Respiratory Examination Flashcards
What 9 things are you looking for during your ‘end of the bed’ general inspection during a respiratory examination?
- Age
- SOB
- Cyanosis
- Cough
- Wheeze
- Stridor
- Oedema
- Pallor
- Cachexia
Potential signs of SOB?
- Nasal flaring
- Accessory musles
- Pursed lips
- Intercostal muscle recession
- Tripod position
What is the tripod position?
Sitting or standing leaning forward and supporting the upper body with hands on knees or other surfaces
Possible underlying diagnoses of SOB?
- Asthma
- Pulmonary oedema
- Pulmonary fibrosis
- COPD
- Lung cancer
Name 3 respiratory pathologies associated with a productive cough?
Bronchiectasis, COPD, CF
Name 2 respiratory pathologies associated with a dry cough?
Asthma, interstitial lung disease
What is a ‘wheeze’?
a continuous, coarse, whistling sound produced in the respiratory airways during breathing
Name 3 respiratory pathologies associated with a wheeze?
Asthma, COPD, bronchiectasis
What is stridor?
a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways
Name an acute and a chronic cause of stridor?
Acute - foreign body inhalation
Chronic - subglottic stenosis
What is cachexia?
Ongoing muscle loss that is not entirely reversed with nutritional supplementation
Which cardiac condition is pedal oedema/ascites typically associated with?
Right ventricular failure
Which cardiac condition is pulmonary oedema typically associated with?
Left ventricular failure
Which respiratory pathologies can be associated with cachexia?
- Underlying malignancy (lung cancer)
- End-stage respiratory diseases (COPD)
Which 7 signs are you assessing when examining the hands during a respiratory examination?
- Colour
- Tar staining
- Skin changes
- Joint swelling/deformity
- Finger clubing
- Fine tremor
- Flapping tremor/asterixis
What could bruising and thinning of the skin of the hands be associated with?
Long-term steroid use (e.g. asthma, COPD, interstitial lung disease)
Which condition cause joint swelling or deformity of the hands be associated with?
Rheumatoid arthritis
What is a respiratory manifestation of rheumatoid arthritis?
Pleural effusions, pulmonary fibrosis
Name 4 respiratory pathologies associated with finger clubbing
- lung cancer
- CF
- interstitial lung disease
- bronchiectasis
How do you assess for a fine tremor?
Ask the patient to hold out their hands in an outstretched position and observe for a fine tremor
A fine tremor is typically associated with the use of what?
beta-2-agonist (e.g. salbutamol)
What is the respiratory cause of a flapping tremor/asterixis?
CO2 retention in conditions that result in type 2 respiratory failure (e.g. COPD)
Name 2 other causes of a flapping tremor
Uraemia, hepatic encephalopathy
How do you assess for a flapping tremor?
- Whilst the patient still has their hands stretched outwards, ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
- Observe for evidence of asterixis during this time period.
What can excessively warm and sweaty hands be associated with?
CO2 retention
What is a bounding pulse asociated with?
Underlying CO2 retention (e.g. type 2 respiratory failure)
What is bradypnoea defined as?
A respiratory rate of fewer than 12 breaths per minute
An overdose of what can lead to bradypnoea?
Opiates
What is tachypnoea defined as?
A respiratory rate of more than 20 breaths per minute (e.g. acute asthma)
How would a raised right atrial pressure affect the IJV?
Distension of the IJV
What is the major respiratory cause of a raised JVP?
Pulmonary hypertension (often due to COPD or interstitial lung disease) –> this causes right sided heart failure
Position of IJV:
What would a plethoric complexion of the face indicate?
Polycythaemia (e.g. COPD) and CO2 retention (e.g. type 2 respiratory failure).
What condition would conjunctival pallor indicate?
Anaemia
What symptom should you also ask about if a patient presents with miosis and ptosis?
Anhydrosis
How can Horner’s syndrome indicate a respiratory pathology?
Horner’s syndrome occurs when the sympathetic trunk is damaged by pathology such as lung cancer affecting the apex of the lung (e.g. Pancoast tumour).
Which 2 major signs are you looking for in the mouth during a respiratory examination?
- Central cyanosis
- Oral candidiasis
What is oral candidiasis associated with?
Steroid inhaler use (due to local immunosuppression)
What is oral candidiasis characterised by?
Pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
Location of;
a) midline sternotomy scar
b) pacemaker scar
c) anterolateral thoracotomy scar
d) left mid-axillary scar
Does the trachea deviate towards or away from a tension pneumothorax?
Away from
Does the trachea deviate towards or away from lobar collapse?
