Respiratory Flashcards
1
Q
Describe the introduction to examination
A
- Introduce yourself and ask for permission to examine the patient
- Ensure patient is in a warm environment
- Expose the chest adequately, preserving dignitiy
- General inspection from the foot of the bed
- Look for pigeon chest, pectus, excavatum, scoliosis, kyphosis
- Observe for distress, use of accessory muscles, any chest asymmetry or scars and a barrel chest
- Look around the bed for peak flow meter, inhalers, nebuliser and sputum pot
2
Q
Describe inspection of the hands
A
- Flapping tremor of carbon dioxide retention for at least 30 seconds (common in salbutimol)
- Simultaneously assess pulse and respiratory rate
- Cyanosis (hands cold or warm)
- Clubbing
Look at the palm of the hand for…
- Tar staining
- Small muscle wasting
- Capillary refill
- Dilated veins
3
Q
Describe examination of the trachea
A
- Determine whether the trachea is deviated or central
- Find the cricoid cartilage to determine the crico-sternal distance (normal 2cm - 2 finger lengths)
- For anatomy of the cricosternal distance see the next slide
- The cricosternal distance is reduced in patients with a chronically hyperexpanded chest wall (barrel chest)
- This is called tracheal tug
- Examine for cervical and axillary lymphadenopathy from behind
- Observe jugular venous pressure
4
Q
Why is the trachea deviated?
A
- If there is something pushing the mediastinum away (tension pneumothorax with air inside one lung)
- If there is something pulling the mediastinum towards one side (collapse and consolidation caused by endobronchial obstruction)
5
Q
Describe the surface anatomy of the left and right lungs
A
Superior Lobe (RHS):
- Apex at 1inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down the right sternal border (RSB) to R4, follows R4 round to T3/4
- Lateral to spine to apex
Superior Lobe (LHS):
- Apex at 1inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down the right sternal border (RSB) to R6 (Deviation at R4-6 2-3cm)
- Round to T3/4
- Lateral to spine to apex
Middle Lobe (RHS):
- RSB R4
- Follows RSB to R6
- Follows R6 to MCL
- Up to R4 MAL
Inferior Lobe (RHS):
- R6 MCL to R4 MAL
- To T3/4
- Down lateral to spine to T10
- Round to R6 MCL
Inferior lobe (LHS)
- 6th rib MCL, 8th rib MAL, 10th rib posteriorly to spine
- Superior border of the inferior lobe follows 6th rib MCL to 4th rib MAL to 3/4th vertebra
6
Q
Describe examination of expansion and symmetry of the chest
A
- Place your hands on the anterior chest wall (also performed on posterior)
- Put thumbs together in the midline
- Ask the patient to breath deeply
- Observe the movement of your thumbs upwards over the sternum and outwards from the lower rib cage
- Less expansion in pulmonary fibrosis
- Then palpate for tactile vocal fremitus
7
Q
How is tactile vocal fremitus assessed?
A
- Place hand in ICS down the spaces and ask the patient to say 99
- Where theres increased tactile vocal fremitus there is a sign of consolidation
8
Q
Describe percussion of the chest
A
- Assess dullness (dullness caused by fluid or consolidation)
- Patient lying 45 degrees, when posterior arms crossed to each shoulder
Superior lobe
- Anterior: Clavicle (medial third), 2nd ICS MCL, 4th ICS MCL (LHS only)
- Posterior: 1st ICS medial sternal border (MSB), 3rd ICS MSB
- Axilla
Middle lobe
- Anterior: 4th ICS MCL RHS, 6th ICSL MAL RHS (Useful in F)
Inferior Lobe
- Anterior: 6th ICS MCL, 6th ICS MAL
- Posterior: 7th ICS Scapular line
9
Q
Describe auscultation of the lungs
A
- Ask the patient to take deep breaths through the open mouth
- Can assess vocal fremitus
Superior lobe
- Anterior: Clavicle (medial third), 2nd ICS MCL, 4th ICS MCL (LHS only)
- Posterior: 1st ICS medial sternal border (MSB), 3rd ICS MSB
Middle lobe
- Anterior: 4th ICS MCL RHS, 6th ICSL MAL RHS (Useful in F)
Inferior Lobe
- Anterior: 6th ICS MCL, 6th ICS MAL
- Posterior: 7th ICS Scapular line
Listen for added sounds (wheeze, crackles, plural rub)
10
Q
Describe posterior chest wall examination
A
- Ask patient to sit forward
- Examine cervical and supraclavicular lymph nodes at first
- Inspect for kyphosis/scoliosis
- Palpation, percussion and auscultation
- Assess chest wall expansion, observing excursion of your thumbs from the posterior wall
- Repeat tactile vocal fremitus
- Look for sacral oedema and peripheral oedema
11
Q
How is conscolidation confirmed?
A
- Ask the patient to whisper one-two-three quietly under the breath
- Listen where you think there is consolidation
- If the lung is normal you wont hear anything, if there is consolidation you will hear clearly
12
Q
Describe the process of taking a peak flow measurement
A
- Ask patient to take a really deep breath
- Make sure the patient does not have his finger on the sliding marker
- Make a good seal with lips around the meter
- Blow as fast as possible
- Assess best of three (units in litres per minute)
13
Q
What is whipppe?
A
Wash hands Introduce Identify patient Permission Pain? Position (45 degree) Expose
14
Q
List what you look for in general inspection of the patient
A
- Colour change
- Shortness of breath (accessory muscles, tripod (sitting) position, dyspnoea, pursed lip breathing)
- Cachexia
- Respiratory rate
- Scars
- Added sounds (cough, stridor, gurgling, wheeze)
15
Q
What do you look for around the bedside?
A
- Nebulisers or inhalers
- Cigarettes
- Sputum pot
- Oxygen mask
