examinations Flashcards
in a resp exam how would you start examination?
Introduction:
- Wash hands
- Introduce yourself – name/ role
- Confirm patient details – name/ DoB
- Explain procedure: today I have been asked to perform a resp examination, do you understand what this will involve
- Chaperone?
- Check understanding and gain consent
how would you prepare a patient for a resp exam after gaining consent?
- Ask patient to undress down to waist behind curtain – can keep bra on, offer blanket
Ask for chaperone - Adjust head of head to 45 degree angel (OSCEs important!)
- Ask patient to expose their lower legs – knee down
- Ask the patient if they have any pain before proceeding
what do you look for within inspection of resp exam?
age, accessory muscle use, lip pursing, sputum pots, cachexia, breathing sounds, nasal flaring (paeds), body position, catheter, breathing devices, meds, cyanosis/ pallor
why is age important within inspection of resp exam?
ideas of what conditions ot expect
what would accessory muscle use/ lip pursing suggest?
resp distress
intercostal recession
what do the different colours suggests within sputum pots?
green - bacterial
red - blood clots (lung cancer), capillaries (excess coughing), TB
what would a high pitched/ resonance wheeze indicate?
COPD/ lung cancer
what would an audible stridor be caused from?
resp emergency - obstructions
foreign body - narrowing of upper airways
what does cyanosis indicate?
lack of perfusion
what does pallor suggest?
anaemia
what is tripod breathing?
sitting up but forwards - optimising resp conditions if patient is struggling
what would a lower fluid output show?
pulmonary embolism
what do you look for in hands in resp exam?
clubbing, tar staining, fine tremour, pulse and resp rate, peripheral cyanosis/ temp
oxygen sats, asterixis, joint swelling
what does clubbing suggest?
asbestos, abscess, bronchiectasis, bronchial carcinoma, CF, emphysema (lack of oxygen) , fibrosing alveolitis (ABCDEF) - interstitial lung disease
what does a fine tremor in hands suggest?
excess salbutamol use
what is asterixis?
hands in resp exam
flapping tremour - hands stretched out and palms flexed - termour will appear
what can joint swelling show in hands section of resp exam?
RA
what do you look for within the face of a resp exam?
conjuctival pallor, central cyanosis in mouth, oral candidias, horners syndrome, erthymatous face
what would conjunctival pallor indicate?
anaemia
what would central cyanosis in the mouth indicate?
hypoxaemia
why may an asthmatic have oral candidias?
steroid inhaler use
what causes horners sydrome?
lung cancer at the apex of the lung - pancost tumour
what are common features of horners sydrome?
miosis - constricting pupils
ptosis - dropping eyelids
anhidrosis - sweating of the face
why could a patient have erythematous face?
polycythaemia, CO2 retnetion seen in COPD
would do you look for at the neck within a resp exam?
JVP, heptajugular reflex, trachea deviation, cricosternal distance, neck lymph nodes
what would a raised JVP indicate?
cor pulmonale - right sided HF secondary to lung or pulmonary arterial disease
>3cm is a concern
when would you do a hepatojuglar reflex?
in a healthy individual
>4cm is a concern
how do you assess trachea deviation?
chin relaxed down - find lateral borders using three fingers
how do you measure crico-sterno distance ?
using three fingers (or patients own if difference in size) from sternal angel to start of cartilage
what would an extended cricosternal distance show?
hyperinflation eg COPD
how do you assess patients neck lymph nodes
stand behind sat down patient and feel along neck
small pea like shape - inflamed
what do you assess within the chest section of resp exam?
inspection, palpitation, percussion, auscultation - quality of sounds, expansion
what do you do within the inspection part of chest resp exam?
scars and deformities
what would chest scars mean?
surgeries - CABG, VR, posterolateral/ thoracotomy
what would an asymmetric chest be a sign of?
pneumonectomy
what would a barrel chest - hyper expansion be casued be?
emphysema - COPD
what would right ventricular heave show?
visible or palpable - large pleural effusions
how do you assess chest expansion?
but thumbs iv V shape across midline and when patient breaths in and out - do they move same distance etc
what does symmetrically reduced chest expansion show?
idiopathic pulmonary fibrosis
what would unilaterally reduced chest expansion show?
pneumothorax
how would you check percussion of chest?
non dominant hand on chest wall, middle finger pressed against chest wall and briskly strike finger
supraclavicular, chest wall x4 bilaterally, and to axilla
what would air sound like when percussing?
loud high pitched, high resonance
what would a solid structure sound like durng percussion?
dull low pitched
what would a hyper-resonant percussion suggest?
pneumothorax
what do you assess when hearing sounds during auscultation?
volume of sound
quality (normal vs not)
added sounds
when would the volume of auscultation be quieter?
pneumothorax/ pleural effusion - liquid/ air blocking normal movements
what type of sounds can be added and essentially abnormal?
wheeze, coarse, stridor, crackles
what would a wheeze indicate?
bronchoconstriction
what would coarse - brief crackles indicate?
pneumonia
what do crackles represent within ausculatation?
interstitial lung disease
what you check for on legs section within resp exam?
pitting oedema
signs of DVT
how would you conclude and finish a resp exam?
- Thank patient
- Cover them up with blanket/ sheet – allow time to for them to redress
- Wash hands
- Summarise findings
- Suggest further assessments and investigations (usually 3) eg sputum sample, peak expiratory flow rate, CXR, ECG
what is arterial blood gases used for?
diagnostic tool
- Used in emergency, intensivist, anaesthesiology and pulmonary medicine
- Alveolar-arterial oxygen gradient is useful measure of lung gas exchange – can be abnormal in patients with ventilation-perfusion mismatch
is ABG quicker than FBC for electrolyte counts?
yes - takes minutes whereas FBC can take an hour
what is the main focus of ABG?
Respiratory gas exchange, acid- base balance
how can lactic acid build up?
Insufficient O2 delivery to mitochondria leads to anaerobic respiration which produces less ATP and lots of lactic acid
what is type I resp failure?
- Type I: low oxygen cell death due to hypoxia. Aetiology: shunt (pneumonia), diffusional (COVID), V/Q mismatch (PE), ventilation (coma) and altitude.
- MORE SEVERE
what is type II resp failure?
- Type II: high carbon dioxide and can have lower oxygen as a result – cell death due to acidaemia
what is the partial pressure of oxygen in room air?
21kPa - like the gas % of air
what type of oxygen should you use when measuring ABG and why?
room air
venturis - know percentage by colour so can compare
how much oxygen does a rebreather oxygen mask give?
percentage is unknown but allows for continuous rapid oxygen - 15L - good in emergency medicine
why is having unnecessary high FiO2 bad?
can causing wasting in lungs and respiratory depression - no need to breathe
in COPD patients do they respond to CO2 like normal physiology?
no as used to chronic CO2 exposure - more likely to respond to hypoxaemia
what is optimal pH?
7.35-7.45
what can acidaemia cause?
myocardial suppression/ arrhythmias, cell death, enzyme dysfunction, excitable tissue, hyperkalaemia
what can alkalaemia cause?
enzyme dysfunction, poor oxygen uptake by tissues, cell death
