Respiratory Exam Flashcards
What position should the patient be in for a respiratory exam?
45 degrees for anterior chest wall
What position should the patient be in for examining posterior chest wall?
Ask patient to lean forwards
What position should the patient be in for examining cervical lymph nodes?
sit across the couch with their legs dangling off the sides
What do you always need to ask for an exam?
CONSENT
What should you offer patient during resp exam?
- Exposed from waist upwards
- offer blanket
- need help removing top
- don’t need to remove bra
What should you look for in inspection from bedside?
- Anything nearby?
- ECG, inhaler, sputum, oxygen, nasal canuale - Patient coughing/breathless/ colour
What should you examine in hands?
- CO2 retention (shut eyes and put hands out (ideally 30s)
- look at skin for steroid use
- Clubbing
- Temperature (back of hands)
What should you examine in the face?
- Pull eyelids down (pale for aneamia)
- Look at tongue for thrush
- Sides of mouth
How do you assess the respiratory rate?
- Say measuring pulse
- observing the anterior chest wall (and abdominal walls) movements for 30 seconds while the subject breaths quietly
- Express as 12-20 breaths/minute
Where does the trachea divide into right and left main
bronchi?
Level of sternal angle
Where is the trachea palpable?
from the larynx to the suprasternal notch
How do you examine the position of the trachea?
- Before examining the patient you will warn them that this can be uncomfortable
- You will ask the patient to lean back and lower their neck slightly so their neck is relaxed
- You will place the forefinger of your right hand at the suprasternal notch of the patient and push it upwards and backwards until the trachea is felt.
- If the trachea is in the midline, your finger will not be able to progress further. If it is displaced to one side then your finger will feel one side of the trachea instead of its middle.
What could cause tracheal displacement towards the side of the lung lesion?
- Upper lobe collapse
- Upper lobe fibrosis
- Pneumonectomy
What could cause tracheal displacement away from the side of the lung lesion?
- Extensive pleural effusion
- Tension pneumothorax
- Chest Expansion
How do you measure chest expansion?
- stand facing the subject and place your hands firmly on the subject’s anterior chest wall (just below 5th or 6th ribs) with fingers extended around the sides of the chest
- thumbs should just meet in the anterior midline (mid-sternal line), resting lightly on the chest wall, to allow its movement during respiration
- In female subjects,the examiner’s hands lie beneath the breasts
- ask the patient to take a deep breath and observe the tips of your thumbs move apart.
- normal healthy subject, it should be at least 5 cm.
- Repeat this examination on the posterior chest wall with thumbs meeting in the posterior midline at the level of 10th thoracic vertebra (T10).
- look for any asymmetry between right and left sides
What does movement of the anterior chest wall indicate?
gives some indication of expansion of the upper and middle lobes
What does movement of the posterior chest wall indicate?
indicates expansion of lower lobes of the lung
What does reduced expansion of the chest wall on one side indicate?
A lesion on that side
What are common causes of unilateral decreased expansion?
- Pneumothorax
- Pleural effusion
- Collapsed lung
- Consolidation
What could cause bilateral decrease in expansion?
- asthma/COPD
- difficult to detect
How should you percuss the chest wall?
- Place your left hand over the subject’s chest wall with the fingers slightly separated.
- Align the middle finger (this is your probing finger) of your left hand along an intercostal space with the middle phalanx pressing firmly on the chest wall.
- Use the pad of the middle finger of your right hand and strike sharply on the middle phalanx of the probing finger of the left hand.
- Hold the percussing finger (right hand middle finger) in a semi flexed position when you strike the middle phalanx of the left hand middle finger. The striking motion must come from the wrist joint, and not from your forearm.
Where should you percuss?
symmetrically all areas of the anterior, posterior, and apical areas of the chest
What do you need to ask to patient when percussing the posterior chest wall?
hug themselves
What would hyperesonant sound indicate?
- Pneumothorax
- Hollow bowels,
- COPD
What would hyporesonant sound indicate?
- Pleural effusion
- Lung tumour
- Consolidation
- Collapse of lung
What are the air sounds heard in auscultation due to?
- result of air turbulence in the airways
- breath sounds do not originate in the alveoli
What are the two types of breath sounds recognizable?
- bronchial sound
- vesicular sound
Where are bronchial sounds heard?
