Respiratory Examination Flashcards
What angle should the bed be at in a resp exam?
45 degrees
What should be exposed in a resp exam?
The chest and the lower legs
What is the importance of age in a resp exam?
May help indicate the pathology
What resp diagnoses are more likely in younger patients?
Asthma or CF
What resp diagnoses are more likely in older patients?
COPD, interstitial lung disease or malignancy
What is cyanosis?
Bluish discolouration of the skin due to poor circulation or inadequate oxygenation of blood
What are some causes of cyanosis?
- Peripheral vasoconstriction secondary to hypovolaemia
- Right-to-left cardiac shunting
What are the signs of shortness of breath clinically?
- Nasal flaring
- Pursed lips
- Use of accessory muscles
- Intercostal muscle recession
- Tripod position (sitting or standing leaning forward and supporting the upper body with hands on knees)
What is a significant indicator of shortness of breath?
Inability to speak in full sentences
What conditions may present with shortness of breath?
- Asthma
- Pulmonary oedema
- Pulmonary fibrosis
- Lung cancer
- COPD
What pathologies may a productive cough be associated with?
- Pneumonia
- Bronchiectasis
- COPD
- CF
What pathologies may a dry cough be associated with?
- Asthma
- Interstitial Lung Disease
What is a wheeze?
A continuous, coarse, whistling sound produce in the respiratory airways during breathing
What conditions is a wheeze associated with?
Asthma, COPD, bronchiectasis
What is stridor?
A high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways
What are causes of stridor?
Foreign bodies or subglottic stenosis
What may cause pallor?
Underlying anaemia or poor perfusion
What conditions may cause pallor?
Haemorrhage, chronic disease, congestive cardiac failure
How does oedema present?
- Swelling of the limbs (pedal oedema)
- Abdominally (ascites)
What is oedema associated with?
Right ventricular failure
What does pulmonary oedema occur secondary to?
Left ventricular failure
What objects and equipment should be noted on a resp exam?
- Oxygen delivery devices
- Sputum pot
- Other medical equipment
- Cigarettes or vaping equipment
- Mobility aids
- Vital signs
- Fluid balance
- Prescriptions
What should be noted on general inspection of the hands in a resp exam?
- Colour
- Tar staining
- Skin changes
- Joint swelling or deformity
What is the importance of the colour of the hands in a resp exam?
Cyanosis of the hands may suggest underlying hypoxaemia
What is the importance of the tar staining of the hands in a resp exam?
- Caused by smoking
- Risk factor for respiratory disease (COPD, lung cancer)
What is the importance of the skin changes of the hands in a resp exam?
- Bruising and thinning of the skin can be associated with long-term steroid use
- Associated with asthma, COPD, ILD
What is the importance of joint swelling or deformity of the hands in a resp exam?
- May be associated with rheumatoid arthritis
- Has extra-articular manifestations e.g. pleural effusions/pulmonary fibrosis
What is finger clubbing?
Uniform soft tissue swelling of the terminal phalanx of a digit
What is finger clubbing associated with?
- Lung cancer
- ILD
- CF
- Bronchiectasis
How do you assess for finger clubbing?
- Place the nails of the index fingers back to back
- Should be a diamond space window
- This is lost in finger clubbing
Why is assessing for a fine tremor important in a resp exam?
Associated with beta-2-agonist use
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
What may a aserixis indicate?
Carbon dioxide retention - type 2 resp failure
How do you investigate for asterixis?
- Ask the patient to cock their hands backward at the wrist
- Observe
What are the important aspects of temperature in a resp exam?
- Cool hands = poor peripheral perfusion
- Excessively warm = CO2 retention
What pulse should be took in a resp exam?
- Radial pulse
- Should be used to calculate heart rate - count for 60s if irregular
When may a bounding pulse be found in a resp exam?
Associated with underlying CO2 retention e.g. type 2 resp failure
When may a pulsus paradoxus be found in a resp exam?
- Late sign of cardiac tamponade
- Severe acute asthma
- Severe COPD exacerbations
What is pulsus paradoxus?
When the pulse wave volume decreases significantly during inspiration
When should you observe a patients resp rate?
While pretending to do the pulse
What asymmetries may there be in the resp rate in a resp exam?
The expiratory phase may be longer in asthma exacerbations/COPD
Name a cause of bradypnoea
Opiate overdose
Name a cause of tachypnoea
Acute asthma
What may the JVP indicate?
An indirect measure of the central venous pressure
How do you measure the JVP?
- Ask the patient to turn their head to the left
- Inspect for the IJV, between the medial end of the clavicle and the ear lobe
- Measure the JVP by assessing the vertical distance between the sternal edge and the top of the pulsation point of the IJV
What is a healthy length for the JVP?
No greater than 3cm
What does a raised JVP indicate?
Venous hypertension
What is a resp cause of raised JVP?
Pulmonary hypertension:
- Causes R HF, due to COPD/ILD
What are 3 cardio causes of raised JVP?
- Congestive heart failure
- Tricuspid regurgitation
- Constrictive pericarditis
What is the purpose of the hepatojugular reflux test?
It involves application of pressure to the liver whilst observing for a sustained raise in JVP
What does a plethoric complexion indicate in a resp exam?
- Polycythaemia (COPD)
- CO2 retention (type 2 resp failure)
What is a plethoric complexion?
A congested red face
What may conjunctival pallor indicate?
Underlying anaemia
What is the importance of looking for Horner’s syndrome in a resp exam?
It occurs when the sympathetic trunk is damaged by a pathology e.g. lung cancer affecting the apex of the lung (Pancoast tumour)
What are the features of Horner’s syndrome?
