Respiratory examination Flashcards
Preparation.
a) Always begin by…?
b) Patient exposure/position
a) - Introducing yourself
- Washing hands
- Identifying patient
- Explaining examination
- Gaining consent
b) - Expose chest
- Lie patient at 45 degrees
c) - Check observation chart
End-of-the-bed-o-gram.
a) Around the bed
b) Attached to the patient
c) General appearance of patient
a) - Oxygen
- Inhalers
- Nebulisers
- Sputum pot
- Peak flow meter
- Fluid bags
b) - Oxygen: Oxygen mask, nasal cannulae, etc.
- IV access: cannulae, PICC lines, etc.
- Drains: chest drain (?effusion, empyema, pneumothorax)
-
c) - Well/unwell
- Comfortable/uncomfortable at rest
- Respiratory distress
- SOB, coughing, chest pain, etc.
- Cyanosed, pale or normal colour
- Confused or alert
- Cachectic
Signs of respiratory distress.
a) Observations
b) Inspection
c) Auscultation
d) Other
a) - Tachypnoea
- hypoxia
- tachycardia
b) - Obviously SOB
- Colour: cyanosis
- Use of accessory muscles
- Pursed lips breathing
- Indrawing of intercostal muscles/ trachea, etc.
- Unable to talk in full sentences
- Unable to lay flat (?orthopnoea)
c) - Reduced air entry (?silent chest)
- Added sounds: wheeze, crackles, bronchial breathing
d) Confusion (?hypercapnia)
Examination of hands.
a) General points
b) Specific signs of possible respiratory disease
c) Once finished inspecting hands, do what 2 things? (over 30 seconds)
d) Then as you go up the arm, say…?
a) - Colour - pale, cyanosed, etc.
- Temperature (cool, warm)
- CRT
b) - Hands outstretched and wrists extended (start with this manoeuvre so as to not forget) - fine tremor (?SABA), flapping tremor (?CO2 retention)
- Clubbing - hypertrophic pulmonary osteoarthropathy (HPOA) - respiratory causes
- Tar staining
- Wasting of intrinsic muscles/ hypothenar eminence (?lesion at T1 eg. lung tumour)
- Bruising/thinned skin - ?chronic steroid use
c) - Pulse (15 secs)
- Respiratory rate (15 secs)
(explain to examiner you would take for a full minute)
d) I would check BP
Causes of clubbing.
CL(ABCDEF)UBBING
Cyanotic congenital heart disease Lung disease: - Abscess - Bronchiectasis - Cancer - Don't say COPD/asthma - Empyema - Fibrosis (IPF, CF, etc.) Ulcerative colitis/Crohn's Biliary disease Birth defects Infective endocarditis Neoplastic GI malabsorptions (Coeliac, etc.)
Examination of face and neck.
a) Eyes
b) Face
c) Mouth
d) Neck - inspection
e) Neck - palpation*
*may do this after inspection of chest, so can also then go straight to apex beat
a) - Subconjunctival pallor
- Horner’s syndrome: unilateral miosis, ptosis, anhidrosis (Pancoast tumour)
b) - Moon facies (Cushingoid) - prolonged steroids use
c) - Central cyanosis
d) - JVP (raised ?cor pulmonale)
- SVC obstruction (?lung tumour)
- Goitre
e) - Lymphadenopathy (may do when examining back)
- Tracheal deviation - deviates towards a collapse, and away from a massive effusion effusion or tension pneumothorax
Inspection of chest.
a) Static elements
b) Dynamic elements
c) What should you ask patient to do to better see any possible scars?
d) Lung surface anatomy - horizontal fissure
a) - Scars - thoracotomy, median sternotomy, pacemaker scars
- Lung inflation - hyper-inflated barrel chest (?chronic airways obstruction)
- Chest wall deformity - kyphosis/scoliosis, carinatum, excavatum
b) - Pattern of breathing - rate, depth (?Kussmaul), regularity (?Cheyne-Stokes), thoraco-abdominal is normal, see-saw breathing (?UA obstruction
- Chest wall movement - symmetry (if asymmetrical, the abnormal side is the one that moves less - effusion, pneumothorax, consolidation or collapse), ?flail chest
- Use of accessory muscles
c) - Raise arms (good for lateral thoracotomy scars or chest drain scars)
- Sit forward (do this when examining the back)
d) - Horizontal fissure at ~ 4th rib on right side (separates upper and middle lobes)
Palpation of chest.
