Respiratory Exam Flashcards
Two components of a respiratory exam
- Extra pulmonary portion
2. Pulmonary portion
Extrapulmonary examination- areas of examination
1) Detection of cyanosis
2) Clubbing of fingers
3) Trachea
4) Accessory respiratory muscles
5) Lymph nodes
6) Ears
7) Noses
8) Sinuses
9) Mouth/throat
Meaning of cyanosis
-bluish coloured skin
Types of cyanosis
- central
- peripheral
Cause of peripheral cyanosis
- usually normal
- related to constriction of vessels in the extremities (ex due to cold)
Cause of central cyanosis
Low oxygen in blood
Sign of central cyanosis
Lips and face?? really thought the lips were not included -want to look orally
Haemoglobin in blood to see cyanosis
-must be 5gm/dl of deoxygenated haemoglobin present to see cyanosis
Clubbing of fingers -in which patients do see
- chronically hypoxemic patients (but also in patients with normal O2 levels)
- congenital heart disease
- lung cancer
- lung absces
- empyema
- cystic fibrosis
- gi causes (rare)
Recognizing clubbing
Curving of the fingernails
Softening of the nail bed
Loss of angle between the nail and dorsum of the finger
Shifting of trachea with age
May be shifted slightly to the right in older people
Pathological shifting of the trachea
1) Pushed to the opposite side by a large pneumothorax or pleural effusion
2) Drawn towards the side of extensive atelectasis
3) Thyroid enlargement may shift it either way
Examination of trachea
Patients head in mild flexion by the one or two finger method
Compare distance from lateral tracheal wall to the bony medial border of the suprasternal notch
Accessory respiratory muscles-when do see
Normally not seen unless the patient is very short of breath
in a patient with obstructive lung disease -seeing this correlated with FEV1 <30%
Accessory resp muscles -which is the most evident in the dyspnoeic patient
-sternocleidomastoid
Lymph nodes -which to palpitate
1) Occipital
2) Pre and post auricular nodes
3) Sub-mandibular nodes
4) Anterior and posterior cervical nodes
Lymph nodes -what to note
- soft, tender, mobile nodes = associated with infection
- firm/hard “matted down” nodes -signify malignancy
Lymph node in neck most frequently involved wiht lung cancer
Supraclavicular nodes (node may feel like a hard pea)
Ears examination
- examine auricle of ear
- check behind ear for nodes
- check the lobule and helix for infected piercings from earrings
- using ototscope look at auditory canal - note wax and other foreign bodies
- look for redness/swelling of otittis externa
- assess tympanic membrane for perforations, redness and bulging
Nose
1) examine the nose looking for foreign bodies
2) assess health of mucosa (redness, swellling, bleeding/scabbing of Little’s area
3) Assess for deviation of the septum
Sinuses
1) Press up on the frontal sinues from under the bony brows
2) Press up on maxillary sinuses
Mouth/throat
- examine the teeth, gingiva, tongue and pharynx
- note presence/absence of tonsils
4 components of pulmonary exam
1) Inspection
2) Palpation
3) Percussion
4) Auscultation
Inspection
1) observe patient for extrapulmonary signs - cyanosis, dyspnoea, accessory muscles
2) antero-posterior diamter
3) Deformities
4) Thoracic and/or abdominal breathing - is it symmetrical/regular
Where see antero-posterior diameter changes
With severe obstructive lung disease
Deformities seen
1) Kyphosis (increase in thoracic convexity)
2) Scoliosis (lateral curve of spine)
3) Kyphoscoliosis (combined kyphosis and scoliosis)
4) Pectus excavatum -severe retraction f sternum
5) Pectus carinatum - anterior protrusion of the sternum
Palpation of chest wall
- feel for masses and tenderness in the ribs and carilage
- feel for nodes in the axillae
Chest wall exercusion
- feel for decreased movement
- with a breath lung begins to move later and move less than the normal one
Chest wall exercusions movement of
a) lower lobe
b) upper and middle lobes
a) lower lobe - lateral movement
b) upper & middle lobe - anterior movement
Methods assessment of lower lobes
- place palms on posterolateral chest with fingers apart
- patient takes deep breath in
- watch movement of your thumbs
OR
- place fingers tightly in the interspaces
- Try to restrict the movement of the chest
- Have patient inhale and feel any variation in thoracic excursion
Upper lobe and middle lobe -method of assessment
Place hands lightly over anterior chest between clavicle and coastal margin
Have patient inhale
