – gown suitable
- Ask whether the pt is comfortable
Resp Exam GI
a. Respiratory distress (particularly breathing through pursed lips or accessory muscle use).
b. Stridor/wheeze
c. Cough
d. Hoarseness
e. Dyspnoea
f. Cyanosis
g. ‘Noting body habitus’ (particularly any weight loss)
h. Posture
i. Aids – sputum mug, O2 mask, nebuliser, peak flow meter, inhaler
& complete vital signs prior to next stage.
Breathing through pursed lips/accessory muscle use may indicate
Severe COPD.
Stridor may indicate
May indicate obstruction of the larynx/trachea - due to foreign body, tumour, infection, inflammation.
Bovine cough character & may indicate
Lack of usual explosive beginning - ‘bovine cough,’ may indicate vocal cord paralysis.
Muffled, wheezy, ineffective cough may indicate
Muffled, wheezy, ineffective cough - may indicate obstructive pulmonary disease.
Loose, productive cough may indicate
Loose, productive cough - may indicate excessive bronchial secretions due to chronic bronchitis, pneumonia, bronchiectasis.
Dry, irritating cough may indicate
Dry, irritating cough - may occur w chest infections, asthma, carcinoma of the bronchus, left ventricular failure, interstitial lung disease, ACE inhibitor use.
Barking or croupy cough may indicate
Barking or croupy cough - may indicate problem w upper airway (pharynx/larynx), pertussis infection.
Hoarseness may indicate
May indicate recurrent laryngeal nerve palsy associated w lung carcinoma, laryngeal carcinoma, laryngitis, use of inhaled corticosteroids, hypothyroidism.
Clubbing may indicate
Commonly indicates hypertrophic pulmonary osteoarthropathy (HPO) (especially when combined w wrist tenderness) - may be caused by primary lung carcinoma, pleural fibromas, infective endocarditis. HPO does not occur as a result of COPD.
Normal range for pulse ox.
> 95%
Muscle wasting may be caused by
Pancose tumour compressing on brachial plexus nerve roots.
Weakness of hand muscles may be caused by
Can be caused by lung tumours compressing the lower trunk of the T1 nerve root.
Asterixis/flapping tremor indicates
Indicates severe CO2 retention (e.g., in severe COPD pts).
Signs of severe CO2 retention
Patients with severe CO2 retention may be confused and typically have warm peripheries, a bounding pulse, positive asterixis.
Resp Exam Hands
a. Look
i. Clubbing
ii. Peripheral cyanosis
iii. Capillary refill
iv. Pulse oximetry
v. Tar staining
vi. Muscle wasting
vii. Weakness of hand muscles(via finger abduction)
viii. Asterixis/flapping tremor
1. Ask pt to hold out arms
2. Spread fingers
3. Dorsiflex wrists
4. Hold for 30secs.
Resp Exam Wrists & Elbow
a. Palpate/Perform
i. Pulse
1. Rate
2. Rhythm
ii. Respiratory rate & character
iii. Wrist swelling/tenderness
iv. Blood pressure
v. Temperature
Tachycardia & pulsus paradoxus are strong indicators for what condition
Asthma
Pulsus paradoxus
Severe weakening of pulse on inspiration
Tachypnoea range
> 25
Bradypnoea
<8
RR normal range
16-25
Wrist swelling/tenderness may indicate
HPO
Resp Exam Face
- Face
a. Look
i. Facial plethora
ii. Cyanosis - Eyes
a. Look
i. Jaundice - Pull eyelids up & ask pt to look down
- Comment on colour
ii. Horner’s syndrome
iii. Pallor - Pull eyelids down
- Comment on pallor of conjunctiva
- Nose/nostrils
a. Look (use torch)
i. Polyps
ii. Engorged turbinates
iii. Deviated nasal septum
b. Palpate
i. Frontal sinus
ii. Maxillary sinus - Ears
a. Look
i. Infection
ii. Perforation - Oral cavity
a. Look
i. Central cyanosis
ii. Dentition
iii. Crowding of the pharynx
iv. Inflammation of the pharynx
b. Palpate
i. Front & maxillary sinuses
Signs of Horner’s syndrome
Ptosis (drooping of one eyelid), miosis (unilateral pupil constriction), anhydrosis (dry skin around one eye).
Potential cause of Horner’s syndrome
Pancoast’s tumour - apical lung carcinoma which may compress the sympathetic nerves in the neck.
