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Examinations - CP1 > Respiratory Exam > Flashcards

Respiratory Exam Flashcards

Theory and Method of Examination

1
Q

What observations would you make about the appearance of the patient relevant to the respiratory system?
Why are they relevant?

A
  1. Respiratory distress - use of accessory muscles, hyperventilation, depth of breathing, pursed lip breathing.
  2. Hoarseness of voice - laryngeal pathology, laryngeal nerve paralysis, obstruction, infection
  3. Audible wheeze (heart failure, asthma, COPD, infection with mucous, brochiectasis) or audible stridor (glottitis, laryngitis, tumour of the throat, obstruction by aspiration).
  4. Pallor - cyanosis, pale, jaundice - gallstone pathology, respiratory failure, anaemia.
  5. Cachexia - weight loss indicating possible cancer or TB
  6. Ask about/look for signs the patient is in pain - helps direct examination and may be indication of trauma
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2
Q

What observations could you make about the patient’s environment?

A
  1. Cigarettes or ash-tray or smell of smoke - smoking status
  2. Sputum pot - inspect mucous colour and amount: large amounts could indicate bronchiectasis (with e.g. associated cystic fibrosis)
  3. Mobility aids - general health and care needs
  4. Inhalers/Spacers/Nebuliser - asthma, COPD. Check inhaler use is correct (dose and frequency, technique, type of inhaler, best before date)
  5. Temperature chart - infection
  6. Drugs on bedside table
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3
Q

What signs in the hands might be relevant to look for in a respiratory examination? (cutaneous signs)

What is their relevance?

A
  1. Tar staining - -history of smoking
  2. Clubbing - present in bronchiectasis, cystic fibrosis, pulmonary fibrosis, lung cancer (especially large cell), TB, empyema, CF. Note: clubbing not really associated with COPD. Also present in heart disease (with chronic hypoxia such as congenital cyanotic heart disease, bacterial endocarditis) and gastrointestinal and hepatobiliary disorders such as IBD, cirrhosis or malabsorption.
  3. Tremor - B2 agonist overuse
  4. CO2 retention flap (asterixis - tremor when wrist is extended)
  5. Peripheral cyanosis
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4
Q

What Oxygen delivery devices exist?

A
  1. Non-rebreathe masks
  2. Hudson mask
  3. Venturi mask
  4. Nasal cannuli
  5. CPAP (continuous positive airway pressure)
  6. Via tracheostomy
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5
Q

What mechanical/anatomical abnormalities are there in relation to the respiratory system disorder?

A

Chest Wall deformities

  1. Pectus excavatum
  2. Pectum carinatum
  3. Barrel chest (increased AP dimension) e.g. in COPD.

Other deformities

  1. Kyphoscoliosis
  2. Flail chest when segment of rib cage breaks due to trauma and become detached from rest of chest wall.
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6
Q

What is the triangle of safety?

A

Made up from horizontal line of nipple (5th ICS) and latissimus dorsi and pectoralis major. This space is used for insertion of chest drains. Avoid large neurovascular bundle below rib.
- 5th ICS in mid-axillary line.

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7
Q

What is the sternal angle?

A

Anterior angle formed by the junction of the manubrium and the body of the sternum (the manubriosternal junction) in the form of a secondary cartilaginous joint (symphysis). This is also called the manubriosternal joint or Angle of Louis.

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8
Q

What signs may you see in the face in relation to respiratory disease?

A
  1. Central cyanosis - check under tongue as less likely to be affected by sweets/foods etc
  2. Horner’s syndrome - ipsilateral partial ptosis, miosis, anhydrosis. Can be caused by pancoast tumours.
  3. Eye conjunctivae - pale may indicate anaemia
  4. Facial swelling and venous distention in the neck and distended veins in the upper chest and arms - could indicate superior vena cava obstruction.
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9
Q

What should you do before the examination?

A
  1. wash hands
  2. wear i.d. badge
  3. bare below the elbow
  4. check patient i.d
  5. get consent
  6. adequate exposure of patient.
  7. position bed at 45 degrees
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10
Q

What parts of the respiratory examination are done in the neck?

A
  1. Tracheal deviation - upper lobe fibrosis, pneumonectomy, tension or normal pneumothorax, massive pleural effusion.
  2. Lymph nodes - may be enlarged in lung cancer, lymphoma, TB, sarcoid and infection
  3. Jugular Venous pressure - IJV runs just medial to sternocleidomastoid muscle, from just medial to clavicular head to the angle of the jaw. Not palpable, complex wave form, moves with respiration (falls on inspiration), obliterated at base of neck.
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11
Q

How do you tell the carotid artery from the JVP?

