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resp exam Flashcards

1
Q

introduction

A

wash hands - vocalise this in exam

introduce yourself

confirm DOB and name

explain exam

gain consent

expose the pts chest - chaperone

position at 45degrees

ask pain

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2
Q

general inspection

A

look at age

comfortable/in distress

cyanosis

coughing

adjuncts

chest wall - scars, asymettry or abnormalities, cachexia

auditory at bedside - wheezy, stridor

stable, alert, breathless

medicine

nebulisors

oxygen

inhalers

sputum pots

cigarettes

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3
Q

significance of age

A

elderly - chronic disease/malignancy (COPD/interstial lung disease)

young - asthma/CF

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4
Q

what are you looking for when you see if a pt is in comfortable/in distress

A

accessory muscles

nasal flare

tripod position - clasp hand around thighs to aid breathing

pursed lips - COPD, pul fibrosis = keep more distant bronchioles open by keeping lung pressure high in severe airway obstruction/ephysema = easier breathing

can pt speak in full sentences, is speech normal (obstruction, recurrent laryngeal nerve palsy)

hoarse voice - malignancy/acid reflux

prolongued expiratory phase - asthma/copd

clicks - bronchiectasis

gurgling - airway secretions

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5
Q

use of accessory muscles

A

COPD

pleural effusion

pneumothorax

severe asthma

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6
Q

describe cyanosis

A

blue tinge around mouth and fingers

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7
Q

significance of cough

A

productive cough = infection/bronchiectasis/COPD/CF in youth

dry - asthma/ILD/malignancy

bovine

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8
Q

what are adjuncts

A

is pt on oxygen (ILD/COPD)

inhalers present/nebulisers - asthma/COPD

sputum pots - pneumonia/bronchiectasis

monitoring devices

medicine

mobility aids

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9
Q

barrel chest

A

suggest COPD

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10
Q

cachexia

A

suggests malignacy if old /CF if young

emphysema

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11
Q

what is stridor

A

inspiratory noise caused by obstruction eg mediastinal masses, bronchial carcinoma, retrosternal thyroid

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12
Q

suggestion from lateral thoracotomy

A

pneumonectomy - lung removed eg malignancy

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13
Q

examination of the hands

A

tar stains - smoking

clubbing

peripheral cyanosis - sat <85%

joint swelling

skin change

tremor

thenar/hypothenar muscle wasting

temperature

cap refill

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14
Q

what is tar staining

A

brown stain around nails

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15
Q

causes and appearance of clubbing

A

bronchiectasis/malignancy/interstitial lung disease/idiopathic pulmonary fibrosis/CF/sarcoidosis/TB

nails are white/grey

shamrocks window - if present = no clubbing

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16
Q

significance of joint swellings

A

rheumatoid arthritus associated with pleural effusion +/- pulmonary fibrosis

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17
Q

significance of skin changes

A

thin skin = long term steroid use

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18
Q

significance of tremor

A

asterixis (CO2 retention in type 2 resp failure) - outstretched hand, wait 30sec

beta agonsit fine tremor - out stretch arms - in asthma/COPD

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19
Q

significance of muscle wasting

A

pancoast tumour press on SNS = wastage

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20
Q

significance of temp change

A

reduced temp = poor perfusion

sweaty, warm, clammy = CO2 retention

21
Q

examination of arms

A

pulse - reg/irreg and rate - tachy might suggest hypoxia in severe asthma or COPD, PE, infection. Bounding = CO2 retention

resp rate

BP

22
Q

sig of RR

A

12-19 normal

>20 tachypnoea - fever, severe lung disease, hyperventilation

>30 worrying - pneumonia or anxiety/panic attack

bradypnoea occurs in opiod toxicity = resp depression, sedation

23
Q

significance of BP

A

need for CURB-65 score

in pneumothorax hypotension might indicate a tension pneumothorax

24
Q

examination of neck

A

carotid pulse - is it bounding

JVP raised in fluid overload/pul hypertension - use hepatojugular reflex test - increased in cor pulmonale

assess trachea deviation - central in health

lymph nodes - anterior and posterior triangles, supraclavicular region, axillary region

tracheal tug

notch-cricoid distance (<3 fingers = lungs hyperinflation)

