Examination Flashcards
General inspection:
Below is a list of lung diseases. Which 3 are more common in older people?
- asthma
- interstitial lung disease (ILD)
- cystic fibrosis (CF)
- COPD
- malignancy
COPD
Interstitial lung disease
Malignancy
General inspection:
What may you find around the bed or in their environment? - 3
Signs of respiratory distress? - 4 - think about SOB getting worse
What is the tripod position? What does it indicate?
What about the patients indicates SOB speech?
O2 (ILD, COPD)
Inhalers or nebulisers (asthma, COPD)
Sputum pots (COPD, bronchiectasis)
Nasal flaring Pursed lips Use of accessory muscles Intercostal muscle recession ---
One sits or stands leaning forward and supporting the upper body with hands on the knees or on another surface.
If they are unable to speak in full sentences
Hands:
What would you see that indicates someone is a smoker?
What does clubbing indicate in respiratory medicine?
Why does it happen?
Peripheral cyanosis - what does it look like? Under what SATS does this occur?
Tar staining on fingers (or nicotine patches on body)
Lung cancer
Interstitial lung disease
Suppurative lung disease - Bronchiectasis, empyema, abscess
TB
Blue nails and fingers
<85%
Hands:
Why can lung cancer cause muscle wasting in the arms?
What may salbutamol inhalers cause in the hands?
What causes a flapping tremor?
Lung cancer mets causing T1 root compression
Fine tremor
CO2 retention in Type 2 respiratory failure - COPD
Hands:
Why do you also look for signs of rheumatological disease such as RA?
Why effects may long term steroids have on the skin on the hands and arms?
What does a low peripheral temperature s suggest?
Associated with pleural effusions and pulmonary fibrosis
Bruising and thinning of the skin
Peripheral vasoconstriction and poor perfusion
Hands:
Pulsus Parodoxus:
- What is it?
- How may you notice this?
- Pulmonary causes? - 3
- Pericardial causes? - 2
Drop in systolic BP with inspiration
Radial pulse intermittently hard to palpate on inspiration
COPD
Asthma
Obstructive sleep apnoea
Pericarditis
Cardiac tamponade
Head and Neck:
What does a raised JVP indicate? - 3
How do you check for pallor in the eyes?
What 4 things can you look for in to rule out/in Horner’s syndrome? How does lung cancer cause this?
Signs of central cyanosis?
What may inhaled steroids cause in the mouth?
Right heart failure - could be due to pul HTN
Raised and fixed SVC obstruction
Lung cancer - tumour blocked SVC in the mediastinum
Checking conjunctiva
Ptosis
Miosis - is sympathetic chain intact, you would get dilatation to SEE more. So opposite happens in Horner’s.
Exophthalmos
Anhidrosis
A malignant neoplasm of the superior sulcus of the lung leads to destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves (stellate ganglion).
Bluish discolouration of the lips / inferior aspect of the tongue
Oral candida
Palpation of the neck:
How do you check the position of the trachea?
What does the trachea deviate away from? - 2
What does the trachea deviate towards? - 2
What is the cricosternal distance?
What does it suggest if it is increased?
Using 2nd, 3rd and 4th finger
Tension pneumothorax - away
Large pleural effusion
Collapse
Lobe/pneumonectomy and fibrosis
REMEMBER THE TRACHEA WILL MOVE TO THE SIDE WITH LESS PRESSURE, SO WITH THE SPACE FILLING UP WITH AIR (NOT FROM OUTSIDE THE BODY). IT WILL MOVES TOWARDS THAT SIDE.
Distance between the inferior border of the cricoid cartilage and the sternum.
> 3cm suggests hyperinflation - COPD - Barrel chest
Inspection of the chest:
What does small mid-axillary scars suggest?
What does a horizontal postero-lateral scars suggest?
What does erythema or thickened skin suggest?
What surgical procedures does asymmetry of the chest suggest? - 2 - not looking at unequal air entry!!!
What deformity is common in those with COPD?
What is the medical name for a dip in the chest?
What is the medical name for a protrusion of the chest?
What is Hoover’s sign? What disease is this seen in?
Chest drains
Thoracotomy from e.g. lobectomy/pneumonectomy
Recent or previous radiotherapy
Pneumonectomy (usually for cancer)
Thoracoplasty (rib removed / previously used to treat tuberculosis)
Barrel chest
Pectus excavatum and carinatum
Paradoxical inspiratory retraction of lower ribs and intercostal spaces - COPD due to diaphragm flattening
Palpation:
Chest expansion - what does reduced expansion on one or both sides suggest?
What may cause a displaced apex beat?
What does a right ventricular heave suggest?
Tactile vocal fremitus (TVF) - it is palpable vibration of the chest wall with speech. This is an alternative to vocal resonance.
- What may cause increased vibrations (resonance)?
- What may cause reduced vibrations (resonance)?
Pneumonia
Pneumothorax
Effusion
PE
LVF - may present with respiratory symptoms
Cor pulmonale - RHF due to chronic hypoxic lung diseases such as COPD or ILD
Increased tissue density - Consolidation, tumour, lobar collapse
Presence of fluid or air outside of the lung - Effusion and pneumothorax
Percussion:
What does hyper resonance suggest (it suggests decreased tissue density)?
Why does this also suggest emphysema?
What does dullness (it suggests increased tissue density) suggest? - 4
What does stony dullness suggest?
Pneumothorax or emphysema (inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones)
Consolidation
Collapse
Pleural thickening
Tumour
Effusion
Auscultation:
How do you ask them to breath in and out?
What does NBS stand for?
(1) Assess quality:
What is normal breathing referred to as?
Bronchial breath sounds:
- What does it sound like? - 2
- Normal breathing is called vesicular breathing. How is it different from bronchial breathing?
- What does it suggest?
(2) Assess volume:
- What quiet breaths suggest?
- What does this suggest?
REMEMBER - State reduced breath sounds rather than reduced air entry when presenting
With their mouths
Vesicular
Harsh sounding - Loud, hollow whoosh sound
With clear pause between I and E
Reduced air entry - consolidation, collapse, pleural effusion
Auscultation:
(3) Added sounds
What does a wheeze suggest? - 2
Fine crackles:
- What does fine to medium MID inspiratory crackles suggest?
- What does fine END inspiratory crackles suggest?
Coarse crackles:
- What do coarse crackles throughout breathing suggest?
- What do END inspiratory coarse crackles suggest?
Asthma / COPD
Oedema - fluid overload
Bronchiectasis
Pneumonia
https://www.youtube.com/watch?v=KRtAqeEGq2Q
Auscultation:
(4) Vocal resonance:
- What does increased volume over an area suggest?
- What does reduced volume over an area suggest?
Increased tissue density - especially if there is dull percussion - consolidation/tumour/lobar collapse
Fluid outside the lungs i.e. pleural effusion
- Especially is there is dull percussion)
Refer to the pic on phone if you forget pattern!
Auscultation:
Rhonchi wheeze (sonorous wheeze):
- What is it?
- What is it heard in?
What is pleural rub? What is it a sign of?
Continuous low pitched noise, like snoring or gargling
COPD and CF
A sound of treading on snow - heard on both I and E
Pleural layers are inflamed and lost their lubrication.
Pleurisy
PE
Pneumonia
Effusion
