Respiratory exam Flashcards
What is the correct positioning and exposure of the patient for the respiratory exam?
At 45°
Chest exposed
What are you looking for upon general inspection of the patient during a resp exam?
- does the patient look well at rest/display signs of shortness of breath (nasal flaring, pursed lips, use of accessory muscles)
- can the patient manage to speak full sentences?
- are they cyanosed?
- any chest wall deformities?
- any scars?
- any form of cough/wheeze/stridor?
- medication such as inhalers, O2, sputum pots etc
What are you looking for when you inspect a patient’s hands in a rest exam?
- Tar staining
- Clubbing
- Cyanosis
- Features of rheumatological disease
- Temperature
- Fine tremor
- Flapping tremor
Why are you looking for tar staining in a resp exam?
increased risk of COPD/lung cancer with smoking
Why are you looking for clubbing in a resp exam?
sign of lung cancer, interstitial lung disease, bronchiectasis
Why are you looking for peripheral cyanosis in a resp exam?
indicates O2 saturation <85%
What is fine tremor of the hands usually a sign of?
Side effect of beta 2 agonist use (salbutamol)
What is flapping tremor of the hands usually a sign of?
CO2 retention - type 2 resp failure (COPD)
When examining the face in a resp exam what are you looking for?
- conjunctival pallor (lower eyelid inspection - could be a sign of anaemia)
- Horner’s syndrome (ptosis/miosis/anhidrosis)
- Central cyanosis (lips/inferior aspect of tongue)
What is the next step in the resp exam following inspection of the hand + face?
- Examination of the lymph nodes
(submental, sublingual, parotid, preauricular, anterior cervical chain, supraclavicular, posterior cervical chain, deep cervical, postauricular and occipital) - feel in a circular motion
(when explaining to the patient call them glands, not lymph nodes)
After examining the lymph nodes, what should be done?
- Tracheal/mediastinal shift
- warn the patient that this will feel uncomfortable
- place index and ring finger at the clavicular heads
- with the middle finger palpate downwards to feel around the base - feel for the apex beat
What would cause the trachea to deviate?
- Tension pneumothorax or large pleural effusions would cause the trachea to deviate away from the lesion
- Lobar collapse or pneumonectomy would case the trachea to deviate towards the lesion
Why do you feel for the apex beat in a resp exam?
Right ventricular heave is noted in cor pulmonale (right heart failure secondary to chronic hypoxic lung diseases)
Displaced apex beat could suggest a lung pathology
At what level does the bifurcation of the trachea occur?
T4, in line with the manubrio-sternal joint (sternal angle)
What are surface markings/anatomical landmarks are used to locate the oblique fissure?
third thoracic spine (T3) to 6th costal cartilage anteriorly
(~medial border of scapula with arm above head)
What are surface markings/anatomical landmarks are used to locate the right horizontal fissure?
horizontal line from sternum at 4th costal cartilage to oblique fissure
What step of the resp exam follows palpation of trachea and apex beat?
Chest expansion
- wide grip from lateral to medial bringing lots of chest wall in and watch thumbs
- note the amount of expansion and symmetry
- relate your findings to lung volumes
What are the average values for the following lung volumes in healthy adults?
- inspiratory reserve volume
- tidal volume
- expiratory reserve volume
- residual volume
- inspiratory reserve volume
- Male: 3.1L
- Female: 1.9L - tidal volume
- Male: 0.5L
- Female: 0.5L - expiratory reserve volume
- Male: 1.2L
- Female: 0.7L - residual volume
- Male: 1.2L
- Female: 1.1L
What are the average values for the following lung capacities in healthy adults?
- vital capacity
- inspiratory capacity
- functional residual capacity
- total lung capacity
- vital capacity
- Male: 4.8L
- Female: 3.1L - inspiratory capacity
- Male: 3.5L
- Female: 2.4L - functional residual capacity
- Male: 2.3L
- Female: 1.8L - total lung capacity
- Male: 5.8L
- Female: 4.2L
What step in the resp exam follows chest expansion?
Percussion
- compare both sides, percussing over:
1. anterior and posterior areas of the lungs
2. direct on the clavicles (lung apices)
3. axillae - technique:
1. compare R+L and percuss over the main lobes of the lungs
2. percuss supraclavicular, infraclavicular, chest wall + axilla
3. when percussing the posterior, ask the patient to fold their arms to avoid percussing the scapulae
In what situations might the lungs sound hyper-resonant, dull or stony dull?
Hyper-resonant: Pneumothorax
Dull: Lobe collapse, pneumonia
Stony dull: Pleural effusion
Which step in the resp exam follows percussion?
Vocal fremitus:
- place the flat of palms over the chest wall and ask the patient to speak
- repeat in superior + inferior position and on the back
When is fremitus increased and decreased?
Increased = areas of consolidation Decreased = pneumothorax or pleural effusion
Which step in the resp exam follows fremitus?
Auscultation:
- listening for:
1. breath sounds
2. crackles
3. wheeze
4. pleural rub
What is bronchial breathing a sign of?
Consolidation
What are reduced breath sounds a sign of?
consolidation, collapse or pleural effusion
What is a wheeze a sign of?
asthma or COPD
What are fine and coarse crackles a sign of?
Coarse = pneumonia, bronchiectasis, fluid overload Fine = pulmonary fibrosis
What further assessments/investigations would you suggest at the end of a resp examination?
- Check oxygen saturation
- Provide supplementary oxygen if indicated
- Perform peak flow assessment (if asthmatic)
- Request a chest x-ray – if abnormalities were noted on examination
- Take an arterial blood gas if indicated
- Perform a full cardiovascular examination if indicated