-feel chest move anteriorly
Modified hoovers sign
-Normally the lateral ribs flare and the costal margin widens with a deep inspiration
-If the lungs are over-inflated with a low flat diaphragm the lateral chest wall may be drawn inwards with inspiration
Very common in patients with severe COPD
Tactile fremitus
Vibrations from a patients voice detected by examiners hand on patients chest
Method of assessing tactile fremitus
-use palms or fingers or ulnar border of hand
-compare sies
Posteriorly:
-upper 1/3 (upper lobe)
-middle 1/3 (superior segment of lower lobe)
-lower 1/3 (basal segments)
a) medial to mid scapular line
b) lateral to mid scapular line
-axillae
Anteriorly
-place hand in area between clavicle and rib margin
In which disorders is tactile fremitus increased
-where lung is more dense –> consolidation of pneumonia or atelectasis
In which disorders is tactile fremitus absent
Pneumothorax
Pleural effusion which decreases the transmision of vibrations
Techique for percussion -position of patient
Patient should be sitting up
When percussing posteriorly have patients cross arm across anterior of chest
Locations to percuss
- same as tactile fremitus
- percuss about 3x at each site comparing side for side
5 types of percussion note and meaning
1) Normal resonance - normal lung
2) Dullness- over consolidation/similar to note over liver
3) Flat - over large pleural effusion / similar to note over thigh
4) hyper-resonance - over large pneumothorax
5) Tympanic -a hollow sound - as over stomach bubble
percussion of the diaphragm - location
Level of 9th posterior rib in mid scapular line
May be 1-2 cm higher on right
Assessing diaphragmatic exercusions
Compare position and maximum expiration and inspiration
Normal exercuion 5–7 cm
(only do so if suspect diaphragmatic weakness)
Stridor
The sound of partial upper airway obstruction
Heard in inspiration
Things to hear without a stethoscope
1) Hoarse voice
2) Stridor
3) Wheeze
4) Normal breathing > 1 m away at rest
Using the stethoscope to assess breath sounds
- patient take deep breaths with mouth open
- compare equivalent sites ver each lung in same areas as tactile fremitus and percussion
Types of breath sounds
- Normal/vesicular breathing - inspiratory phase 3x expiratory phase
- abnormal if these sounds not present - Bronchial breath sounds - high pitched and loud, inspiratory = expiratory phase
- gap between inspiration and expiration
- heard over consolidation (i.e. pneumonia) - Broncho-vesicular sounds
- a little louder than vesicular
- heard over the right upper lobe anteriorly or between the scapulae - Tubular breath sounds -very harsh, normally heard over the trachea or sometimes over consolidation
Crackles
Due to opening of small airways o secretions
Sounds like velcro coming apart
Types of crackles
- coarse
- fine
- early
- late
- continuous
Causes of early crackles
- bronchiectasis
- asthma (occasionally)
Causes of late crackles
- pulmonary fibrosis
- congestive heart failure
Causes of continuous crackles
Pneumonia
Wheezes
a continuous sound in expiration
Causes of wheezes
- bronchospasm
- secretions
- airway collapse or obstruction
Pleural rub
- due to inflamed surface of the pleura rubbing against each other
- present in inspiration & expiration
- sounds like squeaky door
- dissapears with fluid formation
Causes of pleural rub
Pleuritis usually due to pneumonia or pulmonary infarct
If lung cancer is suspected what should do
Feel for
- supraclavicular nodes
- bony tenderness
If sarcoid is suspected what should do
Feel for all lymph nodes
Normal lung
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
a) none
b) N
c) N
d) N
e) O
Consolidation
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
a) none
b) dull
c) bronchial
d) increased
e) crackles
Pleural effusion
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
1) to opposite side
2) dull/flat
3) decrease
4) absent
5) O
Pneumothorax
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
1) to opposite side
2) hyper resonant
3) Decreased
4) Absent
5) O
Atelectasis
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
1) To same side
2) Dull
3) Decreased
4) Increased/decreased
5) crackles
Asthma
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
1) none
2) N
3) N or decreased
4) n
5) Wheezes
Emphysema
a) Tracheal shift
b) percussion
c) breath sounds
d) fremitus
e) adventitious sounds
1) None
2) Hyper resonant
3) Decreased
4) Decreased
5) variable
