Medicine Bedside: Respiratory System Examination Flashcards
General examination
- Respiratory distress
- Tachypnoea - Oxygen supplementation / accessories e.g. sputum mug, inhalers, spacers
- FiO2
- SaO2
- Intercostal drainage tube
- Noninvasive ventilation (NIV) vs Invasive mechanical ventilation (IMV) - Body weight / habitus
- cachexia
- obesity
- kyphoscoliosis
- Cushingoid features - Breathing pattern
- Breathing rate
- Accessory muscles of breathing
- Any difference when patient exerts
- Audible breathing noise
- Stridor
—> during inspiratory phase
—> localised obstruction in larynx, trachea, large bronchi
General inspection
- Pallor
- Horner syndrome: lung tumour compress Right lung apex
—> Pancoast tumor T1 syndrome
—> SVC obstruction: swelling - Central cyanosis
- apparent >5 gh/100ml of reduced Hb
- indicate desaturation of arterial blood
- frank central cyanosis indicate PaO2 <6 kPa
- lips not accurate due to hyperpigmentation - Engorged veins due to SVCO
- Clubbing
- Grade 1: floating sensation / fluctuation / softening of nail bed
- Grade 2: loss of angle between proximal nail fold (nailbed) and nail plate (nail) ∵ ↑ SC tissue
- Grade 3: increased longitudinal curvature of nail
- Grade 4: drumstick appear of fingertips
—> idiopathic / familial
—> cyanotic congenital heart disease
—> infective endocarditis
—> lung cancer
—> chronic suppurative lung conditions (e.g. bronchiectasis, empyema)
—> liver conditions
—> GI (Crohn’s, UC) - Ankle pitting edema
- sacral edema - Cervical lymphadenopathy
- submental
- submandibular
- preauricular
- postauricular
- upper / mid / lower cervical
- supraclavicular
- posterior cervical
Inspection of respiratory system
Front + Back
- Deformity
- Scar
- thoracotomy scar - Pigment / Dilated veins (SVC obstruction)
- Lumps and bumps
- Abnormal physical sign e.g. axillary, lateral chest
- flattening / over-inflation assessed from side - Deep breath
- deformity
- asymmetry of chest expansion (upper, middle, lower zone) - Cough
- strong, non-productive, explosive, sharp
- Rattling sound: bronchial secretions
- Bovine sound: lack of explosive onset suggests vocal cord paralysis
- Muffled wheezing cough: always obstruction e.g. chronic bronchitis - JVP
- Cor pulmonale
Palpation
Start with normal side
- Tracheal position
- patients head look forward, relaxed
- tracheal deviation
- paratracheal gutter - Apex beat
- lowest and most lateral point
—> tell whether mediastinum is displaced
—> dextrocardia, pneumothorax, emphysema - Chest expansion
- movement of thumb for middle / lower zone
- lifting of hand for upper zone
(- normal chest expansion >=5cm (CL Lai)) - Tactile fremitus
Percussion
Start with normal side
Apex —> Lower lung
- avoid cardio dullness by moving laterally
- avoid liver dullness
- along mid-clavicular line
Feel + Listen
Hyper-resonance: COPD, pneumothorax
Resonance: Normal
Dull: Pneumonia, Tumour, Lung collapse
Stony dull: Pleural effusion
- Liver dullness: only slight dullness over resonant lung —> if reduced dullness + increased resonance —> hyperinflation
Auscultation
Breath sounds arise from turbulence in larynx, central (upper, larger) airways and heard over chest wall
- Breath sound —> Distinguish whether additional sounds are in Inspiratory / Expiratory phase
- Normal / Vesicular breath sounds: faint, low-pitched rushing sound with a gentle beginning and end during inspiration, generated by air sacs
- **Bronchial breath sounds:
—> heard over **consolidated areas
—> high frequency “hiss”, loud, hollow, blowing quality in expiratory phase, longer than inspiratory phase —> Sternal area - Added sounds
Wheeze / Rhonchi:
- Wheeze (mainly Expiration): usually high pitch ∵ narrower airways during expiration, does not necessarily parallel degree of ***obstruction
- Rhonchi: low pitch wheeze
Crackles:
- Fine inspiratory crackles (Inspiration / Expiration): Fibrosis, Pulmonary edema
- Coarse crepitations: Pneumonia, Bronchiectasis, Chronic bronchitis, Pulmonary edema
- **Early inspiratory crackles: Airway obstruction but not pulmonary edema
- **Pan / Late inspiratory crackles: Fibrosis, Bronchiectasis, Pulmonary edema
- Rales: low pitch crackles
- Crepitations: high pitch crackles
Pleural rub:
- Pleural rub: interrupted dry scuffing sound, often localised, ***roughening of pleural surface
- Vocal fremitus / resonance
- whisper
- normal: blurred
- ↑ / clear: consolidation (∵ solid conduct sound better)
- ↓: pleural effusion
Reduced (?Increased) tactile / vocal fremitus —> Consolidation / Collapse
From the back
Inspection
Palpation
- Chest expansion (Start from apex)
- Tactile fremitus
Percussion
- tap between scapula medial border and spine
- downwards and laterally
Auscultation
- Breath sound
- Vocal resonance
Sputum inspection
- Truly clear sputum: unusual in city dwellers
- Greyish fragments usually present in true mucoid sputum
- Asthma: Very tenacious sputum
- Purulent (creamy, yellow) reflects bronchial inflammation usually caused by infection
- Brown sputum: altered blood for intra-alveolar haemorrhage
Signs of localised lung disease
- Consolidation
- Pulmonary fibrosis
- Collapse
- Pleural effusion
- Pneumothorax
- Pleural thickening
Consolidation
- ↓ Chest wall movement
- Dull
- ***Bronchial breath sounds
- ***↑ Vocal resonance
- Pan-inspiratory / Late inspiratory crackles
Pulmonary fibrosis
Difficult to distinguish from Consolidation, Collapse (↓ Breath sounds)
- Tracheal deviation in upper lobe fibrosis (may have)
- Flattened + ↓ Chest wall movement
- Dull
- ***Bronchial breath sounds
- Crackles
Collapse
- ↓ Chest wall movement
- Flattening of chest wall
- ***Displacement of mediastinum (towards side of collapse)
- ***Tracheal deviation
- ***↓ Breath sounds
- Consolidation (sometimes)
Pleural effusion
- Mediastinum shifting away (space-occupying effect)
- ↓ Chest wall movement
- ***Stony dull (∵ Fluid)
- ↓ Breath sound
- ↓ Vocal resonance
Large / Tension pneumothorax
~ Pleural effusion except Hyper-resonance
- No signs at all
- Mediastinum shift
- ***Hyper-resonance (∵ Air)
- ↓ Breath sounds
- ↓ Vocal resonance
- Cyanosis (∵ respiratory failure)
