Respiratory Flashcards
Resp introduction?
Wash hands and PPE, introduce, confirm patient data, explain and consent, bed angle to 45 degrees. expose patients chest and ask if they’re in any pain
What general signs are you looking for?
- Age (for younger = asthma/CF. older = COPD or malignancy)
- Cyanosis (peripheral vasoconstriction due to hypovolaemia)
- SOB
- Cough
- wheeze
- Stridor
- Pallor (underlying anaemia)
- oedema (pedal or ascites both associated with right ventricular failure) Pulmonary oedema is left ventricular failure
- cachexia (malignancy or COPD)
What features of SOB should you be looking for?
Nasal flaring, pursed lips, use of accessory muscles and tripod position
What paraphernalia should you look for?
Oxygen delivery device and nebuliser/inhalers. Sputum pot, mobility aids and vapes. Vital signs, fluid balance and other medications
What general features of hands?
Colour for peripheral cyanosis. Tar staining and skin changes (from long term steroid use for asthma/copd). joint swelling or deformity (rhemuatoid arthritis). clubbing
Features of clubbing examination and cause?
Looking for presence of Schamrochs window. Causes include lung cancer, interstitial lung disease, cystic fibrosis and bronchiectasis.
What tremor types?
Fine tremor (use of beta-2 agonist e.g. salbutamol) Asterixis (flapping tremor). this is causd by CO2 retention in T2RF
Asterixis Test and other causes?
Cock hands back at wrist with fingers apart and hold position for 30 seconds. Causes = uraemia and hepatic encephalopathy.
What are you palpating for in hands?
Temperature, Heart rate and respiratory rate.
Features of temperature?
Work distal to proximal. Cool hands for poor peripheral perfusion and warm and sweaty for CO2 retention
What are the pulse abnormalities?
Bounding Pulse (T2RF) and pulsus paradoxus (wave volume decreases in inspiration. Late sign of cardiac tamponade, severe acute asthma and severe COPD)
Resp Rate abnormalities?
Healthy = 12-20. <12 = bradypnoea (opiate overdoes) and tachypnoea (acute asthma)
How to measure Jugular Venous Pressure?
Bed at 45 with patient looking left. Look at IJV between medial end of clavicle and er lobe under medial aspect of SCM. Double wave pulsation to differentiate against single of carotid artery. Measure highest point of pulse to sternal angle. No greater than 3cm in normal people
Also check the hepatojugular reflux test
Causes of raised JVP?
This is venous hypertension caused by pulonary hypertension (right side heart failure from COPD). other cardio causes include congestive heart failure, tricuspid regurgitation and constrictive pericarditis
What facial features are we inspecting for?
Plethoric Complication (red faced appearance associated with polycythaemia e.g. COPD, and T2RF.
Eyes: Conjunctival Pallor (anaemia) and ptosis, miosis and enopthalmos (from horners syndrome. Can be lung cancer e.g. pancoast tumour)
Mouth : central cyanosis and oral candidiasis (from steroid inhaler use)
Chest inspection Scars?
Median sternotomy = CABG and cardiac valve replacement
axillary thoracotomy = Insertion of chest drain
Posterolateral thoracotomy = (scapula and mid-spinal line). used for lobectomy, pneuonectomy and oesaphageal surgery
Infraclavicular scar = pacemaker insertion
What radiotherapy associated skin changes may you see?
Xerosis, hyperkeratosis, scale, depigmentation and telangiectasia
What chest wall deformities may be present?
Pecus carnitus or excavatum. Asymmetry (pneumonectomy or thoracoplasty (TB)
Hyperexpansion (barrel chest from COPD
Airway Test?
Assess tracheal position and crciosternal distance. This distance should be inferior border of cricoid cartilage to the suprasternal notch. Shoould be 3-4 fingers
Causes of tracheal deviation and abnormal cricosternal distance?
Trachea deviates away from tension pneumothorax and large pleural effusion and towards lobar collapse and pneumonectomy.
<3 finger distance = lung hyperinflation (e.g. asthma and COPD)
What Chest features for palpation?
Palpate apex beat in 5th ICS at MCL.
Assess chest expansion.
Resp causes of displaced apex beat?
Right ventricular hypertrophy from pulmonary hypertension, COPD and interstitial lung disease. large pleural effusion and tension pneumothorax
Causes of reduced chest expansion?
Symmetrical = pulmonary fibrosis Asymmetrical = pneumotroax, pleural effusion andf pneumonia
What areas for percussion?
Supraclavicular for lung apices, infraclavicular, chest wall 3-4 locations bilaterally and axilla
What percussion notes are there>
Resonant, dull (density from lobar collapse, consolidation and tumour), stony dullness (pleural effusion). Hyper-resonance (pneumothorax)
How to test for tactile vocal fremitus?
Ask the patient to repeatedly say 99 and palpate areas of the chest.Increased vibration = consolidation, tumour, lobar collapse. Decreased = pleural effusion, pneumothorax
Different quality of breath sounds?
Vesicular = normal Bronchial = harsh sounding with pause between inspiration and expiration.
List the lymph nodes that need to be palpated?
Submental, submandibular, pre-auricular, post-auricular, superficial cervical deep cervical, posterior cervical, supraclavicular and in particualr Virchows nodes
What is Virchows node associated with?
Upper GI malignancy
What are resp causes of lymphadenopathy?
Lung cancer with metastases, TB and sarcoidosis
What are final exam steps?
Check for sacral and pedal oedema (congestive heart failure). Assess the calves for DVT and signs of saphenous vein harvesting. Check for erytherma nodosum for sarcoidosis
How to complete the exam>
Thank patient and ask if they need any help putting clothes back on. Dispsoe of PPE, Summarise.
What further assessments may you do?
Check O2 sat and other vitals, sputum sample, peak flow assessment, chest xray, ABG and full cardio exam if indication
