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MD3001 > Exam of the Respiratory System > Flashcards

Exam of the Respiratory System Flashcards

1
Q

What are the symptoms to look out for in a respiratory system history ?

A
  1. Chest pain
  2. Dyspnoea
  3. Cough
  4. Sputum
  5. Haemoptysis
  6. Wheeze
  7. Systemic upset
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2
Q

What are the main steps to respiratory system exam ?

A

– Introduction and explanation
– Inspection (including general and close inspection)
– Palpation
– Percussion (a new skill for respiratory)
– Auscultation

NB Often easier to do all front chest then all back

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3
Q

What position should the patient be in for respiratory exam ?

A

45 degrees with chest appropriately exposed

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4
Q

What are the features of general inspection ?

A
  • Does the patient LOOK unwell? Cachectic? In pain?
  • Use of accessory muscles / work of breathing
  • Look around the patient (e.g. nebuliser, inhaler, oxygen, sputum pot)
  • Look at the patient (e.g. erythema nodosum)
  • Listen (audible stridor, hoarseness, pattern of speech)
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5
Q

Define stridor, found in general inspection. What could this be a sign of ?

A
  • Loud, harsh, high pitched respiratory sound, usually on inspiration
  • Indicates upper airway obstruction (e.g. epiglottitis)
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6
Q

Define erythema nodosum. What could this be a sign of ?

A

Swollen fat under the skin causing red bumps and patches

-Can be a sign of tuberculosis, sarcoidosis, pneumonia

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7
Q

Identify the main features of close inspection (and palpation).

A

1) Close inspection of the face and hands
• Examine hands
- inspect
- palpate for warmth and venodilation
- palpate/inspect for flapping tremor and fine tremor
- palpate radial pulse (rate and rhythm)

  • Count respiratory rate
  • Inspect face, eyes, mouth and pharynx
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8
Q

Identify possible abnormalities during close inspection of the face and hands. What could each of these be indicative of ?

A

1) Blue lips, skin, tongue
- Central cyanosis

2) Tar staining
- Smoking

3) Clubbing
- Bronchial carcinoma, mesothelioma, chronic suppurative lung disease (e.g. bronchiectasis, lung abscess, emphysema), pulmonary fibrosis, cystic fibrosis

4) Ruddy (i.e. reddish) complexion
- Polycythaemia

5) Unilateral miosis + partial ptosis + facial anhydrosis
- Horner’s Syndrome

6) Fine tremor
- Excessive use of beta-agonists

7) Flapping tremor (often with associated confusion)
- Severe ventilatory failure with CO2 retention

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9
Q

What is the cause of Horner’s Syndrome ?

A

Damage to cervical sympathetic nerves

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10
Q

How can you detect a flapping tremor ?

A

Hold patients’ hands outstretched + wrists cocked back

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11
Q

Describe the main features of close inspection of the chest and neck.

A
  • Scars – cardiac surgery, thoracotomy, chest drain scars
  • Pattern of breathing

• Shape of chest
– Symmetry
– Deformity (kyphoscoliosis / pectus excavatum)
– Increase in A-P diameter (‘barrel shaped’)

• Prominent veins on chest wall
– SVC obstruction

• JVP

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12
Q

What are the main components of close inspection ?

A

1) Close inspection of face and hands (including some palpation)
2) Close inspection of the neck and chest

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13
Q

Identify possible abnormalities during close inspection of the chest and neck. What could each of these be indicative of ?

A

1) Caved-in or sunken deformity of the chest
- Pectus Excavatum

2) Deformity of the chest with abnormal curvature of the spine in both a coronal and sagittal plane (kyphosis + scoliosis)
- Kyphoscoliosis

3) Prominent veins on chest wall
SVC Obstruction

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14
Q

Describe the main features/steps of palpation of the neck and chest.

A

• Palpation of lymph nodes

  • Examine for cervical lymphadenopathy
  • Patient sat forward
  • Palpation of subcutaneous (‘surgical’) emphysema (if appropriate)
  • Palpation for rib fractures (if appropriate, e.g. history of chest trauma)
  • Palpation of mediastinal position
  • Check tracheal position (right middle finger 2 cm superior to suprasternal notch, press down and back + palpate space to either side; trachea should be central)
  • Check cardiac apex
  • Assess for RV heave

• Palpation for chest expansion
– Ask patient to breathe deeply
– Anterior and posterior (posterior when sitting forwards), thumbs should move apart equally

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15
Q

What is subcutaneous emphysema ? How would subcutaneous emphysema feel like upon palpation ?

A

– Air in subcutaneous tissues

– Crackling sensation
– May be diffuse chest, neck, face swelling

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16
Q

What are possible causes of subcutaneous emphysema (possibly felt upon palpation of chest and neck) ?

A

Pneumothorax, trauma

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17
Q

What are possible causes of tracheal deviation ?

A

1) IF DISPLACEMENT TOWARDS LESION
- Lobar collapse
- Pneumonectomy
- Pulmonary fibrosis

2) IF DISPLACEMENT AWAY FROM LESION
- Large pleural effusion
- Tension pneumothorax (life threatening masses)

3) OTHER DISPLACEMENT
- Mediastinal masses

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18
Q

Where do we percuss ? Explain the actions involved in percussion.

A
  • In general, we percuss anterior, posterior and lateral chest. Specifically, percuss over the intercostal spaces, but percuss the clavicles directly (compare L and R for all percussions).
  • Use middle finger / left hand, apply firmly to patient’s chest and strike its middle phalanx with the middle finger of right hand
19
Q

List the percussion sites.

