Respiratory examination

Question 1

structure of the respiratory exam?

Answer 1

1- introduction
2- explanation
3- palpation
4- percussion
5- auscultation

Question 2

introduction?

Answer 2

• ensure adequate hand hygiene
• introduce self
• confirm name and DOB
• explain procedure
• seek permission
• position patin at 45 degrees

Question 3

general inspection?

Answer 3

• 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?

Question 4

stridor?

Answer 4

-loud harsh, high pitched respiratory sound.
- usually on respiration
- upper airway obstruction

Question 4

what do you do on close inspection and palpitation?

Answer 4

examine hands = inspect, palpate warmth and ventilation, flapping terror and fine tremor
- palpate radial pulse
- count respiratory rate
- inspect eyes, face, mouth and pharynx

Question 5

signs of central cyanosis?

Answer 5

blue tongue, lips, hands and feet and mucos membranes of the oral cavity.
palor

Question 6

what are respiratory causes of clubbing?

Answer 6

• bronchial carcinoma
• mesothelioma
• chronic supportive lung disease = (bronchiectasis, lung abscess, empyema)
• pulmonary fibrosis
• cystic fibrosis

Question 7

cause of Horners syndrome?
clinical features?

Answer 7

• damage to cervical sympathetic nerves

clinical features:
- unilateral mitosis
- partial ptosis
- loss of sweating (anhidrosis)

may indicate serious pathology

Question 8

cause of a fine tremor

Answer 8

excessive use of B agonists

Question 9

cause of flapping tremor?

what will it look like?

Answer 9

• severe ventilatory failure with C02 retention
• hold hands outstretched
• wrists cocked back
• look for a jerky, flapping tremor
• associated confusion

Question 11

what are you looking for on close inspection of the chest?

Answer 11

• 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?

Question 12

what are you palpating on the neck and chest?

Answer 12

• lymph nodes
• subcutaneous emphysema
• rib fractures
• mediastinal position
• chest expansion

Question 13

how do palpate for chest expansion?

Answer 13

• do it anterior and posterior
• ask patient to breathe deeply
• thumbs should move apart equally

Question 14

palpation of the mediastinal position?

Answer 14

• 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

Question 15

when you are palpating for subcutaneous emphysema, what are you looking for?

Answer 15

• crackling sensation
• air in subcutaneous tissue
• neck and face swelling?
• consider trauma and underlying pneumothorax?

Question 16

what are the 3 types of displacement of the trachea towards the lesion?

Answer 16

• lobar collapse
• pneumonectomy
• pulmonary fibrosis

Question 17

what are the 2 types of displacement of the trachea away from the lesion?

Answer 17

• large pleural effusion
• tension pneumothorax which is a medical emergency

Question 17

what is the other type of tracheal deviation?

Answer 17

mediastinal masses

Question 18

how do you do percussion?

Answer 18

• 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

Question 19

percussion node and cause?

resonant=
hyper resonant=
dull =
stony or very dull=

Answer 19

remnant = normal lung

hyper resonant = emphysema, large bullae or pneumothorax

dull = collapse, consolidation or fibrosis

stony or very dull = pleural effusion or haemothorax

Question 20

what are you doing in a tactile vocal fremitus?

Answer 20

• 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

Question 21

how do you do auscultation?

Answer 21

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

Question 22

what would a normal (vesicular) breathe sound, sound like?

Answer 22

• 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

Question 23

when would you hear diminished vesicular breathe sounds?

Answer 23

when the normal lug is displaced by air - in obesity - pleural effusion - pneumothorax - collapse - hyperinflation

Question 24

what are abnormal bronchial breathe sounds?

Answer 24

- 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

Question 25

what are added sounds in ausciltation? causes? what is a fine late crackle a sign of?

Answer 25

- 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

Question 26

what are other areas you should look at?

Answer 26

ankle oedema sputum spots (green = infection) obs chart peak slow spirometry

Question 27

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?

Answer 27

* 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

Question 28

what are 3 added sounds we may hear during auscultation?

Answer 28

1) Crackles 2) Pleural rub 3) Wheeze

Question 29

What 3 different types of breath sounds might we hear?

Answer 29

1) Vesicular (normal) breath sounds 2) Diminished vesicular breath sounds 3) Bronchial breath sounds (abnormal)

Question 30

what order should lymph nodes be palpated in the face/neck?

Answer 30

1) Pre-auricular 2) Posterior auricular 3) Submandibular 4) Submental 5) Cervical chain 6) Occipital

Question 31

what is ruddy complexion?

Answer 31

‘Ruddy’ complexion polycythaemia – elevated haemoglobin that causes red skin, especially in the face, hands, and feet

Question 32

What is erythema nodosum? What is it caused by? What is stridor? When can it be heard? What does it indicate?

Answer 32

* 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