Respiratory examination Flashcards
Summary of approach to respiratory examination
Start with “wide angle lens” to make sure you pick up all the obvious peripheral clues first
“Spiral in” on the region of interest i.e. the chest
You should have the diagnosis before you use your stethoscope!
Overall approach of respiratory examination
Introduction (without handshake: covid)
- study the hand and inspect whole patient
Examine extremities -esp. oedema
Expose the chest (consideration…)
Inspect front and back of chest
Examine the back of the chest: palpation, percussion, auscultation
Examine the front of the chest – as before
What to look out for during initial impression in a respiratory examination
Cough (character)
Wheeze (expiratory whistling noise)
Stridor (inspiratory noise)
Laboured breathing
- (raised rate = “tachypnoea”,not breathlessness)
Pursed-lipped breathing in COPD
Nutritional state: obesity may suggest a hypoventilation syndrome
“Paraphernalia”: inhalers, nebulisers, sputum pots
What is the general approach to examination?
Inspection
Palpation
Percussion
Auscultation
What to do during inspection?
Face and skin
Hands and feet
Neck
Expose the chest fully (ask, be considerate, leave bras)
Chest wall
Study breathing movements
What do you look for in the hands of a patient?
Digital clubbing
Tremor
- flapping (asterixis) in respiratory failure
- fine with beta2-agonists
Warmth, oedema, tobacco stains, coal dust tattoos
Where is digital clubbing seen often?
Commonest cause lung cancer
Other respiratory diseases when it is seen:
- Pulmonary Fibrosis
(aka Fibrosing Alveolitis)
- chronic suppurative lung disease e.g. bronchiectasis, empyema
What can be found on a patients pulse?
Bounding” with warm peripheries: CO2 retention
Don’t forget to check the respiratory rate - while the patient thinks you are counting the pulse!
When inspecting face and neck what do you check for?
Complexion, cyanosis
Eyes
Neck
jugular venous pressure:
-elevated with peripheral oedema in cor pulmonale, and in superior vena cava obstruction, when fixed
trachea:
-deviation? tracheal “tug”?
How is respiratory failure shown?
Central cyanosis (tongue, lips) - due to arterial desaturation (low PaO2)
Peripheral cyanosis much less reliable: reaction to cold, poor perfusion, anxiety etc
What to check for when inspecting the chest wall?
Deformity, under- and over-inflation
- kyphoscoliosis, barrel chest in COPD (AP diameter = lateral diameter), flattening
Scars, radiotherapy changes, aspiration wounds
Dilated veins – SVC obstruction
What to look for in chest wall movement
Rate, pattern (rhythm), prolonged expiration
Movement patterns:
Symmetry
Chest vs. abdominal
Use of “accessory” muscles
Assess expansion with your finger tips along the mid-axillary line and thumbs as pointers
What must you do in a chest wall examination?
Need to examine front and back
Most signs in the back
Don’t get patient repeatedly sitting back and forward
What are the causes of reduced chest wall movement?
Any lung, pleural or chest wall disease such as:
Kyphoscoliosis
ankylosing spondylitis
neuromuscular
What to check for when palpating?
Neck (lymph nodes and trachea)
Notch-cricoid distance
Axillae
Apex beat
Chest wall movement
What is the tactile vocal fremitus?
Say “99”
Feel vibrations with side of hands
How can we inspect percussion?
Compare left versus right and one space to the next: ‘Square wave’ pattern
Resonance implies aerated lung tissue below
Horizontal sounding-finger
Do tactile vocal fremitus, vocal resonance if uncertain about presence of dullness
Absence of cardiac and hepatic dullness in emphysema
Where is resonance lost in?
pleural effusion (“stony” dull)
consolidation/collapse/fibrosis
raised diaphragm
over the liver and heart except in emphysema
Where is resonance increased in?
in emphysema
pneumothorax
Where do we percuss posteriorly?
over trapezius
4-5 times each side
lateral chest walls (3-4 times each side)
Where do we percuss anteriorly?
over the clavicles
in mid-clavicular line (4-5 times each side)
Tips for stethoscope to remember?
“Everytime I put my stethoscope on your chest, take a breath in and out through an open mouth”
Hold your breath if you ask them to
“Don’t talk” while listening to carotids
Warm stethoscope in your hands while talking to patient
Know where the cleaning stuff is before taking your stethoscope into a patient bedspace
Don’t store it rolled up
Practice on yourself and others
How do we auscultate?
Use the diaphragm because most of the sounds are high pitched
Ask the patient to take deep breaths through the mouth (demonstrate)
Compare one side with the other
Listen
Where do we listen over when we auscultate?
over trapezius
4-5 times each side posteriorly (patent bending forward with arms forward)
in the mid-clavicular line (4-5 times each side)
over the lateral chest walls (3-4 times each side)
What are normal breath sounds called?
Vesicular
loudest on inspiration, fading smoothly into expiration and dying out
What is bronchial breathing?
Higher pitched, with distinct inspiratory and expiratory phases
heard over fibrotic or consolidated lung, above a pleural effusion
associated with “whispering pectoriloquy”
What do wheezes suggest?
Airflow obstruction
Features of crackles
more noticeable at the bases (small airway closure)
can be caused by
secretions in airways- clear or change on coughing
consolidation
fibrotic lung disease
heart failure
How do we check for vocal resonance
Say “99”
Listen for increased resonance
What is the whispering pectoriloquy?
Whisper 1,2,3
Listen for dramatic increase in volume around consolidated lung