Polyps are associated with what respiratory condition
Asthma
Engorged turbinates are associated with what respiratory condition
Allergic respiratory conditions
What respiratory condition may a broken or rotten tooth predispose a patient to?
Lung abscess or pneumonia.
Crowding of the pharynx is a potential risk factor for
OSA
Inflammation/redness of the pharynx indicates
Infection.
Tenderness over the front &/ maxillary sinuses may indicate
Sinusitis.
In what condition does the JVP appear raised?
R-sided Heart Failure.
Resp Exam Neck
a. Look
i. JVP
1. Ask pt to look towards the left
2. Measure
ii. Prominent veins
iii. Pemberton sign
1. Ask pt to lift arms
2. Wait
3. Look for signs of obstruction
i. Trachea
1. Feel for any deviation (in the suprasternal notch)
2. Tracheal tug
a. Ask pt to breathe in.
ii. Cervical lymph nodes
* Submental: Behind the tip of the mandible
* Submandibular: Midway between the tip and the angle of the mandible
* Tonsillar : At the angle of the mandible
* Preauricular: In front of the ear
* Postauricular: Superficial to the mastoid process/behind the ear
* Occipital: Base of skull - posteriorly
* Superficial cervical: Superficial to the sternomastoid (one side at a time)
* Deep cervical: Hook your fingers around each side of the sternomastoid muscle (one side at a time)
* Posterior cervical: Along the anterior edge of the trapezius – in line w ear
* Supraclavicular: In the angle between the clavicle and the sternomastoid.
Signs of obstruction elicited by Pemberton’s sign
Plethora, cyanosis, distended veins, stridor, dyspnoea.
Normal deviation of trachea
Slight right
What conditions cause the trachea to deviate towards the affected area?
Atelectasis, upper lobe collapse, upper lobe fibrosis, pneumonectomy.
What conditions cause the trachea to deviate away from the affected area?
Pneumothorax, massive pleural effusion.
Other conditions which may cause the trachea to deviate in variable direction?
Retrosternal goitre, upper mediastinal mass.
Tracheal tug is caused by
Downward displacement of the trachea during inspiration.
Rubbery presentation of lymph nodes on palpation may indicate
Cancer
Tender presentation of lymph nodes on palpation may indicate
Inflammation/infection
One-sided swelling of lymph nodes may indicate
TB.
Resp Exam Thorax
- Thorax (Ant, Lat, Post).
a. Inspection
i. Scars
ii. Swelling
iii. Prominent veins
iv. Erythema
v. Rash
vi. Bruising
vii. Apex beat (should observe when pt lying down at 45)
viii. Shape & symmetry - Barrel chest
- Pigeon chest
- Funnel chest
- Spinal deformities
- Harrison’s sulcus
ix. Symmetry of chest wall movement during breathing - Use of accessory muscle of respiration in the neck (e.g., sternocleidomastoid, scalenus & trapezius mms.).
- Retraction of the intercostal space during inspiration.
- Chest expansion of upper chest.
a. Assess from behind & above.
b. Palpation
i. Tenderness/pain
ii. Crepitus
iii. Swelling
iv. Cracking sensation
v. Vocal fremitus - Use two hands to assess simultaneously.
- Ask pt to say 99 on each repositioning of the hands.
a. On lateral side, ask pt to raise arms upwards (like chicken wings).
b. On posterior side, ask pt to hug themselves.
i. NB: Never go beyond 6th rib anteriorly, 8th rib laterally, 10th rib posteriorly.
vi. Apex beat (pt lying at 45) - Locate first
- Compare to expected location of 5th intercostal space on mid-clavicular line
vii. Chest expansion - Anterior - place thumbs on either side of sternum, but ensure that thumbs are not in contact with the sternum.
- Posterior – place thumbs on either side of spine, but ensure that thumbs are not in contact with the spine.
viii. Hoover’s sign
c. Percussion (side to side)
i. Clavicle (without base index).
ii. Rest of chest – between intercostal spaces - On lateral side, ask pt to raise arms upwards (like chicken wings).
- On posterior side, ask pt to hug themselves.
- Note hyperresonance, normal, dull or stony dull resonance.
d. Auscultation (top to bottom, side-to-side) – ask pt to breathe in & out via mouth
i. Lung apices – above clavicles (bell)
ii. Rest of the chest (diaphragm) - On lateral side, ask pt to raise arms upwards (like chicken wings).
