Respiratory Exam- extra notes Flashcards
Where is inhaled material likely to reach
The right main bronchus is more vertical than the left and, hence, inhaled material is more likely to end up in the right lung.
What exactly is cyanosis
Cyanosis (see p. 940) is a dusky colour of the skin and mucous membranes, due to the presence of >50 g/L of desaturated haemoglobin. When it has a central cause, cyanosis is visible on the tongue (especially the underside) and lips. Patients with central cyanosis will also be cyanosed peripherally. Peripheral cyanosis without central cyanosis is caused by a
reduced peripheral circulation and is noted on the fingernails and skin of the extremities with associated coolness of the skin.
In lung disease this is caused by inadequate oxygenation, i.e in asthma, COPD and pulmonary embolism.
Summarise finger clubbing
Finger clubbing is present when the normal angle between the base of the nail and the nail fold is lost. The base of the nail is fluctuant owing to increased vascularity, and there is an increased curvature of the nail in all directions, with expansion of the end of the digit.
Outline the causes of finger clubbing
Respiratory • Bronchial carcinoma, especially epidermoid (squamous cell) type (major cause) • Chronic suppurative lung disease: – Bronchiectasis – Lung abscess – Empyema • Idiopathic lung fibrosis • Pleural and mediastinal tumours (e.g. mesothelioma) • Cryptogenic organizing pneumonia Cystic fibrosis Mesothileoma Cardiovascular • Cyanotic heart disease • Subacute infective endocarditis • Atrial myxoma Miscellaneous • Congenital – no disease • Cirrhosis • Inflammatory bowel disease Hyperthyroidism
When should chest expansion be checked with a tape measure
Chest expansion should be checked; a tape measure may be used if precise or serial measurements are needed, such as in ankylosing spondylitis.
What does discomfort over the costochrondral joints on palpation suggest
Local discomfort over the sternochondral joints suggests costochondritis. In rib fractures, compression of the chest laterally and anteroposteriorly produces localized pain.
Summarise percussion of the chest
On percussion, liver dullness is
usually detected anteriorly at the level of the sixth rib. Liver and cardiac dullness disappear when the lungs are over-inflated
Summarise auscultation of the lungs
The patient is asked to take deep breaths through the mouth. Inspiration should be more prolonged than expiration. Normal breath sounds are caused by turbulent flow in the larynx and sound harsher anteriorly over the upper lobes (particularly on the right). Healthy lungs filter out most of the high-frequency component, and the resulting sounds are called vesicular.
If the lung is consolidated or collapsed, the high-frequency hissing components of breath are not attenuated, and can be heard as ‘bronchial breathing’. Similar sounds may be heard over areas of localized fibrosis or bronchiectasis. Bronchial breathing is accompanied by whispering pectoriloquy (whispered, high-pitched sounds can be heard distinctly through a stethoscope).
Describe a wheeze
Wheeze. Wheeze results from vibrations in the collapsible part of the airways when apposition occurs as a result of the flow-limiting mechanisms. Wheeze is usually heard during expiration and is commonly but not invariably present in asthma and COPD. In acute severe asthma, wheeze may not be heard, as airflow may be insufficient to generate the sound. Wheezes may be monophonic (single large airway obstruction) or polyphonic (narrowing of many small airways). An end-inspiratory wheeze or ‘squeak’ may be heard in obliterative bronchiolitis.
Describe crackles
Crackles. These brief crackling sounds are probably produced by opening of previously closed bronchioles; early inspiratory crackles are associated with diffuse airflow limitation, while late inspiratory crackles are characteristically heard in pulmonary oedema, lung fibrosis and bronchiectasis.
Describe the pleural rub
Pleural rub. This creaking or groaning sound is usually well localized. It indicates inflammation and roughening of the pleural surfaces, which normally glide silently over one another.
Describe vocal resonance
Vocal resonance. Healthy lung attenuates high-frequency notes, as compared to the lower- pitched components of speech. Consolidated lung has the reverse effect, transmitting high frequencies well; the spoken word then takes on a bleating quality. Whispered (and therefore high-pitched) speech can be clearly heard over consolidated areas, as compared to healthy lung. Low-frequency sounds such as ‘ninety-nine’ are well transmitted across healthy lung to produce vibration that can be felt over the chest wall. Consolidated lung transmits these low- frequency noises less well, and pleural fluid severely dampens or obliterates the vibrations altogether. Tactile vocal fremitus is the palpation of this vibration, usually by placing the edge of the hand on the chest wall. For all practical purposes, this duplicates the assessment of vocal resonance and is not routinely performed as part of the chest examination.
What questions should you ask yourself upon general inspection
Is this patient in respiratory distress?
What’s the patient’s respiratory rate?
Can the patient talk to me in full sentencesw without becoming breathless?