- high pitch notes
1. heard over trachea (neck)
2. suprasternal notch
3. manubrium
4. sternal angle
5. sternoclavicular joints
What are these areas of the airways not surrounded by?
not surrounded by alveolar tissue, and therefore, the air turbulence in them is heard without any filtering
When do you use the bell of the stethoscope?
area just above clavicle where apices of lungs are present (rest is diaphragm)
Where do you listen for bronchial sounds?
- over the trachea, suprasternal notch, manubrium and sternal angle
- compare each side with other
What are vesicular breath sounds?
produced within the airways and filtered by the surrounding lung tissues
What are the characteristics of vesicular breath sounds?
- Soft, low pitched, and rustling in quality I
- Inspiratory phase lasts longer than the expiratory phase
- Intensity of inspiration is greater than that of expiration
- Inspiration is higher pitch than expiration
- No pause between inspiration and expiration
When you auscultate the lungs what is it important to note?
intensity of breath sounds
What are the causes of reduction in intensity of vesicular breath sounds?
- shallow breathing
- airway obstruction
- hyperinflation
- pneumothorax
- pleural effusion
- pleural thickening
- obesity
When does expiration become prolonged?
bstructive lung diseases like asthma and chronic bronchitis
What are the characteristics of bronchial breath sounds?
- It is loud, hollow, and high pitch
- Expiratory phase is longer than the inspiratory
- There is distinct pause between inspiration and expiration.
- It is normally heard over the manubrium and interscapular area.
- Bronchial breath sounds are also heard over areas of pathology such as consolidation, localised pulmonary fibrosis, pleural effusion and collapsed lung.
What is tactile vocal remitus?
vibration of the chest wall during vocal sounds
How can you feel tactile vocal fremitus?
- Ask the patient to say “ninety nine”
- Palpate across the chest wall with your hands
- You should feel the vibrations equally in both hands
What would a decrease in tactile vocal fremitus mean?
- decrease in density
- air in a pneumothorax, COPD. -increase in the distance between the chest wall and the lungs
- in pleural effusion
What would an increase in tactile vocal fremitus mean?
- increase in density
- consolidation in pneumonia
- tumour tissue in cancer
How do you examine cervical lymph nodes?
- Position the patient sitting and examine from behind
- You will use both hands to examine the lymph nodes on each side simultaneously
- Using the pads of the fingers in a circular motion palpate across all the cervical lymph node groups
In what movement do you plapate?
- When palpating from one set of lymph nodes to another, make sure to continue palpating in a circular motion without lifting your fingers off the patient
- to ensure no lymph nodes are missed
Where are submental nodes?
inferior to the chin
Where are submandibular nodes?
inferior to the angle of the mandible
Where are preauricular/parotid nodes?
anterior to the ear (technically the preauricular and parotid nodes are two separate sets of nodes, but because of their close proximity, they are usually palpated at the same time.)
Where are postauricular nodes?
posterior to the ear
Where are occipital nodes?
base of the occipital
What are superior deep cervical nodes?
superior part of the sternocleidomastoid
Where are inferior deep cervical nodes?
inferior part of the sternocleidomastoid
Where are supraclavicular nodes?
superior to the clavicle
What are the respiratory causes of cervical lymph node lymphadectomy?
- Lung cancer metastasising to the lymph nodes
- Tuberculosis
- Sarcoidosis
- Respiratory tract infection
What is the respiratory examination order?
- Position and exposure: Patient lying at 45 degrees, exposed from the waist upwards
- Inspection: General inspection
- Palpation: Tracheal position
- Anterior chest expansion
- Anterior chest percussion
- Anterior chest auscultation
- Anterior tactile vocal fremitus
- Position: Patient leaning forwards
- Posterior chest expansion
- Posterior chest percussion
- Posterior chest auscultation
- Posterior tactile vocal fremitus
- Position: Patient sitting across couch
- Cervical lymph node palpation
What are top tips for perucssion?
- Ensure that the middle phalanx of your probing finger is pressed tightly to the chest wall so there is no air to dull the percussion sound
- Ensure that the other fingers in your probing hand are not touching the skin of the patient so they will not dull the percussion sound
- Move your percussing hand quickly off the probing finger after you have struck your probing finger so it will not dull the percussion sound
- Percuss multiple times in each spot on the patient’s chest to ensure consistency
- Make sure you trim the nails of your percussing finger to minimise pain
- Try to ensure consistency of the force of your probing finger and percussing finger to be able to compare different areas
