Respiratory Examination Flashcards
What should be looked for at end of the bed?
General appearance Accessory muscle use, pursed lip breathing Cachexia/nutritional status Oxygen, fluids, meds Sputum pot (look inside)
what is pursed lip breathing a sign of?
lower airway obstruction (usually COPD)
what does cachexia suggest?
copd, malignancy
what should be checked on the hands?
Peripheral cyanosis Temperature Dilated veins Tar staining/ coal dust tattoos 1st wed space wasting
what is the temperature of the hands in central cyanosis?
warm
what is the temperature of the hands in peripheral cyanosis?
Cold
What is Raynaud’s?
Change in peripheries colour to white
Caused by spasm of small arteries restricting blood flow
What does dilation of the blood vessels in the skin suggest?
Hypercapnia
what does tar staining/ coal dust tattoos show?
Smoker
Mining
Risk for coal-workers pneumoconiosis
What does 1st web space wasting on hands suggest?
T1 lesion (e.g. pancoast tumour)
what needs to be looked at on the nails?
Finger clubbing
Koilonychia
what are the respiratory causes of clubbing
Interstitial lung disease
Malignancy (bronchogenic carcinoma, mesothelioma)
Suppurative lung disease
what are the types of suppurative lung disease?
Bronchiectasis (pus in the tubes)
Abscess (pus in a collection)
Empyema (pus outside lung)
Cystic fibrosis (pus everywhere)
what are the cardiovascular causes of clubbing?
Infective endocarditis
Cyanotic congenital heart disease
Atrial myxoma
what are the gastro causes of clubbing?
IBD
Hepatic cirrhosis
GI lymphoma
Coeliac disease
what is koilonychia a sign of?
Iron deficiency anaemia (cause of SOB)
what should be looked for in the wrist?
Flapping tremor (asterixis)
Fine physiological tremor
Respiratory rate
Radial pulse (rate and volume)
what is asterixis a sign of?
Respiratory failure (CO2 retention) Hepatic/renal failure
what drug can cause a fine physiological tremor?
Beta agonist (salbutamol)
how do you take respiratory rate?
Count over 15sec while pretending to take pulse
what may cause a bounding pulse?
Hypercapnia
what do you check for on the face?
cushingoid (moon face, plethora, acne, hirsute)
what may cause cushingoid face?
long term steroid treatment (e.g for cryptogenic fibrosing alveolitis, asthma, COPD, pulmonary fibrosis)
what should be checked for in the eyes?
conjunctival pallor
horner’s
what are some signs of horner’s in the eyes?
ptosis
miosis
what is a cause of conjunctival pallor?
anaemia
what are the causes of horner’s syndrome?
central lesion T1 root lesion brachial plexus lesion neck lesion with cluster headaches
what may be the cause of central lesion in horner’s syndrome?
stroke/tumour/MS
syringobulbia
what are the causes of T1 root lesion causing horner’s syndrome?
spondylosis
neurofibroma
what are the causes of brachial plexus lesion causing horner’s syndrome?
pancoast tumour
cervical rib
trauma/birth injury
what are the causes of neck lesion causing horner’s syndrome?
tumour
carotid artery aneurysm
sympathectomy
what should be checked for in the mouth?
central cyanosis
candida
what are the causes of central cyanosis?
hypoxic lung disease
cardiac shunt
abdormal Hb- methaemoglobinaemia (drugs, toxins)
what are the causes of peripheral cyanosis?
peripheral vascular disease
raynaud’s syndrome
heart failure
shock
what may cause candida in the mouth?
steroid inhalers
immunocompromised patient
what should be checked in the neck?
JVP
trachea
lymph nodes
how should the trachea be palpated?
“im going to feel for your windpipe”- always warn patient
position
cricosternal distance
“take a deep breath in”- any tug on inspiration
what may cause trachea deviation?
towards collapse
away from tension/big effusion
what is the normal cricosternal distance?