Is the patient’s breathing noisy (wheeze or stridor)?
What is the patient’s pattern of breathing?
Are there inhalers, sputum pots or oxygen around the bedside?
Is there any hint as to the underlying cause of the respiratory disease - i.e cachexia in lung cancer or classic features of scleroderma in lung fibrosis?
Is there any evidence of potential side-effects of respiratory medications- i.e steriors or tremor with salbutamol excess?
What are the features of respiratory distress
Use of accessory muscles (trapezius and SCM)
Nasal flaring
Mouth breathing
Patient fixing thorax by leaning forward
Tachypnoea
Subcostal/intercostal recession (important in children)
Pursed lip breathing
Describe some abnormal breathing patterns
Kussmaul’s respiration (hyperventilation with deep sighing respirations) - DKA, Aspirin overdose, acute massive pulmonary embolism
Cheyne-Stokes Respiration (increased rate and volume of respirations followed by periods of apnoea) — terminal disease and raised ICP
Prolongation of expiration — air flow limitation
Pursed-lip breathing — air trapping
What is meant by clubbing
Clubbing is a painless, bulbous enlargement of the distal fingers, which is accompanied by softening of the nail bed and loss of the nail bed angle. One method of detecting clubbing is to look for the Shamroth’s sign.
What are the side-effects of long term steroid treatment
Rounded face acne hirsutism Centripetal obesity Intrascapular fat pad thin skin striae proximal myopathy osteoporosis easy bruising
Describe CO2 retention
There are several signs of CO2 retention that may be detected in the hands:
Warm, well-perfused hands
Palmar erythema (reddening of the palms)
Bounding radial pulse
CO2 retention flap
The CO2 retention flap is a coarse, irregular tremor.
Describe muscle wasting and bony deformities in the hand
Unilateral muscle wasting of the hands (particularly in T1 distribution) may hint at the presence of a Pancoast’s tumoour
Patients with rheumatoid arthritis have classiical hand deformities (swan neck, boutonniere, ulnar deviation and Z thumbs): this autoimmune condition is also associated with lung fibrosis.
List some causes of tachycardia
Pain Shock Infection Thyrotoxicosis Sarcoidosis P.E Drugs e.g salbutamol Iatrogenic causes
Describe some causes of a bounding pulse
CO2 retention Thyrotoxicosis Fever Anaemia Hyperkinetic states
Describe the assessment of pulses paradoxus
In normal individuals the pulse decreases slightly in volume on inspiration and systolic blood pressure falls by 3-5mmHg.
In severe obstructive diseases (e.g severe asthma) the contractile force of the respiratory muscles is so great that there is a marked fall in systolic pressure on inspiration
A fall of greater than 10mmHg is pathological.
What signs should you look for in the face and mouth
Signs of SVC obstruction
Cushingoid features
Look in the mouth for:
Candida infection- white coating on tongue, often seen after steroids or antibiotics.
Central cyanosis.
What are the signs of SVC obstruction
Facial oedema
Cyanosis
Engorged neck veins
Can occur in patients with apical lung tumour
Describe the respiratory context of Horner’s syndrome
Partial ptosis (drooping of eyelid)
Miosis (small pupil)
Anhydrosis (lack of sweating)
Pancoast’s tumour- can press on sympathetic chain as it ascends in the neck.
Why are deformities in the chest wall and spine important
Because they can restrict the ventilatory capacity of the lungs
Describe palpation in the respiratory examination
Involves assessing chest expansion both anteroposteriorly and laterally.
When testing chest expansion in the AP direction, place the palms of both hands in the pectoral region and ask the patient to take a deep breath. The chest should expand symmetrically.
Any asymmetry suggests pathology on the side that fails to expand adequately.
Next examine the position of the apex beat.
What can cause displacement of the apex beat
Pulmonary fibrosis
Bronchiectasis
Pleural effusions
Pneumothoraces
Describe some abnormalities of JVP
Raised with normal waveform:
Cor pulmonale
Fluid overload
Raised with absent waveform:
SVC obstruction
Absent:
Dehydration, shock
Summarise the chest wall deformities
Pectus excavatum- benign condition whereby the sternum is depressed in relation to the ribs
Pectus carinatum (pigeon chest)- sternum more prominent compared to the ribs- often caused by severe childhood asthma
Barrel chest: the AP diameter of the chest is greater than the lateral diameter- caused by hyperinflation of the lungs.
What can cause Kyphosis
Osteoporosis and ankylosing spondylitis.
Describe the different percussion notes
Hyperresonant- Pneumothorax, also possible in ephysema with large bullae
Dull -consolidation, fibrosis, pleural thickening, collapse and infection
Stony dull- pleural effusion.
What are normal breath sounds described as
Vesicular and have a rustling quality heard in inspiration and the first part of expiration.
