Respiratory exam Flashcards
What do you inspect during examination?
What do you think of these abnormalities?
Inspection of both the environment and patient
- Inspection of environment:
- pulse oximetry; ECG
- O2 and mode of delivery (nasal cannulae; 15l o2 mask; controlled like venturi mask)
- inhalers (blue-SABA like salbutamol; brown-corticosteroid like beclomethason; spiriva- ipratroprium bromide)
- nebulisers
- NIV
- Inspection of the patient:
-alert or orientated/ confused and drowsy?
breathing abnormality:
- tachypnoeic or dyspnoeic
- pursed lip breathing
- tripod position and use of accessory muscles
- intercostal recessions/tracheal tug in children
- symmetry of the chest, chest wall deformities (pectus excavatum and carinatum; hyperinflated chest in emphysema) while asking patient to take a deep breath
- check for patient’s pattern of ventilation at the end of bed-hyperventilation, kussmaul’s breathing (deep sighing breaths in met acidosis), cheyne stocks
- ask them to cough: dry or productive
What are these?
What do you check for in the hands?
Inspect the hands for these abnormalities
Clubbing (chronic conditions like bronchiectasis, pulmonary fibrosis and lung cancer)-side and m sign
Tar staining
Peripheral Cyanosis
Hypertrophic Pulmonary osteoarthropathy (lung cancer causes both periostitis and clubbing, swelling occurs in DIPs and MCPs) and the wrist as well
Small muscle wasting (Pancoast tumour affects T1 and causes muscle wasting in hand)
Yellow nail syndrome (often occurs with chylothorax and lymphoedema in triad)
Thin bruised skin (long term steroids)
-Time PR-rate, rhythm, volume and character; RR and pattern of breathing; then check for fine tremor (salbutamol use) and flapping tremor (CO2 retention in type 2 RF)-hold back the hands for 10 s each (ask them to close their eyes)
What are the causes of clubbing (respiratory)?
Causes of clubbing:
- bronchiectasis
- cystic fibrosis
- idiopathic pulmonary fibrosis
- empyema
- lung abscess
- lung carcinoma
What do you identify in the arms?
- any bruising of the skin due to steroid use
- offer BP- CURB 65
What do you identify in the neck?
JVP (measuring distance from angle of louis)-internal jugular vein deep to SCM
Cricosternal distance (3 fingers) reduced in hyperinflation
Carotid pulse-bounding in CO2 retention
Cervical lymphadenopathy- submental, submandibular, upper middle lower cervical lymph nodes, supraclavicular, posterior triangle, occipital, post auricular and pre-auricular. Then scalene (tilt head towards the affected side)
What are the causes of raised JVP?
Raised JVP:
- cor pulmonale
- tension pneumothorax
- PE
What are the causes of tracheal deviation (away and towards)?
Tracheal deviation away:
- tension pneumothorax, large pleural effusion
Tracheal deviation towards:
- pneumonectomy or lung collapse (decrease in pressure)
What do you identify in the face?
What are these due to?
Eyes- conjunctival pallor (signs of anaemia); horner’s syndrome (sign of pancoast tumour)
Face-lupus pernio, cushing facies, facial swelling due to SVC obstruction
Tongue-sign of central cyanosis (if patient is struggling to breathe) underneath tongue; dry mucous membranes
bright red tongue-CO poisoning
What are the causes of central cyanosis?
Causes of central cyanosis (anything that causes V/Q mismatch):
- acute respiratory distress syndrome
- acute asthma/COPD
- pleural effusion
- pulmonary embolism
- pneumothorax
Identify the lobes of the lung. How do you identify the fissures (R-horizontal, oblique; L-oblique)
What do you inspect in the chest area?
What is the normal distance in lung expansion?
What else do you palpate for?
- chest wall deformities-pectus excavatum and carinatum
- thoracotomy scarring
- Test for chest expansion and see if it is symmetrical
- Anterior and posterior
- lateral: >5cm
- palpation-check for RV heave in cor pulmonale
What are these?
- Barrel chest-often in emphysema
- Kyphoscoliosis
- Pectus carinatum with Harrison’s sulcus-groove in lower costal margin often seen in rickets or those with asthma/copd
- pectus excavatum
Where do you percuss in the chest area?
What does it mean by hyper resonance or dull?
Hyper resonance:
- pneumothorax
Dullness on percussion:
- pleural effusion/chylothorax/haemothorax
- percussion must be in between the ICS spaces
What is this due to?
Coarse crackles
- excessive fluid secretion in the airways (typically does not clear after coughing)
- caused by bronchiectasis, cystic fibrosis, pneumonia, pulmonary oedema from heart failure
What else do you check in the peripheries?
- Sacral and ankle oedema-right sided heart failure due to cor pulmonale
- Erythema nodosum seen in sarcoidosis
