Respiratory exam Flashcards
How would you explain and gain consent for a respiratory exam?
- I’ve been asked to do an examination of your lungs today - it will involve having a look at your hands face and neck as well as having a feel and a listen to your lungs. You will have to be exposed from the waist up and the examiner will act as a chaperone today
- would that be ok?
- are you in any pain at all
What is the general layout of a resp exam?
1) WIPE INSPECT, PALPATE, PERCUSS, ASCULTATE 2) Gen inspection (pt and bedside) 3) hands 4) pulse and Resp rate 5) face 6) Neck : JVP raised?, feel for lymphadenopathy. 7) palpate axillary nodes 8) Chest inspection 9) Palpation chest 10) percussion 11) tactile vocal fremitus / resonance 12) auscultation 13) peripheral and sacral oedema
what do you look for on gen inspection of the patient and bedside in a resp exam?
1) Patient
- alert, comfortable and well at rest , doesn’t look in pain
- cachexic
- SOB / respiratoru distress
- position of patient
- cyanosed
2) Bedside
- oxygen mask
- inhaler
- nebuliser
- peak flow meter
- sputum pot
- spacer
What do you look for on inspection of the hands in a resp exam?
- cap refill
- tar staining
- peripheral cyanosis
Nails:
- clubbing
TREMOR
CO2 FLAP
what could cause a fine tremor in a resp exam?
- excessive use of beta agonists like salbutamol or theophylline bronchodilators
What do you look for on inspection of the face?
Eyes:
- conjuctival pallor (anaemia)
Horner’s syndrome:
- ptosis
- miosis (constricted pupil)
Lips
- peripheral cyanosis
- angular stomatitis
tongue - central cyanosis
mouth - oral thrush
what are the causes of hyperventilation?
- anxiety
- metabolic acidosis
- toxins
- head injury
What does hypoventilation indicate?
- ventilatory failure
what does the pulse feel like in CO2 retainers?
Pulse will be large in volume (bounding) do to the vasodilatory effects of CO2 and tachycardic.
peripheries will be warm
what are the resp causes of a raised JVP?
- Cor pulmonale
- elevated intrathoracic pressures (acute sever asthma or tension pneumothorax)
- SVC obstruction
What are the causes of clubbing (respiratory and other)
- bronchial carcinoma
- chronic suppurative lung disease e.g. cystic fibrosis, bronchiectasis
- fibrosing alveolitis
- cyanotic heart disease
- infective endocarditis
- liver cirrhosis
- Inflammatory Bowel Disease
- Idopathic
- familial
How could you describe a palpable lymph node?
- rubbery (hodgkin’s disease)
- tender (tonsilitis)
- matted together (TB and metastatic disease)
What do you look for on inspection of the chest in a resp exam?
- scars (thoracotomy, sternocotomy)
- chest wall deformities (kyphoscoliosis, barrell chest, pectus excavatum, pectus carinatum)
- chest drain
- dilated superficial veins due to SVC obstruction
What is barrel chest usually associated with
- COPD (hyperinflation)
- kyphoscoliosis
What is pectus excavatum associated with?
pulmonary hypertension
What is thoracic kyphoscoliosis associated with?
May be idiopathic or secondary to childhood poiomyelitis.
Or spinal TB.
It causes decreased ventilatory capacity and increased work of breathing
what is pectus carinatum associated with?
pectus carinatum aka pigeon chest.
sign of chronic resp disease since childhood.
what do you palpate in a resp exam?
- tracheal position (assess for any tracheal deviation)
- palpate of apex beat
- chest expansion (upper, middle and lower zones
What are the diagnosis of an impalpable apex beat?
- emphysema
- dextrocardia
- obesity
- large pleural effusion
What are the causes of unilateral reduced expansion?
- pneumothorax
- pleural effusion
- pneumonia
- collapse
What conditions would you find tracheal deviation towards the pathology?
lobar collapse
pneumonectomy
What conditions would you find tracheal deviation away from pathology?
large pleural effusion
tension pneumothorax
what could be the cause of a hyper resonant percussion note (resp exam)?
Large air filled spaces e.g.
- markedly emphysemous lung
- pneumothorax
What could be the cause of a dull percussion note (resp exam)?
Lung separated from the chest wall
e. g. pleural fluid
- consolidation
- collapse
what could be the cause of a stony dull percussion note (resp exam)?
stony dull percussion is characteristic of a large pleural effusion
What does normal vesicular breathing sound like?
- rustling quality
- sound should increase steadily during inspiration then fade quickly during expiration
What could be the cause of diminished vesicular breathing sounds?
Thick chest wall:
- pleural thickening
Or if sound conduction is reduced:
- emphysema or shallow breathing
What does diminished vesicular breathing sound like?
- similar in character to normal vesicular breathing but quieter.
What does bronchial breathing sound like?
- breath sounds are loud and billowing.
- similar pitch and length of inspiration and expiration.
- audible gap between inspiration and expiration.
what could be the cause of bronchial breathing?
- pneumonic consolidation
what are the causes of early inspiratory crackles?
small airway disease such as bronchiolitis
what are the causes of mid inspiration crackles?
pulmonary oedema
what are the causes of late inspiration crackles
- interstitial lung disease
- COPD
- pneumonia
what causes crackles throughout inspiration and expiration?
bronchiectasis
what is the creaking sound that sounds like crunching snow or creaking of leather -heard on auscultation?
Pleural rub
what are the causes of pleural rub heard on auscultation whilst deep breathing?
pneumonia
pulmonary embolism
on tactile vocal resonance what could be a cause of increased sound transmission ?
consolidation
how do you differentiate between consolidation and pleural effusion with tactile vocal resonance?
consolidation - sound will be louder
pleural effusion - sound will be quieter.
what are the causes of interstitial lung disease?
1) idiopathic
2) Extrinsic allergic alveolitis:
- pigeon fancier’s lung
- farmer’s lung
3) Sarcoidosis
4) Autoimmune
- RA,
- systemic sclerosis
- ankylosing spondylitis
5) Occupational
- asbestos
- pneumoconiosis
- silicosis
6) drugs
- methotrexate
- amiodarone
- nitrofurantoin
7) familial