Describe some abnormal breath sounds
Diminished vesicular breath sounds – airway obstruction, COPD and asthma
Bronchial breathing – harsh breath sounds whereby inspiration and expiration are of equal duration – consolidation, pneumonia and empyema
Describe some added breath sounds
Monophonic wheeze - prolonged musical sound (expiratory)- large-airway obstruction
Polyphonic wheeze – prolonged musical sound (expiratory)- many notes — small-airway obstruction (asthma)
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Coarse crackles- non-musical uninterrupted sounds (inspiratory) – consolidation and COPD
Fine crackles- non-musical uninterrupted sounds (inspiratory)- like velcro. early inspiration- pulmonary oedema, end-inspiratroy- fibrosis.
Pleurla rub - pneumonia, pulmonary embolism and pleurisy.
What is important to remember about added sounds
If they disappear when the patient coughs, they are not significant.
Describe whispering pectoriloquy
Variation of vocal resonance that can be used to confirm the presence of consolidation.
The patient is asked to whisper ‘99’.
In normal lung, this cannot be heard by auscultation.
However, solid lung conducts sound better than normal aerated lung and thus in patients with areas of consolidation the words are clear and seem to be spoken into the examiner’s ear.
Table for summary of physical signs
See table in kumars can crash course.
Why do patients use pursed lip breathing
puffing through pursed lips
prevents bronchial wall collapse by keeping lung pressure high in severe airway obstruction/emphysema
Summarise noises
Noises: patients’ speech normal? (obstruction, recurrent laryngeal nerve palsy), stridor (large airway obstruction e.g. mediastinal
masses, bronchial carcinoma, retrosternal thyroid), wheeze, cough (dry/bovine/productive), prolonged expiratory phase (asthma,
COPD), clicks (bronchiectasis), gurgling (airway secretions)
Summarise the features in the face
Face: Cushingoid (steroid use), plethoric (CO2 retention), telangiectasia/microstomia (systemic sclerosis), butterfly rash (SLE), lupus pernio (sarcoid), lupus vulgaris (TB)
Describe the chest Wall movements in emphysema
mainly upwards (emphysema)
Describe the in-drawing of the intercostal muscles
: in-drawing of intercostal muscles (generalised is hyperinflation; localised is bronchial obstruction)
Describe palpation for heaves
feel for RV heave and palpable P2
pulmonary hypertension
Describe listening for a loud P2
Listen for loud P2 i.e. loud second heart sound over pulmonary area (pulmonary hypertension)
Summarise abnormal breathing patterns
Kussmaul respiration is deep, sighing breaths in severe metabolic acidosis (blowing off CO2), eg diabetic or alcoholic ketoacidosis, renal impairment.
• Neurogenic hyperventilation is produced by pontine lesions.
• The hyperventilation syndrome involves panic attacks associated with hyperventilation, palpitations, dizziness, faintness, tinnitus, alarming chest pain/tightness, perioral and peripheral tingling (plasma ↓Ca2+). Treatment: relaxation techniques and breathing into a paper bag (↑inspired CO2 corrects the alkalosis).nb: the anxious patient in a&e with hyperventilation and a respiratory alkalosis may actually be presenting with an aspirin overdose
Summarise Cheyne-stokes breathing
Breaths get deeper and deeper, then shallower (±episodic apnoea) in cycles. Causes—brainstem lesions or compression (stroke, ↑icp). If the cycle is long (eg 3min), the cause may be a long lung-to-brain circulation time (eg in chronic pulmonary oedema or ↓cardiac output). It is enhanced by opioids.
What can tender writs be a sign of
Tender wrists (hypertrophic pulmonary osteoarthropathy—cancer
Describe the pneumothroax click
Shallow left pneumothorax between layers of parietal pleura overlying heart, heard during cardiac systole
Describe the tracheal tug as a sign of respiratory distress
• Tracheal tug (pulling of thyroid cartilage towards sternal notch in inspiration).
Describe Harrison’s suclus
Pectus carinatum (pigeon chest). Prominent sternum, from lung hyperinflation while the bony thorax is still developing, eg in chronic childhood asthma. Often seen with Harrison’s sulcus, a groove deformity caused by indrawing of lower ribs at the diaphragm attachment site. This usually has little functional significance in terms of respiration but can have significant psychological effects
Psychological effects are interesting and not to be dismissed as their effects may be greater than any physical effects.8 Because these people hate exposing their chests they may become introverted, and never learn to swim, so don’t let them sink without trace. Be sympathetic, and remember Herr Minty, who inaugurated Graham Greene’s theory of compensation: wherever a defect exists we must look for a compensating perfection to account for how the defect survives. In Minty’s case, although ‘crooked and yellow and pigeon-chested he had his deep refuge, the inexhaustible ingenuity of his mind.