- Ptosis
- Miosis
- Enophthalmos
- May also be anhydrosis
What are two important mouth signs to look for in a resp exam?
- Central cyanosis (hypoxaemia)
- Oral candidiasis (fungal infection associated with steroid inhaler use)
What are the importance off inspecting scars in a resp exam?
See if there has been any cardio/resp procedures or radiotherapy-associated skin changes
What is the importance of noting asymmetry in chest wall deformities?
Typically associated with pneumonectomy or thoracoplasty
What is pectus excavatum?
A caved-in or sunken appearance of the chest
What is pectus carinatum?
Protrusion of the sternum and ribs
What is barrel chest?
- Chest wall appears wider and taller than normal
- Associated with chronic lung diseases such as asthma and COPD
How do you assess tracheal position?
- Dip your index finger into the thorax beside the trachea
- Gently apply side pressure to locate the border of the trachea
- Compare this space to the other side of the trachea using the same process
- Difference in space = deviation
In what conditions does the trachea deviate away from the affected side?
- Tension pneumothorax
- Large pleural effusions
In what conditions does the trachea deviate towards the affected side?
- Lobar collapse
- Pneumonectomy
What is the cricosternal distance?
The distance between the inferior border of the cricoid cartilage and the suprasternal notch
How do you assess the cricosternal distance?
- Measure the distance between the suprasternal notch and cricoid cartilage using fingers (BASED ON PATIENT FINGERS)
What does an abnormal cricosternal distance indicate?
Lung hyperinflation e.g. asthma, COPD
Why is it important to palpate the apex beat in a resp exam?
Due to there being resp causes
How do you palpate the apex beat?
- Place fingers horizontally across the chest
- Usually in the 5th intercostal space in the midclavicular line
What are respiratory causes of a displaced apex beat?
- R ventricular hypertrophy (pulm HTN, COPD, ILD)
- Large pleural effusion
- Tension pneumothorax
How do you assess chest expansion?
- Place the 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
- Reduced movement of one of your thumbs indicates reduced expansion on that side
What are symmetrical causes of reduced chest expansion?
- Pulmonary fibrosis
- Reduces lung elasticity, restricting overall chest expansion
What are asymmetrical causes of reduced chest expansion?
- Pneumothorax
- Pneumonia
- Pleural effusion
What areas should be percussed on a resp exam?
- Supraclavicular region (lung apices)
- Infraclavicular region
- Chest wall (3-4 locations bilaterally)
- Axilla
What may a resonant percussion mean in a resp exam?
Normal finding
What may a dull percussion mean in a resp exam?
- Increased tissue density
- Causes - cardiac dullness, consolidation, tumour, lobar collapse
What may a stony dullness percussion mean in a resp exam?
Underlying pleural effusion
What may a hyper-resonant percussion mean in a resp exam?
- Decreased tissue density
- Cause - pneumothorax
How do you assess tactile vocal fremitus?
Palpate over different areas of the chest while an number (e.g. 99) is constantly repeated using the ulnar border of your hand
What does increased vibration in tactile vocal fremitus mean?
- Increased tissue density
- Consolidation, tumour, lobar collapse
What does decreased vibration in tactile vocal fremitus mean?
- Presence of fluid or air outside the lung
- Pleural effusion, pneumothorax
What is the technique to auscultate the chest?
- Place the stethoscope over the relevant locations of the chest
- Listen on expiration and inspiration
- Assess the quality and volume of breath sounds, and added sounds
What is the relevance of a vesicular breath sounds on a resp exam?
Normal in healthy people
What is the relevance of a bronchial breath sounds on a resp exam?
- Harsh sounding
- Inspiration & expiration are equal and there is a pause between
- Associated with consolidation
What does a quiet breath sound on auscultation indicate?
Reduced air entry into that region of the lung e.g. pleural effusion, pneumothorax
What does a wheeze sound like on auscultation?
A continuous, coarse, whistling sound produced in the respiratory airways during breathing
In which conditions may there be a wheeze?
Asthma, COPD and bronchiectasis
What does a stridor sound like on auscultation?
A high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways
In which conditions may there be a stridor?
Foreign body inhalation & subglottic stenosis
What do coarse crackles sound like on auscultation?
Discontinuous, brief, popping lung sounds
In which conditions may there be coarse crackles?
Pneumonia, bronchiectasis and pulmonary oedema
What do fine end-inspiratory crackles sound like on auscultation?
Separating velcro
In which conditions may there be fine end-inspiratory crackles?
Pulmonary fibrosis
How do you assess vocal resonance?
Auscultating over different areas of the chest while a patient repeats a number
What does an increased volume of vocal resonance indicate?
- Increased tissue density
- Consolidation, tumour, lobar collapse
What does a decreased volume of vocal resonance indicate?
- Presence of fluid or air outside the lung
- Pleural effusion, pneumothorax
What are respiratory causes of lymphadenopathy?
- Lung cancer with metastases
- Tuberculosis
- Sarcoidosis
Which lymph nodes should be felt in a respiratory exam?
- Under chin
- Behind ears
- Along length of clavicle
Which types of oedema should be noted in a resp exam and what may it indicate?
- Sacral
- Pedal
- Congestive heart failure
Why should the calves be assessed in a resp exam?
- To look for signs of a DVT
- May have SOB secondary to a PE
What further assessments and investigations should be carried out after a resp exam?
- Vital signs
- Sputum sample
- Peak flow
- Chest X-ray
- ABG
- Cardio exam if indicated