A

POLICE

P: palpation (non-palpable)
O: occlusion (readily occluded)
L: location (b/t heads of SCM, lateral to carotid)
I: inspiration (drops with inspiration)
C: contour (biphasic waveform)
E: erection/position (drops when sitting erect).

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12
Q

Why might JVP be elevated?

A

Increased right ventricular pressure and reduced compliance:

  • pulmonary stenosis
  • pulmonary hypertension (e.g. in cor pulmonale)
  • RV infarction
  • RV failure

Right ventricle inflow impedance

  • tricuspid stenosis
  • RA myxoma
  • constrictive pericarditis
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13
Q

How would you assess chest expansion? What might it tell you?

A

Infra or supra-mammary expansion anterior and posterior. Normal if 2-5cm expansion.

  1. If bilaterally reduced expansion: COPD due to hyperinflation, or due to muscle weakness or pulmonary fibrosis.
  2. If unilaterally reduced - pneumothorax, pleural effusion on that side, flail chest.
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14
Q

Describe how you percuss the chest and what sounds you might hear? Relevance?

A

Percuss 6-8 positions on the anterior and then posterior chest, including axillary and apical regions.
Sound can be:
1. Hyper-resonant - pneumothorax
2. Resonant - normal
3. Dull - consolidation e.g. pneumonia or pleural thickening
4. Stony dull - e.g. pleural effusion

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15
Q

When auscultating the chest, what common abnormalities of breath sounds are there? Relevance?

Is the expiratory phase prolonged?

Are additional sounds localised or widespread?

A

Ask patient to breathe through mouth (increased airflow) and listen with diaphragm.

Bronchial Breathing = increased intensity and quality. Gap between inspiration and expiration and expiration is longer than inspiration. May indicate pneumonia, atelectasis or pleural effusion.

Crackles =

  • fine due to snapping open of airways: fibrosis or oedema (e.g. in HF)
  • coarse due to fluid: infection like pneumonia or bronchiectasis

If crackles clear on coughing - airway secretions.

Wheeze = indicates obstruction to flow of air through narrowed airways. Pitch depends on flow rate.
- asthma or COPD.

Stridor (inspiratory wheeze) - larynx obstruction.

Pleural rub = pleural linings rubbing together.

  • empyema
  • pleurisy due to e.g. viral infections, pneumonia that has caused inflammation of pleura, peripheral PE which has led to infarction of pleura.
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16
Q

What is tactile vocal fremitus?

A

Ask patient to say 99 whilst listening with stethoscope or whilst placing ulnar surface of hands on chest.

  • Increased sound/vibration in consolidation
  • Reduced in pleural effusion / thickening or lobar collapse and pneumothorax
17
Q

What might you do to investigate further following a respiratory examination?

A
  1. Sputum sample if productive
  2. Peak flow measurement (best of 3 and correlated against weight and height).
  3. Chest X-ray
  4. CTPA if suspected PE
  5. Spirometry to assess obstructive vs restrictive lung disease
  6. Arterial blood gas analysis - respiratory failure with hypoxia or hypercapnia
  7. FBC - look for WBC count (infection or inflammation), anaemia (to explain fatigue, SOB or pallor)
18
Q

What might you do to investigate further following a respiratory examination?

A
  1. Sputum sample if productive
  2. Peak expiratory flow measurement (best of 3 and correlated against weight and height).
  3. Chest X-ray
  4. CTPA if suspected PE
  5. Spirometry to assess obstructive vs restrictive lung disease
  6. Arterial blood gas analysis - respiratory failure with hypoxia or hypercapnia
  7. FBC - look for WBC count (infection or inflammation), anaemia (to explain fatigue, SOB or pallor)
19
Q

What is HPOA?

A

Hypertrophic Pulmonary Osteo-Arthropathy

  • abnormal proliferation of skin/bone (periosteal bone formation), can be associated with clubbing. Can cause pain in extremity joints and synovial effusions.
20
Q

What is SOBAR?

A

Shortness of breath at rest

21
Q

Symptoms of CO2 retention?

A
  1. Warm peripheries
  2. Sweaty palms
  3. Hyperdynamic pulse
  4. Flapping tremor
  5. Drowsiness
  6. Confusion
  7. Coma
22
Q

Describe the anatomy of the ocular sympathetic supply. (in relation to Horner’s)

A

Starts from hypothalamus (1st neuron) which projects to the intermedio-lateral column of cervical cord (2nd neuron).
Through nerve roots - fibers enter the sympathetic chain - superior cervical ganglion - 3rd neuron.
Efferent sympathetic fibers - travel along the carotid sheath upwards in the neck - enter the cranial cavity.
Supply the eye through the ophthalmic division of the trigeminal nerve (V1).
Supplies the pupil, levator palpebrae superioris, and the sweat glands of the face (sympathetic cholinergic).

23
Q

Causes of Horner’s syndrome?

