RESPIRATORY EXAMIMATION Flashcards
How would you start any examination?
WIPER QQ Wash hands Introduce yourself Ask permission Expose the patient Reposition the patient
Ask if they are in any pain or discomfort
How exposed should the patient be for the respiratory examination?
Top half of their body fully exposed
How should the patient be positioned for the respiratory examination?
Lying down at 45 degrees
What are you looking for from the end of the bed at the beginning of your respiratory examination? (Name 3 things about the patient and 3 things around the bed)
Comfortable at rest Tachypnoeic Nasal flaring Tracheal tug (pulling of thyroid cartilage towards sternal notch in inspiration) Use of accessory muscles Scars of surgery, chest drains or radiotherapy Symmetrical chest wall movement Paradoxical respiration Inhalers Oxygen masks Cigarettes
What is paradoxical respiration?
When the abdomen is pulled in during inspiration.
What is paradoxical respiration a sign of?
Diaphragmatic paralysis
What signs would you look for in the hands of a patient during a respiratory exam?
Clubbing
Tar stains
Fine tremor
Wasting of intrinsic muscles
What are the respiratory associated reasons for someone developing clubbed fingers?
Non-small cell lung cancer Interstitial lung disease Complicated TB Bronchiectasis Empyema Cystic fibrosis Lung abscess Mesothelioma of pleura
What might make a respiratory patient have a fine tremor?
Salbutamol inhaler (Beta 1 agonist)
What might lead to wasting of the intrinsic muscles in a respiratory patient?
Pancoast tumour leading to a T1 lesion
What is asterixis a sign of?
CO2 retention
How long should a patient how up their arms to test for asterixis in a respiratory exam?
30 seconds
In terms of respiratory medicine, what might a bounding radial pulse be a sign of?
CO2 retention
What would you look for in the neck during a respiratory exam?
Jugular venous pressure
What might a raised JVP be a sign of?
Right sided heart failure
Hypervolaemia
Cor pulmonale
Should the JVP naturally go and up with breathing?
Yes, there should be a decrease in the JVP with inspiration.
What is the Kussmaul sign?
This is when the JVP paradoxically increases during inspiration. It is indicative of limited right ventricular filling.
What should you look for in the patient’s eyes during a respiratory examination?
Ptosis Constricted pupils (Horner's syndrome)
What is a pancoast tumour?
Tumor of the pulmonary apex
Which lymph node is it most important to palpate in a respiratory examination?
Virchow’s node (left supraclavicular node)
What might you be looking during your inspection of the chest in a respiratory examination?
Abnormalities such as pectus excavatum
Scars
What must you not forget to palpate in the midline of the neck during a respiratory examination before moving on to palpation of the chest?
The trachea
What would tracheal deviation be a sign of?
Tension pneumothorax
Collapsed lung/lobe
How far should your thumbs move apart when assessing chest expansion during a respiratory exam?
5 cm
What are you looking for when assessing chest expansion during a respiratory exam?
Extent of expansion
Symmetry of expansion
When might chest expansion be reduced bilaterally?
COPD
Asthma
Generalised fibrosis
When might chest expansion be asymmetrical?
Pneumonia Lobe collapse Localised fibrosis Pleural effusion Large pneumothorax
What might produce a dull percussion note during a respiratory exam?
Lobar pneumonia Lobe collapse Localised fibrosis Pleural effusion Tumour
What might produce a hyperresonant percussion note during a respiratory exam?
Pneumothorax
Emphysema
What are you looking for when auscultating during a respiratory exam?
Reduced breath sounds Increased or reduced vocal resonance Polyphonic wheeze Stridor Fine crackles Coarse crackles
How would you describe healthy breath sounds?
Vesicular
When might you hear more bronchial breath sounds during a respiratory exam?
Pneumonia
Localised fibrosis
Lobar collapse
When might you hear reduced breath sounds during a respiratory exam?
Pleural effusion
Pneumothorax
In healthy lungs, are high frequency notes (such as whispering) better or less well transmitted through the lungs than low frequency sounds (such as saying ‘99’)?
High frequency notes are normally attenuated compared to low frequency notes, in healthy lungs. So low frequency notes will be better transmitted.
In a consolidated lung, how might low frequency sounds be transmitted compared with a healthy lung?
Less well. High frequency sounds are heard better, so get the patient to whisper if you suspect consolidation. The sound should be enhanced.
During a respiratory exam, when might vocal resonance be increased?
Pneumonia
Collapsed lobe
Fibrosis
During a respiratory exam, when might vocal resonance be reduced?
Collapsed major bronchus
Pleural effusion
Pneumothorax
During what part of the respiratory cycle is wheeze usually heard?
Expiration
During a respiratory exam, when might a polyphonic wheeze be heard?
Asthma
COPD
What is the underlying pathology of an expiratory wheeze?
Narrowing of the airways. Apposition as a result of the flow-limiting mechanisms.
Why might wheeze not be heard in a patient suffering a severe asthma attack?
Insufficient airflow to generate any sound. This is indicative of an emergency.
When might an end inspiratory wheeze be heard?
Obliterative bronchiolitis
During what part of the respiratory cycle are crackles usually heard?
Inspiration
During a respiratory exam, what might fine late inspiratory crackles be an indication of?
Pulmonary oedema
Generalised fibrosis
During a respiratory exam, what might coarse inspiratory crackles be an indication of?
Bronchiectasis
COPD
Localised fibrosis
Consolidation (pneumonia)
What are crackles, often heard during a respiratory exam?
The re-opening of airways during inspiration, which had become occluded during expiration.
What is pleural rub, sometimes heard during a respiratory exam, and what does it indicate?
A creaking or groaning sound that is usually well localised. It indicates inflammation and roughening of the pleural surfaces. Present with an adjacent pneumonia or pulmonary infarction.
What would you tell an examiner you would like to do to finish a respiratory exam?
Check their O2 sats
Sputum sample
Peak expiratory flow rate
What are the different types of abnormal breathing patterns that might be exhibited by a patient during a respiratory exam?
Kussmaul breathing
Neurogenic hyperventilation
Hyperventilation syndrome
Cheyne-Stokes breathing
What is Kussmaul breathing a sign of?
Metabolic acidosis most often seen in a patient suffering DKA.
What drug might a patient have taken an overdose of if they present to A&E with hyperventilation and respiratory alkalosis?
Aspirin
What is Cheyne-Stokes breathing?
Breathing gets deeper and deeper and then starts to get shallower in cycles.
What is Cheyne-Stokes breathing a sign of?
Brainstem lesions or compression
Opioid use
When inspecting a sputum sample, what might black carbon specks in the sputum be indicative of?
Smoking
When inspecting a sputum sample, what might yellow/green sputum be indicative of?
Infection
Pneumonia
Bronchiectasis
When inspecting a sputum sample, what might pink frothy sputum be indicative of?
Pulmonary oedema
When inspecting a sputum sample, what might bloody sputum be indicative of?
TB
Malignancy
Infection
Trauma