- On posterior side, ask pt to hug themselves.
a. Listen for:
i. Breath sounds
ii. Intensity of breath sounds
iii. Bronchial breath sounds
iv. Adventitious/additional sounds - Crackles
- Wheezes
- Stridor
- Pleural friction rub
v. Vocal resonance - Ask the pt to say 99
vi. Whispering pectoriloquy - Ask the pt to whisper 64.
Typical cause of prominent veins in the thoracic region.
Pts w SVC obstruction.
Barrel chest often presents in pts with
Severe asthma/emphysema.
Pigeon chest often indicates
Severe childhood asthma or rickets.
Funnel chest may indicate
Congenital abnormality.
Harrison’s sulcus describe appearance
Linear depression of the lower ribs (like funnel w largest part @ xiphoid process).
What may Harrison’s sulcus indicate?
Severe childhood asthma or rickets.
Crepitus on palpation of the thoracic region may indicate
Subcutaneous emphysema.
Crackling sensation on palpation of the thoracic region may indicate
Subcutaneous emphysema.
Under what circumstances is vocal fremitus increased or decreased
Increased - object present in lungs (e.g., pneumonia)
Decreased - increased barrier btw lungs & ribs (e.g., pneumothorax, pleural effusion…).
Remember solids conduct vibrations better than air.
When may the apex beat be impalpable?
Chest that is hyperexpanded due to COPD.
Normal chest expansion measurement
> 5cm.
Hoover’s sign may indicate
COPD.
Describe Hoover’s sign
Diaphragm compensates for chest -> thumbs & sternum pulled upwards.
Percussion is hyperresonant over
Hollow structures.
Percussion is dull over
Consolidations.
Percussion is stony dull over
Fluid-filled cavities.
Hyperresonance on percussion of the thoracic cavity may indicate
Pneumothorax or COPD.
Decreased dullness over the heart may be observed in what conditions
Emphysema or asthma.
Stony dull resonance on percussion of the thoracic cavity may indicate
Pleural effusion.
What must you ask pts to do during auscultation?
Breath in & out via mouth.
What is asymmetric reduction of breath sounds on auscultation a sign of?
Bronchial obstruction - potential causes include COPD (esp. emphysema), pleural effusion, pneumothorax, pneumonia, large neoplasm, pulmonary collapse.
Bronchial breath sounds on auscultation may indicate.
Lung consolidation, localised pulmonary fibrosis, pleural effusion (above), collapsed lung.
(Caused by turbulence in large airways, which occurs when air cannot be filtered by the alveoli).
Early inspiratory crackles suggest
Disease of the small airways (e.g., COPD).
Late or pan-inspiratory crackles suggest
Disease confined to the alveoli.
Fine crackles suggest
Interstitial lung disease (e.g., pulmonary fibrosis).
Medium crackles suggest
L Ventricular Heart Failure.
Coarse crackles suggest
Pools of retained secretions (e.g., bronchiectasis).
Pleural friction rub indicates
Pleurisy, spontaneous pneumothorax, pleurodynia or rarely, malignant pleural involvement.
High pitched wheezes usually arise from
Small bronchi (e.g., asthma).
Low pitched wheezes usually arise from
Larger bronchi (e.g., COPD).
Wheezes tend to be louder on…
Expiration, but may be heard on inspiration or expiration or both.
An inspiratory wheeze implies
Severe airway narrowing.
Stridor is always heard on…
Inspiration.
Where is a stridor heard loudest on auscultation?
Trachea.
On vocal resonance, numbers will become clearer over
Regions of consolidation.
When is whispering pectoriloquoy used
Confirm consolidation.
Resp Exam Ending
- Examine CVS, liver & LLs.
- Thank pt
- HH
- Present findings.
Sharp chest pain on inspiration may indicate
Pneumonia.
Define pulsus paradoxus. Describe process on how to check for it?
Pulsus paradoxus = a fall of systolic blood pressure of >10mmHg during the inspiratory phase.
To check for pulsus paradoxus:
1. Look for first Kortokoff sound which appears then disappears during inspiration.
2. Listen for when first Kortokoff sound no longer disappears w inspiration.
Pulsus paradoxus is commonly associated with what conditions?
May be present in cardiac tamponade, constrictive pericarditis, asthma/COPD exacerbations, PE, tension pneumothorax, pleural effusion.
Reduced breath sounds may indicate
COPD (esp emphysema), pleural effusion, pneumothorax, pneumonia, large neoplasm, pulmonary collapse.
