Repsiratory- Physical Exam- Neck, Face And Thorax

Question 1

Face- name and describe pathophysiology of diseases

Answer 1

• Superior vena cava obstruction causes dusky, generalised swelling of the head, neck and face with subconjunctival oedema (looking like a tear inside the lower lid,but not mobile)
• This usually indicates tumour invasion of the upper mediastinum.
• Tumours at the root of the neck may disrupt the sympathetic nerves to the eye, which run from the upper thoracic spinal segments via ganglia in the neck to join the carotid artery sheath.
• This causes unilateral ptosis, hypohydrosis, pupillary constriction and apparent enophthalmos (Horner’s syndrome)

Question 2

Face exam

Answer 2

• Check the conjunctiva of one eye for pallor of anaemia.
• Check the colour of the tongue for the blue-grey discolouration of central cyanosis
• Check for ptosis (drooping of upper eye lid) and pupil asymmetry.
• Check the jaw and mouth for abnormalities, which may obstruct the airway (e.g.,macroglossia, small mandible, large tonsils).
• Central cyanosis only becomes visible when enough deoxy-haemoglobin is circulating. This makes cyanosis harder to detectin anaemia compared to polycythaemia at the same level of tissue hypoxia.
• Methaemoglobinaemia may also cause cyanosis,which persists despite oxygen treatment.

Question 3

Neck- pathophysiology that can occur

Answer 3

• Jugular venous pressure (JVP) is raised in many patients with pulmonary hypertension and may be acutely raised in those with tension pneumothorax or large pulmonary embolism.
• In superiorvena cava obstruction, the JVP may be raised above the angle of the jaw, making pulsatility invisible.
• In those who are using the sternocleidomastoids as accessory muscles, it is frequently impossible to see the JVP, as the internal jugular vein lies deep in the active muscle

Question 4

Neck exam

Answer 4

• Support the patient’s head with a pillow to facilitate relaxation of the sternocleidomastoid muscles.
  -Using a tangential light source, examine the jugular venous pressure.
• Check for tracheal deviation by gently advancing a single finger resting in the sternal notch in the midline. The trachea should be equidistant from the two sternomastoidheads.
• Check the cricosternal distance (the vertical distance between the sternal notch and the cricoid cartilage,the first prominent ridge felt above the tracheal rings).
• In health, three average fingers fit between the sternal notch and the cricoid.
• Examine the cervical lymph nodes from behind with the patient sitting forward.

Question 5

Neck exam meaning in respiratory patients

Answer 5

• Tracheal deviation away from the affected side is seen acutely in tension pneumothorax.
• Chronic tracheal deviation towards the affected side occurs with loss of lung volume in upper lobe fibrotic scarring or collapse and following lobectomy or pneumonectomy.
• Reduction in cricosternal distance is a sign of hyperinflation and reflects upward displacement of the sternum
• Upward movement of the sturnum and downward movement of the trachea on inspiration are normal but may become more obvious with forceful inspiratory efforts in respiratory disease.
• Rarely, systolic downward movement of the trachea is felt in patients with aortic aneurysm (sometimes called ‘tracheal tug’).
• Palpable cervical lymph nodes may be a sign of metastatic disease from lung cancer.
• They are also a common presentation of lymph node tuberculosis and lymphoma.