Towards
Does the trachea deviate towards or away from a pneumonectomy?
Towards
Does the trachea deviate towards or away from a large pleural effusion?
Away from
What is the cricosternal distance?
The distance between the inferior border of the cricoid cartilage and the suprasternal notch.
What is the cricosternal distance in healthy individuals?
3-4 fingers
What should you do when measuring cricosternal distance if the patient’s fingers are significantly different in size from your own?
Use their fingers - cricosternal distance is actually based on the size of the patient’s fingers.
What does a distance of fewer than 3 fingers suggest?
Lung hyperinflation
What conditions is lung hyperinflation seen in?
Asthma, COPD
In healthy individuals, where is the apex beat located?
5th intercostal space midclavicular line
What are 3 major respiratory causes of a displaced apex beat?
- Right ventricular hypertrophy caused by e.g. pulmonary hypertension, COPD, interstitial lung disease
- Large pleural effusion
- Tension pneumothorax
How do you assess chest expansion?
- Place your hands on the patient’s chest, inferior to the nipples.
- Wrap your fingers around either side of the chest.
- Bring your thumbs together in the midline, so that they touch.
- Ask the patient to take a deep breath in.
- Observe the movement of your thumbs
How should your thumbs move when assessing chest expansion in healthy individuals?
They should move symmetrically upwards/outwards during inspiration and symmetrically downwards/inwards during expiration
What is a respiratory cause of symmetrical reduced chest expansion?
Pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion
Name 3 respiratory causes of asymmetrical reduced chest expansion?
pneumothorax, pneumonia and pleural effusion would all cause ipsilateral reduced chest expansion.
What are the 4 areas of the chest to percuss when conducting a respiratory exam?
- Supraclavicular region: lung apices
- Infraclavicular region
- Chest wall: percuss over 3-4 locations bilaterally
- Axilla
Make sure you repeat/compare on each side!
Which part of the lung are you percussing in the supraclavicular area?
Lung apices
What is a ‘normal’ percussion note?
Resonant
What does a ‘dull’ percussion note indicate?
Suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).
What condition is a ‘stony dull’ percussion note typically caused by?
An underlying pleural effusion
Which percussion note is the opposite of ‘dull’?
Hyper-resonant
What does a hyper-resonant percussion note suggest?
Decreased tissue density (e.g. pneumothorax).
Which respiratory pathology could cause decreased tissue density?
Pneumothorax
What would increased vibration over an area suggest when assessing tactile vocal fremitus?
Increased tissue density (e.g. consolidation, tumour, lobar collapse)
What would decreased vibration over an area suggest when assessing tactile vocal fremitus?
The presence of fluid or air outside of the lung (e.g. pleural effusion, pneumothorax).
What is the breath sound of a healthy individual?
Vesicular
What is lung consolidation?
Lung consolidation occurs when the air that usually fills the small airways in your lungs is replaced with something else e.g. pus, water, blood
What type of breath sound is associated with consolidation?
Bronchial
Describe a bronchial breath sound
Harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a pause between
How would reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax) affect the volume of breath sounds?
Quiet breath sounds
What conditions is a wheeze associated with?
Asthma, COPD and bronchiectasis
Describe fine-end respiratory crackles
Sound similar to the noise generated when separating velcro
What respiratory pathology are fine-end respiratory crackles associated with?
Pulmonary fibrosis
What does assessing vocal resonance involve?
Assessing vocal resonance involves auscultating over different areas of the chest wall whilst the patient repeats a word or number consistently.
What are 3 respiratory causes of lymphadenopathy?
1) Lung cancer with metastases
2) Tuberculosis
3) Sarcoidosis
When assessing the posterior chest during a respiratory exam, how should the patient have their arms? Why?
With the patient still sitting forwards, ask them to fold their arms across their chest so that their hands are touching the opposite shoulder.
This results in rotation of the scapulae to better expose the underlying chest wall for assessment.
What 5 things are involved during assessment of the anterior AND posterior chest?
1) Inspection
2) Chest expansion
3) Percussion
4) Tactile vocal fremitus / vocal resonance
5) Auscultation
Percussion locations on posterior chest:
Auscultation locations on posterior chest:
What 3 things should you assess for during the final steps of your respiratory examination?
- Sacral & pedal pitting oedema
- Assess calves for DVT (patient may have shortness of breath secondary to pulmonary embolism)
- Erythema nodosum
What is erythema nodosum?
Erythema nodosum is a type of panniculitis, an inflammatory disorder affecting subcutaneous fat. It presents as tender red nodules on the anterior shins.
What respiratory pathology can erythema nodosum be associated with?
Sarcoidosis