A

Clavicles, apices of the clavicles (both anterior and posterior, and both R and L)

IC spaces (both anterior and posterior, and both R and L)

Basically 6 sites on one side anteriorly (1 is apices, 2 is clavicles, 3 to 6 is IC spaces). On the other side it’s just a mirror image of those sites.
7 sites on one side posteriorly.

Check exactly the sitesI on image of page 5 of lecture on “Exam of Respiratory System)

20
Q

Identify the different percussion notes usually heard, and what the cause of each is.

A
  • Resonant = normal lung
  • Hyper resonant = Emphysema, large bullae, pneumothorax
  • Dull = Collapse, consolidation, fibrosis
  • Stony, very dull = Pleural effusion, haemothorax

If the note is dull, need to check tactile vocal fremitus (now) or vocal resonance (after auscultation).

21
Q

Explain what Tactile Vocal Fremitus is and how to perform it.

A

Palpation of the chest wall to detect changes in the intensity of vibrations created with certain spoken words in a constant tone.

Use palm or ulnar border of the hand, ask patient to say 99 and feel for vibration.

22
Q

What are possible causes of increased or decreased fremitus ?

A

Increased fremitus - consolidation or fibrosis

Decreased fremitus - pleural effusion, pneumothorax or collapse

23
Q

Describe the main features of auscultation in respiratory exam.

A
  • Compare side to side, anterior, posterior and lateral (similar to percussion sites)
  • Use bell for apices and diaphragm for the rest
  • Ask patient to breathe deeply in and out through mouth, and listen (for breath sounds and added sounds) through full inspiration and full expiration
24
Q

What questions are you asking yourself whilst auscultating for breath sounds and added sounds ?

A
  • Are breath sounds present? Are they vesicular in nature? Are they equal on both sides? Are there any bronchial ones ?
  • Are there any added sounds such as crackles, wheezes or pleural rubs?
25
Q

Define a vesicular breath sound.

A

Soft and low pitched sound with a rustling quality

26
Q

Identify the possible breath sounds heard in auscultation during a respiratory exam ?

A

1) Vesicular (normal)

2) Bronchial (abnormal)

27
Q

Define a vesicular breath sound.

A
  • Low pitched, soft, heard over most of lung fields
  • Intensity of sounds relates to airflow
  • Inspiration longer than expiration, and no gap between inspiration and expiration (however is after expiration)
28
Q

What are possible abnormalities in vesicular breath sounds ? What are possible causes for this ?

A

Diminished vesicular breath sounds

• When normal lung displaced by air, e.g:

  • Obesity
  • Pleural effusion
  • Pneumothorax* (sound diminished to absent)
  • Collapse
  • Hyperinflation (in emphysema in COPD)
29
Q

What are the main causes of pneumothorax ?

A
  • Primary spontaneous in healthy people (typically young men)
  • Secondary associated with underlying lung disease, traumatic or iatrogenic
30
Q

Define a bronchial breath sound.

A
  • Loud, harsh, high-pitched in expiration
  • Expiratory component dominates, with gap between inspiration and expiration
  • Noise originates from larger airways
  • Occurs when damage to small airways / alveoli
  • Heard over the manubrium and trachea (larger proximal airways)
31
Q

What are the possible causes of bronchial breath sounds ?

A

Consolidation – when alveoli and small airways fill with dense material (e.g. with pneumonia, infection on top of pleural effusion) or fibrosis

32
Q

Identify possible added sounds heard in auscultation.

A

Crackles (i.e. crepitations, rales), pleural rub, wheeze

33
Q

Describe the added sound of crackles.

A

High-pitched, discontinuous sound (similar to rubbing your hair between your fingers)

34
Q

What are the main causes of crackles heard in auscultation ?

A 
Pneumonia 
Pulmonary oedema 
Pulmonary fibrosis 
Bronchial secretions 
COPD 
Lung abscess 
TB 
Bronchiolitis 
Bronchiectasis
Cryptogenic Fibrosing Alveolitis (fine late crackles)
35
Q

Describe the added sound of pleural rub.

A

Low pitched, like creaking leather

May be associated with pleuritic pain (sharp on inspiration / coughing)

36
Q

What are the main causes of pleural rub ?

A

Pneumonia
PE
Vasculitis

37
Q

Describe the added sound of wheezing.

A

Musical quality, high pitch, louder on expiration (produced by continuous oscillation of opposing airway walls)

38
Q

What are the main causes of wheezing ?

A

Generalised – Asthma / COPD (due to airway narrowing)

Localised – lung tumour

39
Q

What added sounds might you hear in severe airway obstruction?

A

None, because in such situations, it’s silent chest.

40
Q

Describe the vocal resonance test.

A

-Performed if area of dullness on percussion (i.e. not in the “normal”) but only it’s either vocal resonance or tactile vocal fremitus, no need for both.

-Use stethoscope, ask patient to say “one, one, one”. Assess quality and amplitude and compare with the other side.
Ask patient to whisper “one, one, one”. Whispering is not heard over a normal lung but in consolidation the sound is transmitted.

41
Q

What are possible causes of increased vocal resonance ?

A

Consolidation or fibrosis

42
Q

What are possible causes of decreased vocal resonance ?

A

Pleural effusion, pneumothorax or collapse

43
Q

Once the main steps of a respiratory exam are performed, what are other areas which can be looked at ?

A
  • Ankle oedema
  • Sputum pot
  • Observation chart – Pulse, BP, Temp, Oxygen saturation
  • Peak flow (used in asthma, possibly acute situations)
  • Spirometry (used in asthma, COPD, not acute situations)

MD3001 (75 decks)

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