Respiratory exam Flashcards
What are you looking for in general inspection in a resp exam?
Bed area: oxygen devices, sputum pot, inhalers
Patient: colour (cyanosis?, pallor?), breathing, build (obesity? cachexic?), discomfort
What are you looking for in the hands in a resp exam?
Cyanosis (hypoxaemia)
Tar staining (smoking)
Joint swelling/deformity (resp manifestations of RA)
Finger clubbing (chronic lung disease)
Fine tremor (use of beta-2 agonist)
Flapping asterixis (CO2 retention)
Temperature (cold - poor perfusion, excessively warm - CO2 retention)
Radial pulse (bounding pulse? pulsus paradox?)
* count respiratory rate while feeling pulse
How do you asses JVP?
- The patient should be lay at 45 degrees with their head turned to the left
- Look between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid
- The JVP has a double wave pulsation and is not palpable (which helps distinguish it from the carotid artery)
- Measure the JVP by assessing the vertical distance between the top of the sternal angle and the top point of the JVP
- should be less than 3cm, raised = cor pulmonale/pulmonary hypertension
What are you looking for in the face in a resp exam?
Red-faced: CO2 retention
Facial swelling: SVC obstruction
Conjunctival pallor: anaemia
Ptosis, miosis: Horner’s syndrome due to lung cancer
Central cyanosis: hypoxaemia
Angular stomatitis: anaemia
What are you looking for in inspection of the chest in a resp exam?
Scars
Muscle wasting
Chest/abdominal/accessory muscle breathing
Barrel chest: hyperinflation
Pectus excavatum (caved-in) or carinatum (protrusion)
How do you asses the trachea as part of the resp exam?
- Asses the position of the trachea, which should be central
- deviation suggests pneumothorax/effusion (away) or collapse/fibrosis/pneumonectomy (towards)
- Asses cricosternal distance
- should be 3-4 fingers, less suggests hyperinflation (COPD, asthma)
How do you palpate the chest in a resp exam?
- Palpate apex beat: deviation = right ventricular hypertrophy, large effusion/pneumothorax
- Asses chest expansion (wrap fingers around the chest and observe the movement of the thumbs)
- should move up and out when inspiring and down and in when expiring symmetrically
- reduced chest expansion = fibrosis (symmetrical), or pneumothorax/pneumonia/effusion (asymmetrical)
- Asses tactile vocal fremitus (ask the patient to say 99 and palpate the chest on both sides with the side of your hand, covering all major regions)
- increased vibration = tissue density (consolidation, tumour, collapse)
- decreased vibration = fluid/air (effusion/pneumothorax)
How do you percuss the chest in a resp exam?
Starting at the apices and percuss from side to side, ensuring every lobe is covered, listening for:
- resonance = normal
- dullness = increased tissue density (consolidation, tumour, collapse)
- stony dullness = pleural effusion
- hyper resonance = decreased tissue density (pneumothorax)
How do you auscultate the chest in a resp exam?
Ask the patient to breathe deeply through their mouth
Starting at the apices auscultate from side to side, covering all lung regions, listening for:
- vesicular breathing = normal
- bronchial breathing (harsh-sounding) = consolidation
- quiet breath sounds = reduced air entry (effusion/pneumothorax)
- wheeze (expiratory) = asthma, COPD, bronchiectasis
- stridor (inspiratory) = foreign body inhalation, subglottic stenosis
- coarse crackles = pneumonia, oedema
- fine end-inspiratory crackles = fibrosis
How do you asses vocal resonance in a resp exam?
- Auscultate over all major regions of the chest while the patient repeats 99
- Increased volume = increased tissue density (consolidation, tumour, collapse)
- Decreased volume = presence of air/fluid (effusion/pneumothorax)
What needs to be assessed on the back in a resp exam?
Inspection (scars, asymmetry etc)
Palpation (chest expansion)
Percussion (+tactile vocal fremitus)
Auscultation (+vocal resonance)
How do you examine the lymph nodes in a resp exam?
- Start under the chin (submental)
- Move posteriorly under the mandible (submandibular)
- Feel anterior (preauricular) and posterior (posterior auricular) to the ears
- Follow the anterior border of sternocleidomastoid to the clavicle (anterior cervical chain)
- Follow the posterior border of sternocleidomastoid to the mastoid process (posterior cervical chain)
- Ask the patient to tilt their head, and palpate behind the clavicle (supraclavicular), on each side
*lymphadenopathy = lung cancer, TB, sarcoidosis
How do you complete a resp exam?
Check for sacral and peripheral oedema
Check sputum spot (volume, colour, consistency, haemoptysis)
Asses peak flow (just state in OSCE)
