Respiratory examination Flashcards
structure of the respiratory exam?
1- introduction
2- explanation
3- palpation
4- percussion
5- auscultation
introduction?
- ensure adequate hand hygiene
- introduce self
- confirm name and DOB
- explain procedure
- seek permission
- position patin at 45 degrees
general inspection?
- does the patient look well?
- look around patient
- look at patient
- listen (audible stridor, hoarseness, pattern of speech)
- any pathological signs?
- do they have an inhaler, nebuliser?
stridor?
-loud harsh, high pitched respiratory sound.
- usually on respiration
- upper airway obstruction
what do you do on close inspection and palpitation?
examine hands = inspect, palpate warmth and ventilation, flapping terror and fine tremor
- palpate radial pulse
- count respiratory rate
- inspect eyes, face, mouth and pharynx
signs of central cyanosis?
blue tongue, lips, hands and feet and mucos membranes of the oral cavity.
palor
what are respiratory causes of clubbing?
- bronchial carcinoma
- mesothelioma
- chronic supportive lung disease = (bronchiectasis, lung abscess, empyema)
- pulmonary fibrosis
- cystic fibrosis
cause of Horners syndrome?
clinical features?
- damage to cervical sympathetic nerves
clinical features:
- unilateral mitosis
- partial ptosis
- loss of sweating (anhidrosis)
may indicate serious pathology
cause of a fine tremor
excessive use of B agonists
cause of flapping tremor?
what will it look like?
- severe ventilatory failure with C02 retention
- hold hands outstretched
- wrists cocked back
- look for a jerky, flapping tremor
- associated confusion
what are you looking for on close inspection of the chest?
- scars= cardiac surgery, tharoctomy, chest drains ect
- pattern of breathing
- shape of chest (symmetry, deformity, increase in AP diameter)
- prominent veins on chest wall (SVC obstruction)
- JVP?
what are you palpating on the neck and chest?
- lymph nodes
- subcutaneous emphysema
- rib fractures
- mediastinal position
- chest expansion
how do palpate for chest expansion?
- do it anterior and posterior
- ask patient to breathe deeply
- thumbs should move apart equally
palpation of the mediastinal position?
- trachael position
- look for the parasternal notch
- right middle finger 2cm above the notch
- gently press don and back
- palpate space to either Side
- should be central
- look for cardiac apex and assess for right ventricular heave
when you are palpating for subcutaneous emphysema, what are you looking for?
- crackling sensation
- air in subcutaneous tissue
- neck and face swelling?
- consider trauma and underlying pneumothorax?
what are the 3 types of displacement of the trachea towards the lesion?
- lobar collapse
- pneumonectomy
- pulmonary fibrosis
what are the 2 types of displacement of the trachea away from the lesion?
- large pleural effusion
- tension pneumothorax which is a medical emergency
what is the other type of tracheal deviation?
mediastinal masses
how do you do percussion?
- percuss, anterior, posterior and lateral chest
- use middle finger/left hand
- apply firmly to patients chest
- strike its middle phalanx with the middle finger or the right hand
- percuss over intercostal space
- however perks clavicles directly
- compare the left and right
- listen to the sound produced
percussion node and cause?
resonant=
hyper resonant=
dull =
stony or very dull=
remnant = normal lung
hyper resonant = emphysema, large bullae or pneumothorax
dull = collapse, consolidation or fibrosis
stony or very dull = pleural effusion or haemothorax
what are you doing in a tactile vocal fremitus?
- use palm/ulnar border of hand
- get them to say 99 and feel for vibration
increased fremitus = consolation or fibrosis
decreased fremitus= pleural effusion, pneumothorax or collapse
how do you do auscultation?
1- use bell or diaphragm of stethoscope (bell for apices and diaphragm for chest)
2- ask patient to breathe deeply in and out through mouth
3- listen through full inspiration and full expiration
4- compare ides
5- listen for breathe sounds and added sounds
what would a normal (vesicular) breathe sound, sound like?
- intensity of sounds relates to airflow
- inspiration longer than expiration
- low pitched, quiet, heard over most of lung fields
- no gap between inspiration and expiration
when would you hear diminished vesicular breathe sounds?
when the normal lug is displaced by air
- in obesity
- pleural effusion
- pneumothorax
- collapse
- hyperinflation
what are abnormal bronchial breathe sounds?
- when the noise originates from larger airways
- when damage to the small airways/ alveoli
- harsh in nature
- gap between inspiration and expiration
- expiratory component dominates
what are added sounds in ausciltation?
causes?
what is a fine late crackle a sign of?
- crackles
= high pitched discontinuous sounds
(similar to the sound produced by rubbing your hair between your fingers
causes = pulmonary oedema, pulmonary fibrosis, bronchial secretions.
a fine late crackle is a feature of cryptogenic fibrosing alveolitis.
Pleural rub
= may be associated with pleuritic pain (sharp on inspiration/ coughing)
- low pitched
causes = PE, pneumonia, vasculitis.
wheeze
- continuous oscillation os opposing airway walls
- high pitched
- implies airway narrowing
- louder in expiration
causes = generalised = asthma/ COPD
localised = lung tumour
what are other areas you should look at?
ankle oedema
sputum spots (green = infection)
obs chart
peak slow
spirometry
When is vocal resonance used?
What are the 3 steps of vocal resonance?
What 2 things can increased vocal resonance indicate?
What 3 things can decreased vocal resonance indicate?
- If there is a dull percussive note when there shouldn’t be, we need to check tactile vocal fremitus now or vocal resonance after auscultation – no need to do both
- 3 steps of vocal resonance:
1) Use stethoscope, ask patient to say “one, one, one”
2) Compare with the other side. - Assess quality and amplitude
3) Ask patient to whisper “one, one, one”. - Whispering is not heard over a normal lung but in consolidation the sound is transmitted
- 2 things increased vocal resonance can indicate:
1) Consolidation
2) Fibrosis - 3 things decreased vocal resonance can indicate:
1) Pleural effusion
2) Pneumothorax
3) Collapse
what are 3 added sounds we may hear during auscultation?
1) Crackles
2) Pleural rub
3) Wheeze
What 3 different types of breath sounds might we hear?
1) Vesicular (normal) breath sounds
2) Diminished vesicular breath sounds
3) Bronchial breath sounds (abnormal)
what order should lymph nodes be palpated in the face/neck?
1) Pre-auricular
2) Posterior auricular
3) Submandibular
4) Submental
5) Cervical chain
6) Occipital
what is ruddy complexion?
‘Ruddy’ complexion polycythaemia – elevated haemoglobin that causes red skin, especially in the face, hands, and feet
What is erythema nodosum?
What is it caused by?
What is stridor? When can it be heard?
What does it indicate?
- Erythema nodosum is inflammation of fat under skin causing raised red tender lumps that are painful with pressure
- Caused by streptococcal infections
- Stridor is a loud, harsh, high pitched respiratory sound
- It can usually be heard on inspiration
Stridor is indicative of an upper airway obstruction