25
what does trachea deviation suggest
away from tension pneumothorax/large pleural effusion/haemothorax trachea deviates towards lobar collapse/pneumonectomy
26
what does lymphadenopathy suggest
infective/malignant pathology pneumonia TB sarcoidosis
27
examination of head
conjunctival pallor - anaemia or chronic disease central cyanosis - blue tinge of lips and under tongue mucus membranes - see if dehydrated pursed lips ptosis, myosis, anhidrosis = horner's syndrome via pancoasts tumour (sometimes lower eyelid is elevated) are they dry/fluid overloaded cushingoid (steroid use) plethoric - CO2 retention telangiectasia/microstomia (systemic sclerosis) butterfly rash (SLE) lupus pernio (sarcoid) lupus vulgaris (TB)
28
what do you look for on inspection of the chest
scars skin changes asymettry deformities radiotherapy tattoos chest wall movements breathing
29
what do different scars indicate
small mid-axillary scars = chest drains for haemothorax or pneumothorax horizontal postero-lateral scars - thoracotomy eg from lobectomy/pneumonectomy pacemakers
30
summarise skin changes
may indicate recent or previous radiotherapy - erthyma/thickened skin
31
what does asymettry indicate
majory surgery pneumonectomy - usually for cancer - there is reduced expansion on the side of the scar thoracoplasty - rib removed to relax rib cage, previously used to treat TB
32
summarise chest deformities
barrel chest = COPD or emphysema pectus excavatum = sunken in chest eg in marfans pectus carinatum = pointy chest eg i childhood asthma or rickets thoracic kyphosis/scoliosis - can impact breathing, restricts chest movements posture - ankylosing spondylitis (cause of pul fibrosis) = round back and head stooped forward
33
describe chest wall movements
mainly upwards - emphysema asymettrical - fibrosis, collapsed lung, pneumonectomy, pleural effusion, pneumothorax
34
describe breathing
in-drawing of intercostal muscles (generalised is hyperinflation, localised is bronchial obstruction) powerful expirations (asthma, chronic bronchitis) hyperextended chest (COPD)
35
palpation of chest
supramammary and inframammary chest expansion * when exhale put hands around the chest * ask pt to take deep breath * look at thumbs move from midline - look for unilateral reduction in expansion cardiac * feel for cardiac apex (might not be felt in hyperexpansion of lungs/obesity) * RV heave and palpable P2 - pulmonary hypertensin
36
what does asymettrical chest expansion indicate
pneumonectomy - reduced expansion on that side lobar collapse pneumonia effusion pneumothorax
37
abnormalities in apex beat palpation
displaced apex in pneumonectomy/collapse towards the abnormality away from abnormality in pleural effusion or pneumothorax parasternal heave - RVH secondary to COPD/PE
38
percussion technique
non-dominant hand on chest wall, middle finger over the lung space dominant hand middle finger strikes middle phalanx of non-dominant middle finger firm and brisk strikes generates a resonant sound - normal percuss apex of lungs first, then first rib, then 3 places on either side is sufficient down to axilla
39
What could be found by percussion of apex
pancoasts tumour
40
type of percussion note
resonant - normal dullness - suggests increased tissue density - consildation, fluid, tumour, collapse stony dullness - pleural effusion, its a more metallic sound hyper-resonance - the opposite of dullness - suggestive of decreased tissue density, ie increased air space - pneumothorax, COPD, emphysema, bronchitis
41
what are you assessing in auscultation
quality volume added sounds vocal resonance listen for loud P2 ie loud second hert sound over pul area - pul hypertension
42
quality - auscultation
vesicular breath sounds = normal bronchial (harsh, louder breathing) is abnormal in periphery (listen for trachea over normal bronchial breathing and compare) = consolidation in pneumonia
43
volume in auscultation
quiet v loud breath sounds quiet = reduced air entry - collapse, consolidation, effusion, lung removed, emphysema, pneumothorax
44
added sounds on auscultation
wheeze = asthma/copd coarse crackles = pneumonia, bronchiectasis, fluid overload, consolidation fine crackles = pul fibrosis (if severe can be coarse crackles so need to look at the whole picture) fine inspiritory crackles at bases - pul odema pleural rub = pulmonary infarction, pneumonia, pleural malignancy
45
vocal resonance
stethoscope on skin - say 99 reduced with fluid - effusion, pneumothorax increased over increased density - tumour, pneumonia, lobar collapse, consolidation
46
examination of the posterior thorax
inspect, palpate, percuss, auscultate get pt to lean forward and cross arms - moves scapular out the way look for sacral oedema - pt lying down a lot, fluid oeverload, congestive HF tactile fremitus and vocal fremitus
47
examine the legs
pitting oedema - fluid overload in cor pulmonale - press and hold the release erythema nodosum - sarcoidosis/IBD/TB check for DVT - tight tender calf, unilateral - squeeze calf muscle ask if painful, see if swollen/red
48
to complete...
SPOTX: sputum, peak flow, O2 sat, temperature, x-ray full CVS exam blood tests CT spirometry for obstructive/restrictive lung disease
49
auscultation technique
pt breathes in and out deeply compare sides starting in the supraclavicular area and ending in axillae

Yr 3 examinations (10 decks)

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