Lower Respiratory Exam Flashcards by Sarah Gillen

Normal adult respiratory rate

14-20/min

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_____ = decreased depth (shallow) and rate (slow) of respiration

Hypopnea

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_____ = regular breathing rhythm but slower rate than normal - about 14/min

Bradypnea

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__________ = increased depth of breathing and rate of respiration (occurs in exercise)

Hyperpnea

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______ = rapid breathing at a rate greater than 20/min

Tachypnea

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________ = feeling short of breath

Dyspnea

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________ = deficiency of the amount of oxygen reaching the tissues

Hypoxia

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_________ = oxygen deficiency in arterial blood

Hypoxemia

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_______ = no breathing

Apnea

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_______ = collapse of lung tissue that affects the alveoli from normal O2 absorption

Atelectasis

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______ = hyperextended middle finger of nondominant hand in percussion

Pleximeter finger

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_______ = tapping finger, dominant hand, for percussion

Plexor finger

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What chief complaints are related to lower respiratory issues?

Cough (with or without blood)

Trouble breathing (rest, conversional, exertional)

Wheezing

Swelling

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What past medical history findings are relevant to the lower respiratory system

Asthma
Chronic bronchitis
Heart failure

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What types of medications might affect the lower respiratory tract

Chemo

Amiodarone

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What social hx findings are relevent to lower respiratory complaints

Ilicit drug use
Alcohol
Smoking history (PPD x yrs)

Hobbies, allergies, and travel are also important

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What occupations are relevant to lower respiratory complaints?

Farmer
Wood worker
Mining
Asbestos exposure
Duct/vent cleaning

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What are the 3 main systems that should be documented when someone presents with a lower respiratory complaint?

Constitutional
Respiratory
ENT

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What are some ENT ROS considerations for a lower respiratory complaint?

Otalgia
Tinnitis
Ear drainage
Epistaxis
Nasal congestion
Rhinorrhea
Post nasal drainage
Lymphadenopathy
Hoarseness
Sore throat
Sinus pressure
Goiter

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What are some respiratory ROS considerations for a lower respiratory complaint?

Chest pain
SOB
Dyspnea
Cough (productive?color?)
Wheezing
Hemoptysis
Asthma
Pneumonia

Note if the above are with/without activity

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When a patient presents with a respiratory complaint, what are some important things to note on your PE in terms of patient position, muscles used, fingers, lips, and nails?

Observe sitting position and breathing pattern, ability to speak

Use of accessory muscles

Color of fingers and lips. Shape of nails.

Breathing through pursed lips

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When a patient presents with a respiratory complaint, what are some important things to note on your PE in terms of chest, spine, and trachea position?

Look for chest and spinal deformities, such as chest excursion

Is the trachea in midline?

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When a patient presents with a respiratory complaint, what are some important things to note on your PE in terms of palpation of the thoracic cavity and use of your stethoscope?

Check for lymphadenopathy

Note any tactile fremitus (vibration felt through the chest wall)

Percussion

Lung sounds

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What vital signs are important to obtain when a patient presents with a respiratory complaint?

Respiratory rate
HR
BP
Temp
O2 sats

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What are the 4 major parts to a lower respiratory exam?

Inspection Palpation Percussion Auscultation

Capillary pulse brings the arterial blood to fingers. Oxygenated Hgb absorbs infrared light and allows red light to pass through. Deoxygenated blood is the opposite, absorbing red light and allowing red light to pass through. What instrument is used to detect this phenomenon?

Pulse oximeters - sense pulse, record red light (oxyhemoglobin) and blue light (deoxyhemoglobin) and pulse rate is displayed % saturation = red/red+blue

What instrument is used to record the following: Take a slow deep breath as deep as you can, as you breathe the piston or ball inside a large column moves up; try to move the piston or ball as high up as you can or to the level your doctor recommends. When you can't breathe in anymore, hold your breath for 2-5 seconds

Incentive spirometer

What type of test is non-invasive and shows how well the lungs are working; also used to diagnose lung disorders between obstructive vs. restrictive

Pulmonary function test (PFT)

_______ is also considered a pulmonary function test because it measures lung function based on the amount and speed of air inhaled and exhaled. It can diagnose between obstructive and restrictive diseases

Spirometry

What are some abnormal respiratory findings in patient posture/position?

Chest and abdominal retractions (using accessory muscles) Pursed lips Tripoding

What are some aspects of visual inspection during respiratory PE?

Rate, rhythm, depth, effort Color Inspect neck, hands, shape of chest, how chest moves

What are some accessory muscles that you might see in the cervical region being used in a patient struggling to breathe?

Trapezius Scalenes SCM

Accessory muscle use is a sign of respiratory distress. In what type of conditions might you see accessory muscle use for breathing?

Asthma COPD Airway obstruction Viral illness (RSV)

_________ is a sign of hypoxia and may be seen at the nail beds or in perioral region

Cyanosis

_________ ________ can indicate a significant respiratory issue due to pneumothorax (tension and non-tension), pleural effusion, atelectasis, or mass

Tracheal deviation

What change in the fingers might be seen in congenital heart disease, interstitial lung disease, bronchiectasis, pulmonary fibrosis, cystic fibrosis, lung abscess, malignancy (lung cancer), or IBD?

