Respiratory Exam LAB osce Flashcards
In inspection of the anterior chest, you look for:
- respiratory distress (wheezing, stridor, labored breathing)
- work of breathing: accessory m. use, intercostal indrawing, abdominal breathing, flail chest, rate/ depth
- swelling, erythema, atrophy, deformities, scars, lesions
- central or peripheral cyanosis
- clubbing
- trachea midline
- thorax: pectus excavatum/carinatum, increased AP diameter (barrel chest)
- symmetrical chest expansion
Posterior chest inspection:
- deformities: kyphosis, scoliosis
- work of breathing: accessory muscle use, intercostal indrawing, abdominal breathing
- swelling, erythema, atrophy, deformities, scars/lesions
- symmetrical chest expansion
LO#2 is identify anatomical landmarks in assessing chest, so um not sure what landmarks they want but some important ones are:
left and right scapular lines, vertebral line, mid axillary line and anterior and posterior axillary lines..take a look?
no idea what else specifically we should know lol
but the upper right lung lobe goes from fourth rib to fifth rib @ mid axillary (horizontal fissure)
the upper left lung lobe ends at the 6th rib midclavicular line
What should you palpate for in a respiratory examination?
anterior/posterior chest wall tenderness masses tactile fremitus assess for chest expansion palpate trachea to ensure midline
why would you want to assess for chest expansion?
If there is unilaterally reduce posterior chest expansion–> lung collapse or pneumonia
What could decreased fremitus mean?
pleural effusion, thickened chest wall, pneumothorax, emphysema (decreased vibration)
What could increased fremitus mean?
consolidation of lung tissue, pneumonia, tumor, fibrosis (increased vibration)
What is crepitus and what could it mean when heard?
crackling sensation over skin surface
could mean subcutaneous emphysema
How would you percuss the anterior chest wall?
Position patients arm across chest
intercostal spaces using ladder technique (ensure bw scapulae and spinous processes)
either dull, resonant, or hyperresonant
How would you percuss the posterior chest wall?
breath sounds, air entry quality
presence of adventitia: crackles, wheezes, rhonchi, pleural friction rubs
types of breath sounds/location: vesicular, bronchovesicular, bronchial or tracheal
How do you percuss in a resp exam?
palm over chest wall, middle finger strikes 2nd phalanx, movement from waist
What would bone percussion sound like?
flatness
What would diaphragm, masses, and fluid percussion sound like?
dullness (normal on left 3rd - 5th ICS)
What would lung percussion sound like?
resonant
What would hyperinflated lung percussion sound like?
hyperresonant
What would abdominal percussion sound like
tympany
What is diaphragmatic excursion?
determine level of diaphragm w/ inspo and expo on posterior thorax
normal 3-5.5
What would you do in auscultation on a resp exam?
assess ant and posterior, ask pt to breathe with mouth open, in and out
posterior chest: arms crossed over chest to move scapulae laterally
use stethoscope and ladder pattern sweeping side to side comparing symmetry at each level
listen for major breath/adventitious sounds
What does it mean if bronchovesicular/bronchial breath sounds are heard in locations where vesicular sounds are expected?
means that air filled lung has most likely been replaced by fluid filled or solid lung tissue
What is the duration + location of the normal vesicular(soft) breath sounds?
duration: longer than inspiration
location: over most of both lungs
What is the duration + location of the normal bronchovesicular (medium intensity) breath sounds?
duration: equal in inspo + expo
location: in 1st + 2nd ICS anteriorly, intrascapular area posteriorly
What is the duration + location of the normal bronchial (loud) breath sounds?
duration: longer in expo, silent gap bw inspo and expo
location: central, around sternal area
What is the duration + location of the normal tracheal (very loud) breath sounds?
duration: equal in inspo and expo, silent gap
location: trachea, upper portion of parasternal aspects to ICS 2
What is hyperpnea?
deep breathing
What is obstructive breathing like?
prolonged expiratory phase iv.
What is Cheyne-stokes?
cyclic crescendo-decrescendo respiratory effort (rate and volume) followed by periods of apnea
What is Kussmaul?
deep breathing w/ metabolic acidosis; rate may be fast, slow or normal
What is ataxic breathing?
irregular and unpredictable breathing which may be shallow or deep and may stop for periods of time
What are the signs of respiratory distress (theres a lot lol):
accessory muscle use
tripod position
pursed lip breathing
intercostal in-drawing
tracheal tug
stridor
displacement of trachea from midline
chest expansion
skin color /cyanosis
clubbing
chest deformities
pectus excavatum/carinatum
barrel chest
flail chest
paradoxical movement
abnormal spinal curvatures
altered work of breathing–> V/Q mismatch
Central cyanosis involves the:
lips, frenulum, buccal mucosa
Peripheral cyanosis involves the:
fingers, toes, ears, nose
Flail chest:
multiple sequential rib fractures form an independently mobile segment of chest wall
Paradoxical movement:
chest moves inward during inspo and outward on expo
What are some visual signs of airway obstruction?
Agitation, poor air movement, rib retraction, deformity, foreign material
What are some auditory signs of airway obstruction?
Speech? “How are you”
hoarseness, noisy breathing, gurgle, stridor
What are some palpatory signs of airway obstruction?
fracture crepitus
tracheal deviation
hematoma
face
What order do you perform the exam in a resp patient?
inspect–> palpate–> percuss–> auscultate
What is an important finding of consolidation?
increased bronchial breath sounds
What is an important finding of pleural effusion?
decreased percussion note (duller)
What is an important finding of lobar collapse?
mediastinal shift TOWARDS collapse
What is an important finding of pneumothorax?
increased percussion note (more resonant)
opp of pleural effusion and most other issues
What is an important finding of pneural thickening?
decreased chest wall movements
How do you assess adventitious sounds?
assess location and timing in resp cycle (inspo and expo) and whether they clear with cough
Does basilar atelectasis clear with cough?
Yes, with cough or deep breath
What are discontinuous breath sounds?
intermittent, NON musical
CRACKLES!
scratching sound
fine, soft, high pitched, brief
What are continuous breath sounds?
musical and prolonged
WHEEZING (rales)- relatively high pitched, lower airway obstrxn
may have end inspo or end expo charater
What do rhonchi sound like?
low pitch with snoring quality
denotes secretions/fluids in airways
What does stridor sound like?
high pitched on INSPO, typically appear airway (above sternal notch) denoting obstrxn either intrinsically or extrinsically
Quick review of the transmitted voice sounds specialty tests (not an LO), but describe bronchophony, egophany, and whispered pectorliquoy:
Bronchophony: auscultate posterior chest “nighty-nine”; should be soft and muffled; if LOUD and clear, consider LUNG CONSOLIDATION
Egophany: evaluates intensity of spoken voice; have pt say “eee”; should hear soft, muffled “eee”; if “aaa” heard–> LUNG CONSOLIDATION
Whispered Pectoriloquoy: performed when (+) bronchophony auscultated; have pt whisper “1,2,3” sound should be faint, and muffled; clear with lung consolidation