2-3 fingers
what may change cricosternal distance?
reduced in hyperinflation –> COPD
what should be checked before palpating lymph nodes?
any pain in neck
what does tender lymph nodes suggest?
infection
what do non-tender raised lymph nodes suggest?
suspicious of malignancy
what should be checked on inspection?
anterior-posterior diameter (A-P diameter)
scars (check back and sides)
deformity of chest/spine
intercostal indrawing (Hoover’s sign)
what can A-P diameter increase be a sign of
hyperinflation (COPD)
what scars may be seen on the chest?
thoracotomy (lobectomy/ pneumonectomy)
old chest drain sites
what deformities of the chest may be seen?
pectus excavatum
pectus carinatum
scoliosis
what disease may cause pectus carinatum?
asthma
what disease may cause hoover’s sign?
hyperinflation (COPD)
what should be done on palpation of respiratory system?
chest expansion
apex beat
RV heave
what should be assessed in chest expansion?
palpate chest wall in 2 separate places
asymmetry
what may cause displacement of apex beat?
mediastinal shift (collapse, tension, big effusion)
what may cause RV heave
right ventricular hypertrophy (possible cor pulmonale)
how many places should be checked on percussion?
8-10 places
where should you start in percussion?
supraclavicular fossae and work down chest
how should auscultation be carried out?
- take deep breath in and out through mouth”
any wheeze or crepitations
if crepitations heard, ask patient to cough and lsiten again - vocal resonance- 99
what does increased vocal resonance suggest?
consolidation
what does decreased vocal resonance suggest?
collapse
effusion
pneumothorax
what should be done in areas of increased vocal resonance?
whispering pectoriloquy
what is whispering pectoriloquy?
whisper 99 every time i touch your chest with stethoscope
whispering would usually not be heard
what causes whispering pectoriloquy?
loud conduction of whispered voice due to consolidation
what causes wheeze?
small airway obstruction (COPD)
what causes crepitations?
fluid in airspaces: secretions, pus, oedema
what should be checked on back?
sacral oedema
what should be checked on legs?
peripheral oedema
what causes sacral and peripheral oedema?
right heart failure (e.g cor pulmonale)
what should be done in conclusion?
review observation chart (HR, BP, RR, SpO2, temp)
investigation:
- peak flow
- PFTs
- CXR
- ABGs to check perfusion
what should be done after all anterior tests?
repeat same process posteriorly
what findings would be found on consolidation? mediastinal shift percussion note breath sounds vocal resonance
no change in mediastinal shift
percussion dull
breath sounds bronchial or low
vocal resonance increased
what findings would be found on collapse/lobectomy/pneumonectomy? mediastinal shift percussion note breath sounds vocal resonance
mediastinal shift towards collapse
percussion note dull
breath sounds decreased on absent
vocal resonance decreased or absent
what findings would be found on effusion/ raised hemidiaphragm
mediastinal shift away if big
percussion node stony dull
breath sounds low or absent
vocal resonance low or absent
what findings would be found on pneumothorax?
mediastinal shift away if tension
percussion hyper-resonant
breath sounds low or absent
vocal resonance low or absent
what findings would be found on pneumonectomy?
mediastinal shift towards
percussion note dull
breath sounds absent
vocal resonance absent
how do you distinguish between collapse and lobectomy/pneumonectomy?
thoracotomy scar on chest
indications for lobectomy/pneumonectomy?
bronchogenic cancer (25% non-small cell lung cancer are resectable)
bronchiectasis
trauma
TB
how do you distinguish betwen effusion and raised hemidiaphragm?
examination findings identical
CXR to differentiate
what are the cause of raised hemidiaphragm?
phrenic nerve palsy
caused by thoracic surgery, trauma, malignancy
what are the signs of hyperinflation?
reduced cricosternal distance +/- tracheal tug increased A-P diameter intercostal indrawing (Hoover's sign) apex beat not palpable hyper-resonant percussion note
what are the features of bronchial breathing?
loud and blowing
inspiration length= expiration
audible gap between inspiration and expiration
reproducible by placing stethoscope over trachea
what are the types of pleural effusion?
transudate and exudate
what are the differences between transudate and exudate pleural effusion
transudate protein <30g/l
exudate protein >30 g/l
what are the causes of transudate pleural effusion?
LVF
volume overload
hypoalbuminemia
meig’s syndrome
what are the causes of exudate pleural effusion?
infection- pneumonia, TB
infarction- PE
inflammation- rheumatoid arthritis, SLE
malignancy- bronchogenic, mesothelioma
what are the types of breathing
bronchial and vesicular
where are vesicular breath sounds heard?
normally over most of lung