Clubbing

Chest deformity characterized by depression in the lower portion of the sternum, causing compression of the heart and great vessels (may be associated with heart murmur)

Pectus excavatum

Chest deformity characterized by increased AP diameter that is considered normal in infancy; is often accompanied by aging and COPD

Barrel chest

Chest deformity characterized by anteriorly displaced sternum, increasing the AP diameter. Costal cartilages adjacent to the protruding sternum are depressed

Pectus carinatum

Chest deformity characterized by multiple rib fractures may result in paradoxical movements of the thorax (as descent of diaphragm decreases intrathoracic pressure, on inspiration the injured area moves inward and on expiration moves outward)

Traumatic flail chest

Chest deformity characterized by abnormal spinal curvatures and vertebral rotation deforms the chest; distortion of underlying lungs may take interpretation of lung findings difficult

Thoracic kyphoscoliosis

Patient presents complaining with daily productive cough for 3 months. They state that they have had similar illnesses occur over the past 2 years. On physical exam they are overweight, cyanotic, with peripheral edema, rhonchi, and wheezing. Labs reveal elevated hemoglobin. What is your likely diagnosis?

Chronic bronchitis

______ is characterized by permanent enlargement and destruction of air spaces distal to terminal bronchioles resulting in severe dyspnea, with x-ray often revealing hyperinflation and flattened diaphragm

Emphysema

What are the elements of an OSE for respiratory complaints

Rib motion - inahlation or exhalation dysfunction Thoracic somatic dysfunction (is thoracic expansion symmetrical?)

What is tactile fremitus?

Palpable vibrations through chesst wall as patient says "99" or "1-1-1"

What conditions might be indicated if tactile fremitus is decreased or absent?

COPD Pleural changes: effusions, fibrosis, air (pneumothorax), infiltrating tumor

What condition might be indicated if tactile fremitus is increased

Pneumonia (consolidation)

Describe a respiratory percussion exam

Nondominant hand on chest/back, dominant hand used to strike this hand Have patient cross hands in front of chest, grasping opposite shoulder with each hand (pulls scapulae laterally) Work down "alley" between scapula and vertebral column so that you are not percussing over bone Strike distal IP joint of your middle finger; impact should be crisp All other fingers of non dominant hand should not be resting on patient (to minimize dampening of percussion notes) 2 or 3 sharp taps per spot, compare 2 sides in a ladder pattern

Describe a flat percussion note based on: Relative intensity Relative pitch Relative duration

Soft High pitch Short duration

Describe a dull percussion note based on: Relative intensity Relative pitch Relative duration

Medium intensity Medium pitch Medium duration

Describe a resonant percussion note based on: Relative intensity Relative pitch Relative duration

Loud Low pitch Long duration

Describe a hyperresonant percussion note based on: Relative intensity Relative pitch Relative duration

Very loud Lower pitch Longer duration

Describe a tympanitic percussion note based on: Relative intensity Relative pitch Relative duration

Loud High pitch Longer duration

Which of the following percussion notes would you expect to hear by tapping on the thigh? ``` A. Flat B. Dull C. Resonant D. Hyperresonant E. Tympanitic ```

A. Flat

Which of the following percussion notes would you expect to hear by tapping on a gastric air bubble or puffed-out cheek? ``` A. Flat B. Dull C. Resonant D. Hyperresonant E. Tympanitic ```

E. Tympanitic

Which of the following percussion notes would you expect to hear by tapping on the liver? ``` A. Flat B. Dull C. Resonant D. Hyperresonant E. Tympanitic ```

B. Dull

Which of the following percussion notes would you expect to hear by tapping on a healthy lung? ``` A. Flat B. Dull C. Resonant D. Hyperresonant E. Tympanitic ```

C. Resonant

Which of the following percussion notes would you not expect to find anywhere? ``` A. Flat B. Dull C. Resonant D. Hyperresonant E. Tympanitic ```

D. Hyperresonant

What are some pathologic examples of percussion sounds?

Dullness replaces resonance Generalized hyperresonance or unilateral hyperresonance

Describe diaphragmatic excursion test

Patient exhales completely and holds it Percuss for level of diaphragm and mark with a pen Patient breaths normally for a few breaths then inhales completely and holds it Percuss again for level of diaphragm and mark with a pen The distance between the 2 is the diaphragmatic excursion

What is a normal diaphragmatic excursion

3-5.5 cm

What is an abnormal result for diaphragmatic excursion and what would it indicate/

Asymmetry with one side higher than the other - indicates pleural effusion or high diaphragm secondary to atelectasis or phrenic n. paralysis

At a minimum, how many spaces must you auscultate the lungs?

5 spots - at least once at each lobe

Which part of the stethoscope should be used for lung auscultation - the diaphragm or bell?

Diaphragm

Which lung sound is coarse low-pitched and may clear with cough?

Rhonchi

Which lung sound is whistling, high pitched bronchus?

Wheeze

Which lung sound is coarse, loud, and heard with consolidation?

Bronchial

Which lung sound is scratchy and high pitched?

Rub

Which lung sound is fine crackling and high pitched?

Crackles

Which lung sound is high pitched and breezy?

Vesicular

_______ is an abnormal vocal resonance finding characterized by spoken words getting louder

Bronchophony

_______ is an abnormal vocal resonance finding characterized by whispered words getting louder and clearer

Whispered pectoriloquy

_______ is an abnormal vocal resonance finding characterized by "ee" sound made by patient sounding like an "A" which is nasal and localized

Egophony

What are normal findings for vocal resonance?

Words are muffled and indistince to auscultation Whispered words are faint and indistinct, if heard at all When patient says "ee" you hear a muffled long E on auscultation

You are reading another physician's soap note and their respiratory exam for your patient reads: Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular, no rales, wheezes, or rhonchi. Diaphragm descends 4 cm bilaterally. Is this normal?

Yes

What is the A-I mnemonic for CXR interpretation?

``` Adequate/assessment of quality Airwa Bones + soft tissues Cardiac size Diaphragms Fields and fissures Foreign body Great vessels Gastric bubble Hilar masses Impression (overall findings) ```