A 
Medulla & cord - 
Lateral medullary syndrome /Tumour 
Root lesions - 
Cervical spondylosis / Disc prolapse 
Vertebral trauma / Tumour / Abscess
Supra-clavicular fossa - 
Pancoast tumour 
Lymph node involvement 
Brachial plexus lesion (Traumatic, post-irradiation.. )
Neck - 
Lymph node involvement 
Malignancies - e.g. Thyroid Ca 
Carotid A lesions - 
Aneurysm / Dissection 
Pericarotid tumours /Cluster headache
24
Q

Surface anatomy of lung fissures?

A

Oblique fissure:
T2 spinous process
6th rib in mid-axillary line
6th costocondral cartilage

Horizontal fissure:
4th cc cartilage in ant midline
6th rib in mid-axillary line

25
Q

Once you have finished looking at the chest, what other things might you do to complete the exam?

A

Peripheral oedema -

26
Q

Once you have finished looking at the chest, what other things might you do to complete the exam?

A

Peripheral oedema

27
Q

What would you see on examination for left sided pleural effusion? Mention trachea, expansion, percussion, auscultation, vocal resonance.

A
  1. Trachea - normal or deviated away from fluid.
  2. Expansion - decreased on side of fluid
  3. Stony dull percussion on side of fluid.
  4. Auscultation - decreased breath sounds on side of fluid.
  5. Decreased vocal resonance on side of fluid
28
Q

What signs would you find on examination with right lower lobe consolidation? Mention trachea, expansion, percussion, auscultation and vocal resonance.

A
  1. Trachea - would be normal
  2. Decreased expansion on side of consolidation
  3. Percussion would be dull over site of consolidation
  4. Coarse crackles and bronchial breathing over consolidation.
  5. Vocal resonance would be increased over consolidation
29
Q

What signs would you see on examination with left penumonectomy? Trachea, expansion, percussion, auscultation, vocal resonance.

A
  1. Trachea deviates towards removed side.
  2. Expansion decreased on side removed.
  3. Percussion dull on side removed.
  4. Auscultated - decreased/no breath sounds on left/removed side.
  5. Vocal resonance - decreased on left.
30
Q

What signs would you see on examination of right pneumothorax? Trachea, expansion, percussion, auscultation, vocal resonance?

A
  1. trachea - normal or deviated away from large/tension pneumothorax
  2. Expansion - decreased on right.
  3. Percussion - hyper-resonant on right
  4. Auscultation - decreased air entry on right
  5. Vocal resonance - decreased on right
31
Q

What signs would you see on examination of small airway obstruction e.g. COPD? Trachea, expansion, percussion, auscultation, vocal resonance?

A
  1. Trachea - normal
  2. Expansion - hyper-expanded or normal
  3. Normal percussion
  4. Auscultation - bilateral wheeze or rhonchi
  5. Normal vocal resonance.
32
Q

What signs would you see on examination of pulmonary hypersensitivity? Mention trachea, expansion, percussion, auscultation and vocal resonance.

A
  1. Trachea - normal
  2. Expansion - bilaterally reduced
  3. Percussion - normal
  4. Auscultation - bilateral fine inspiratory crackles usually at both lung bases.
  5. Vocal resonance - normal
33
Q

Causes of SOB? Within mins/hours/days-weeks?

A
  1. Within mins - pneumothorax, foreign body causing airway occlusion, PE
  2. Within hours - pneumonia, asthma, exacerbation of COPD.
  3. Days - weeks - COPD, pulmonary fibrosis, lung cancer.

Also, pulmonary oedema secondary to cardiac failure, anaemia, respiratory muscle weakness, deconditioning and obesity, hyperventilation syndromes

34
Q

Causes of cough - hours, days, weeks/months and years?

A

Hours - inhaled substance
Days - infection or inflammation
Weeks/months - lung cancer, GORD, allergic reaction
Years - COPD, asthma, post-infective, bronchiectasis, pulmonary fibrosis

35
Q

Causes of sputum production?
Acutely if bloody, clear or green/brown?
Chronic?

A

Acute:

  • blood - PE, infection or lung cancer.
  • clear - heart failure
  • green/brown - infection

Chronic:
- COPD or bronchiectasis,

36
Q

Respiratory causes of chest pain - acute, gradual, longer.

A
  1. Sudden - pneumothorax, PE, pleurisy, fractured rib
  2. Gradual - pneumonia
  3. Longer - lung cancer with pleural involvement or bone mets
37
Q

Causes of wheeze?

A

If large airways - inhaled, lung cancer causing obstruction.

If small airways, asthma or COPD.

38
Q

Red flag signs for respiratory history?

A

Weight loss, night sweats, myalgia, fevers.

Examinations - CP1 (3 decks)

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