Respiratory Examination

Question 1

Causes of Cyanosis

Central

Peripheral

Answer 1

Central cyanosis

1. Decreased arterial oxygen saturation
   
   • Decreased concentration of inspired oxygen: high altitude
   • Hypoventilation: coma, airway obstruction
   • Lung disease: chronic obstructive pulmonary disease (COPD) with cor pulmonale, massive pulmonary embolism
   • Right-to-left cardiac shunt (cyanotic congenital heart disease)
2. Polycythaemia
3. Haemoglobin abnormalities (rare)
   
   • Methaemoglobinaemia (ferrous [Fe2+] ions of haem are oxidised to the ferric [Fe3+] state, usually due to drugs such as dapsone or topical anaesthetics in adults, which can be fatal if not immediately recognised and treated)*

Peripheral cyanosis

1. All causes of central cyanosis cause peripheral cyanosis
2. Exposure to cold
3. Reduced cardiac output: left ventricular failure or shock
4. Arterial or venous obstruction

Question 2

Resp Exam - Intro

Question 3

Resp Exam - General Inspection

Answer 3

Sick / Not Sick

Orientated, confused, drowsy

Respiratory distress - rate, rhythm, symmetry, accessory muscles, chest wall deformity, skin changes, stridor

Other - febrile, sputum mug, IV treatment, oxygen, other ventilation, medications

Question 4

Resp Exam - Hands

Answer 4

clubbing, pallor, radial pulse, peripheral cyanosis, C8-T1 lesion, tobacco staining

hypercapnoea (asterixis, peripheral vasodilation/bounding pulse, confision)

Question 5

Resp Exam - Head & Neck

Answer 5

Cyanosis

JVP

Trachea

Lymph nodes (stand behind patient)

Question 6

Resp Exam - Chest

Answer 6

Inspection - chest movement, accessory muscles, scars, pigmentation, barrel, pigeon

Palpation - chest movement (normal =4cm, <2cm = abnormal), symmetry, tenderness

Percussion - anterior, posterior, axillae

increased: pneumothorax, hyperinflation, lung cyst
decreased: consolidation, collapse, fibrosis, plural fluid, elevated hemidiaphragm

Auscultation - normal (vesicular), increased (bronchial - consolidation), decreased (airflow obstruction, effusion, pneumothorax, obesity), crepitations (crackles), rhonchi (wheezes - bronchitis, oedema, foreign body, tumor, COPD, asthma), pleural/pericardial rub, vocal resonance, stridor (large airway obstruction)

Question 7

Resp Exam - Completion

Answer 7

FEV (listen over trachea, normal < 3seconds, obstruction > 6seconds)

Heart – esp for features of pulmonary hypertension (but also for other explanations of dyspnoea, haemoptysis)

Abdomen – features of right heart failure (JVP), liver metastases etc

Legs – features of right heart failure, venous thrombosis

Question 8

Hypertrophic Osteoarthropathy

Answer 8

NSCLC

periosteum of wrist is thickened w/ tenderness of ulna and radius

Question 9

Cyanosis Definition

Answer 9

deoxy Hb > 4g/100ml

Peripheral = circulatory insufficiency = increased extraction of O2

Central = respiratory insufficiency = decreased O2 Hb saturation

Question 10

Lung Surface Markings

Question 11

Altered Breath Sounds

Question 12

Added Chest Sounds - Wheeze

Answer 12

Mechanism
– Partial bronchial obstruction
– High or low pitched, inspiratory or expiratory – Focal or diffuse

Can you think of some causes?

Asthma, chronic bronchitis, pulmonary

oedema, foreign body, lung tumour

Musical sounds - high or low pitched

• monophonic or polyphonic
• inspiratory and expiratory

Question 13

Added Chest Sounds - Stridor

Answer 13

stridor = upper airway upstruction (i.e. large airway)

Question 14

Added Chest Sounds - Crackles (crepitations)

Answer 14

Short explosive non musical sounds – High or low pitched
– Inspiratory or expiratory (early or late)

• Why might they occur?
• Mechanism

– Bubbling of air through secretions

– Sudden opening of small airways and alveoli with rapid equalisation of pressures

Causes:

1. Pulmonary fibrosis
2. Pulmonary Oedema
3. Pneumonia
4. Bronciectasis
5. Bronchitis
6. Atelectasis

1 = sudden opening with rapid equalisation (noise occurs late on inspiration), lung collapses on expiration. High pitched - ‘velcro’.

2-6 = air bubbling through secretions (occur on ispiration and expiration)

Get patient to cough and see if it is just mucus/secretions in airway

Question 15

Added Chest Sounds - Pleural Rub

Answer 15

Non musical sound, usually longer and lower pitch than crepitations, inspiratory with mirror image in expiration, not cleared by coughing, may be may be palpable and often associated with pleuritic pain

Mechanism - sliding of roughed pleural surfaces (without intervening pleural fluid)

pleuritic pain can radiate to the shoulder if pathology is rubbing against the diaphragm

Causes
– Inflammation (infective and non infective) – Tumour

Question 16

Causes of Reduced Percussive Note at Lung Bases

Answer 16

Consolidation / collapse or dense fibrosis of lung

Pleural effusion or thickening

Elevated hemidiaphragm (pulled-up, pushed-up or paralysed)

Question 17

Causes of Hypoxaemia

Answer 17

Reduced inspired O2

– Altitude, fires

Ventilation-perfusionmismatch

– Pneumonia, pulmonary embolus

Impaireddiffusion
– Pulmonary fibrosis, COPD (decreased A-C membrane area)

Shunt
Hypoventilation (as pCO2 goes up, pO2 must fall)

Question 18

Causes of Hypercapnia

Answer 18

Central depression
– Narcoticoverdose,sedation

Completely blocked upper airway

Primary “pump” failure

– NeuromusculardiseaseegGuillainBarreSyndrome,MND

Muscle fatigue

– Usuallyasaconsequenceof­WOB

Intrinsic lung disease eg severe COPD (most common)

Chest wall abnormalities

– Obesity

– Kyphosis