CLIN SKILLS: Resp Exam

Question 1

central sleep apnoea vs obstructive sleep apnoea

Answer 1

• CSA: brain doesn’t signal for breathing to happen during sleeping (no snoring/gasping bc you’re not even trying to breathe)
• OSA: tongue blocks airway whilst sleeping (gasping/snoring)

Question 2

general process of resp exam

Answer 2

• intro
• general inspection
• inspection: hands, face, neck
• inspection of thorax
• palpation of thorax
• percussion of thorax
• auscultation of thorax
• legs
• conclusion

Question 3

what to look for in general appearance (resp exam)

Answer 3

• respiratory distress
• use of accessory muscles
• pursed lips
• body build
• cough (dry/wet/barking?)
• stridor/wheeze
• SOB
• equipment/device e.g. oxygen
• posture (COPD can cause people to lean forward to breathe)
• smoker
• hoarse voice

Question 4

what to look for in hands (resp exam)

Answer 4

• peripheral cyanosis
• tar staining
• palpate over wrists for swelling/tenderness
• muscle wasting
• muscle weakness
• clubbing
• fine tremor or flapping tremor (asterixis)

Question 5

what does tenderness/swelling in the wrists indicate (resp exam)

Answer 5

• hypertrophic pulmonary osteoarthropathy

Question 6

what can muscle wasting indicate (resp exam)

Answer 6

• apical lung tumour compressing T1 nerve root

Question 7

how to test for muscle weakness (resp exam)

Answer 7

• resisted finger abduction (get them to spread their fingers out and keep it there while you press in)

Question 8

how to check for asterixis and what does it indicate?

Answer 8

• asterixis = flapping tremor
• hold out both hands in stop sign and spread out fingers.
• 2 to 3 second cycle flap = due to severe CO2 retention/metabolic disease (e.g. COPD)
• HOWEVER mild tremor can be associated w/ bronchodilator use

Question 9

tachypnoea and bradypnoea limits

Answer 9

• tachypnoea > 25
• bradypnoea < 8

Question 10

4 categories to check in face (resp exam)

Answer 10

• eyes
• nose
• tongue
• face

Question 11

what to check in eyes (resp exam)

Answer 11

• use torch
• conjunctival pallor: get Pt to look up and pull lower eyelid down
• jaundice: get Pt to look down and pull upper eyelid up
• horner’s syndrome (unilateral ptosis, anhidrosis and miosis - compression of sympathetic nervous system due to apical lung tumour)

Question 12

what to check for nose (resp exam)

Answer 12

• get the Pt to look up and use torch
• polyps (extensions on a stalk)
• engorged turbinates (side projections of the nasal wall)
• deviated septum

Question 13

what to check for mouth (resp exam)

Answer 13

• use torch and tongue depressor
• tongue (central cyanosis)
• teeth hygiene (risk factor for lung abscesses or aspiration pneumonia)
• pharyngeal crowding - check there is enough space between the uvula and soft palate (can cause obstructive sleep apnoea) and look for redness

Question 14

what to check for general face (resp exam)

Answer 14

• redness (facial plethora)
• feel over the frontal (above eyebrows) and maxillary (under eyes) sinuses for tenderness
• pemberton’s sign - ask the patient to lift their arms over their head, wait for a minute and look for signs of obstruction - watch for plethora, dyspnoea, cyanosis, stridor

Question 15

what to check for neck (resp exam)

Answer 15

• tracheal deviation (in suprasternal notch): pointer and ring finger on either side, middle finger on the trachea - comment on if its midline
• tracheal tug: trachea moves down with each inspiration due to gross over-expansion of the chest due to airflow obstruction such as in COPD - watch them breathe
• cervical lymph nodes: palpate from behind with a circular motion of index and middle fingers

Question 16

cervical lymph nodes

Answer 16

• 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
• occipital: base of skull - posteriorly
  -superficial cervical: superficial to the SCM
• deep cervical: hook your fingers around each side of the SCM (one side at a time)
• posterior cervical: along the anterior edge of the trapezius
• supraclavicular: get them to shrug the shoulders up - in the angle between the clavicle and the SCM

Question 17

what to inspect for chest (resp exam)

Answer 17

• skin - scars, swelling, prominent veins, erythema, rash
• shape and symmetry: barrel chest, pigeon chest, funnel chest, spinal deformities, harrison’s sulcus
• symmetry of movement of the chest wall: are the left and right sides moving the same
• use of accessory muscles (SCM, scalenes, and trapezius muscles)
• retraction of the intercostal spaces during inspiration
• expansion of the upper part of the chest (look from behind and above)

Question 18

chest deformities to look for (resp exam)

Answer 18

• barrel chest (AP diameter of the thorax is greater than the transverse diameter)
• pigeon chest: anterior sternal protrusion anteriorly - childhood respiratory disease or rickets
• funnel chest: localized depression of the lower end of the sternum
• spinal deformities: (scoliosis, kyphosis, lordosis)
• harrison’s sulcus: linear depression of the lower ribs due to severe childhood asthma

Question 19

what to palpate for around the chest

Answer 19

• crackling sensation (subcutaneous emphysema)
• vocal fremitus (get them to continue saying 99 and palpate the back with the sides of the hands to ensure it’s the same on both sides) - pneumonia
• apex beat: should be L 5th intercostal space midclavicular
• chest expansion: place hands on lateral and posterior back w thumbs together - should be symmetrical and > 5cm
• Hoover’s sign - inward instead of outward movement of the lower chest during inspiration

Question 20

how to percuss chest (resp exam)

Answer 20

• tap over clavicle DIRECTLY using the tip of your right middle finger to examine lung apices
• percuss the front of the chest, moving the percussed finger down about 6-8 cm at a time.
• tap over the back of the chest using the tip of the middle finger of your right hand over the middle finger of your left hand – use wrist movements
• ask the patient to cross their arms in front of them, putting each hand on the opposite shoulder to move scapulae out of the way.
• lateral chest wall > ask Pt to put their hands on their head

Question 21

how to auscultate chest (resp exam)

Answer 21

• auscultate 3-4 spots on each side of the back (one side then the other to compare), a couple on front (use bell for above the clavicles) and sides (top to bottom)
• ask the patient to breathe through the mouth more deeply and more slowly than in usual respiration
• adventitious/additional sounds e.g. cackles, wheezes (rhonchi), pleural rub
• egophony
• whispering pectiroloquy

Question 22

what do normal vs bronchial breath sounds sound like?

Answer 22

• normal vesicular breath sounds are low pitched and have a soft intensity- inspiration is longer than expiration
• bronchial breath sounds are high-pitched- expiration is equal to or longer than expiration

Question 23

how to auscultate for egophony and whispering pectoriloquy

Answer 23

• egophony: Ask the patient to say 99 as you auscultate down along the back on each side. Should become more muffled towards the lower chest. Consolidated lung = clearer
• whispering pectiroloquy: Ask the patient to whisper 99. Should be indistinct/faint. WP = sounds are clear and distinct