Respiratory Examination Flashcards
General Inspection
- Use of accessory muscles – sternocleidomastoid, platysma, pectoral muscles used in COPD, asthma.
- Stridor – harsh, croaking inspiratory noise caused by foreign body or tumour in the larynx or trachea.
- Hoarseness or bovine cough (low pitched) – due to damage of left recurrent laryngeal nerve by tumour.
- Central cyanosis – blue discolouration skin, mucous membranes – deoxyhaemoglobin or SATS <90%.
- Assess for CURB 65 score – confusion, respiratory rate >30/min, diastolic BP <60mmHg and age >65.
Assess Breathing
Assess chest movements and respiratory rate – normal is between 12-20 per minute:
- Increased RR – increased ventilatory drive in fever, acute asthma, exacerbation of COPD, or decreased ventilatory capacity in pneumonia, pulmonary oedema, interstitial lung disease.
- Decreased RR – opioid toxicity, hypercapnia, hypothyroidism, raised ICP, hypothalamic lesion.
- Cheyne-Stokes breathing – periodic breathing with increases and decreases in rate and depth of breaths relating to a delay between the lung and chemoreceptors in brainstem stroke or severe heart failure.
- Kussmaul breathing – hyperventilation with deep sighing respiration in response to metabolic acidosis in diabetic ketoacidosis, acute renal failure, lactic acidosis or salicylate or methanol poisoning.
Inspect the Hands
- The flapping tremor of carbon dioxide retention > 30 seconds – also electrolyte disturbance, drugs, CNS.
- Clubbing – angle loss at nail bed, increase fluctuation, curvature, soft tissue over terminal phalanges. Causes include benign, malignant tumours – both lung and oesophageal, interstitial lung disease – fibrosing alveolitis or asbestosis, sepsis – bronchiectasis, empyema or abscess, CF or AV shunt.
- Peripheral cyanosis – seen in the fingers and toes but usually due to circulatory disorders or the cold.
- Tobacco staining – brownish staining of the fingers and nails (caused by tar not nicotine).
- HPOA – hypertrophic pulmonary osteoarthropathy is rare and almost always associated with cancer. There is pronounced clubbing of the fingers and toes and pain and swelling of the wrists and ankles.
- Fine tremor – excessive use of β agonists or theophylline bronchodilators drugs.
Inspect the Face
Inspect the eyes and mouth for central cyanosis, hydration, pallor for anaemia and signs of Horner’s.
Ptosis / Horner’s syndrome caused by a pancoast tumour disrupting sympathetic innervation to eyes.
Palpate the Traches
Determine whether it is central or deviated:
- Towards the side of the lung lesion – upper or lower lung collapse, pneumonectomy, fibrosis.
- Away from the side of the lung lesion – tension pneumothorax or massive pleural effusion.
- Upper mediastinal mass – retrosternal goitre, lung cancer or lymphoma.
Examine the Neck
- Crico-sternal distance <2cm - increased with hyperexpanded chest wall in emphysema – tracheal tug.
- Palpation of cervical glands – start with post-auricular nodes and descend into the posterior triangle and to the supraclavicular nodes. The lower, middle and upper cervical nodes are anterior to SCM. Finally palpate pre-auricular nodes, submandibular, submental and finally pre-tracheal lymph nodes.
- JVP – chronic hypoxia leads to pulmonary artery vasoconstriction, pulmonary hypertension, right heart dilatation and a raised JVP = cor pulmonale. Also tension pneumothorax, acute severe asthma or PE.
Inspect the Chest
- Look for scars of previous heart or lung surgery and for swellings and subcutaneous lesions.
- Scoliosis, kyphosis or lordosis – spine is curved laterally, posteriorly, anteriorly respectively.
- Barrel chest – increase in anterior-posterior diameter of chest which - suggests severe COPD.
- Pectus carinatum (pigeon chest) – protruding sternum - inefficient respiration and gas exchange.
- Pectus excavatum – sunken sternum displaces heart or decrease the capacity of the lung bases.
Palpate the Chest
Assess chest expansion and symmetry both anteriorly and laterally by placing thumbs in the midline.
- Unilateral reduced expansion – pleural effusion, lobar collapse, pneumothorax or fibrosis.
- Bilateral reduced expansion – severe COPD or diffuse pulmonary fibrosis.
Tactile vocal fremitus – use lateral hand to feel vibrations on both sides when the patient says ‘99’ – increase suggests consolidation or decrease suggests pleural effusion (can also use vocal resonance).
Percussion
Percuss each lobe of the patient’s chest – resonance is normal, dullness suggests collapse or consolidation, stony dullness suggests pleural effusion and hyper-resonant suggests pneumothorax.
Auscultation
Use stethoscope over each lobe, patient takes deep breaths through open mouth – vesicular breath sounds are normal or if reduced are due to obesity, pleural effusion, pneumothorax and bronchial breath sounds (high pitched breath sounds with a blowing quality) are due to consolidation.
- Added sounds - crackles (interrupted non-musical sounds) in pulmonary oedema, fibrosis or infection (pneumonia or COPD) or expiratory wheeze in asthma or COPD.
- Vocal resonance – ask patient to say 99 and assess quality and amplitude of vocal resonance – numbers are clearly audible in consolidated areas and muffled over effusion or collapsed lung.
- Pleural friction rub – a creaking sound when inflamed parietal and visceral pleura move over one another – can be caused by a pulmonary infarction, pneumonia or vasculitis.
Inspect the Legs
- Erythema nodosum (bright red skin with nodules) over the shins may herald acute sarcoidosis
- Peripheral oedema – may suggest the presence of pulmonary oedema – also check sacral oedema
- Hypertrophic pulmonary osteoarthropathy – associated with squamous cell lung carcinoma – pronounced clubbing at the fingers and toes will occur and pain and swelling at the wrists and ankles
To Complete my Examination
Check sputum pot, perform peak flow and check temperature chart.
Pleural Effusion
Expansion - Reduced
Percussion - Stony dull
Auscultation - Reduced breath sounds and tactile vocal resonance.
Collapse
Expansion - Reduced
Percussion - Dull
Auscultation - Reduced Breath Sounds and Tactile Vocal Resonance.
Asthma
Expansion - Hyperinflation
Percussion - Normal
Auscultation - Polyphonic Wheeze