a) What should be assessed?
b) Reduced chest expansion - causes?
c) Asymmetrical chest expansion - causes?
d) Increased tactile vocal fremitus - causes?
e) Reduced tactile vocal fremitus - causes?
a) - Neck palpation (tracheal deviation and nodes) if not done already
- Apex beat palpation if not already
- Chest expansion - assess via 2 flat hands on upper chest and wrapped hands on lower chest (normal > 2cm)
- Tactile vocal fremitus (“99”)
- Assess for tenderness if ?costochondritis
b) - Restrictive lung disease
c) - Pneumothorax
- Pleural effusion
- Collapse
- Pneumectomy
- Chest wall deformity - eg. flail chest, scoliosis
d) - Consolidation
e) - Effusion
- Collapse
- Hydrothorax/ haemothorax
Percussion of chest.
a) Anterior and posterior locations
b) What areas will be dull normally?
c) Dullness - causes?
d) Hyper-resonance - causes?
e) Possible special test
a) Anterior.
1. Supraclavicular (apical)
2. Infraclavicular (upper zone)
3. Mid zones
4. Lower zones
5. Axilla - 2 sites (upper and lower)
Posterior.
- Supra-scapular
- Medial to the scapula (not over the bone itself)
- Infra-scapular
- Lower zones
- Axilla - 2 sites (upper and lower)
b) - Upper border of liver (right side)
- Heart (left side)
c) - Consolidation
- Collapse
- Effusion
d) - Pneumothorax
- Hyperinflation of chest (will be bilateral)
e) - Shifting dullness in hydropneumothorax
Auscultation of chest.
a) Sites
b) What should be assessed?
c) Normal vs abnormal breath sounds
d) Added sounds
a) Same as for percussion
b) - Auscultate breath sounds
- Vocal fremitus (“99”)
- Whispering pectoriloquy (whisper “99”)
c) - Vesicular (normal)
- Bronchial (normal over upper airways, abnormal elsewhere)
d) - Crackles - coarse (pneumonia), fine (pulmonary oedema, fibrosis)
- Wheeze (lower obstruction)
- Stridor (UA obstruction)
- Pleural rub
Make sure to do everything again on…
The back:
- Examine lymph nodes in neck
- Inspect for any scars (eg. thoracotomy scars on the sides)
- Palpation: chest expansion in upper and lower zones, tactile vocal fremitus, palpate for any sacral oedema
- Percussion
- Auscultation: breath sounds, vocal fremitus, ?whispering pectoriloquy
Finally, examine…
a) In all cases (2 main findings relevant to resp exam)
b) If signs of RHF / cor pulmonale
a) Legs.
- squeeze for calf swelling/tenderness (?DVT - PE)
- press for pitting oedema - ?cor pulmonale/ heart failure
- often also appropriate to check pedal pulses in clinical practice
b) Liver - ?hepatomegaly
- Abdomen - ?ascites
To complete my examination, I would…
a) In all cases
b) If focal signs found - ?
c) If obstructive/restrictive lung pattern found?
a) - Measure oxygen saturations
- Check sputum pot (and obtain sample if appropriate)
- Check peak flow and compare with best efforts
b) - Order a CXR
c) - Spirometry
- ?HRCT
Spot diagnosis.
a) No tracheal deviation, symmetrical chest expansion, unilateral dullness to percussion and bronchial breath sounds
b) No tracheal deviation, symmetrical chest expansion, unilateral dullness to percussion and reduced breath sounds
c) Tracheal deviation to the left, reduced chest expansion and resonant percussion on the right, reduced breath sounds on the right
d) Tracheal deviation to the left, reduced chest expansion and dull percussion on the left, reduced breath sounds on left
e) Finger clubbing, reduced chest expansion bilaterally, fine (velcro-like) bilateral end-inspiratory crackles at the bases
f) No clubbing, hyper-inflated chest, coarse sporadic crackles heard over sporadic lung areas
a) Pneumonia
b) Pleural effusion
c) Tension pneumothorax
d) Lobar collapse
e) Pulmonary fibrosis
f) Chronic bronchitis - commonly heard in COPD
Muscles of respiration.
a) Muscles of passive respiration
b) Accessory muscles of inspiration
c) Accessory muscles of expiration
a) - Diaphragm
- Internal intercostals (for expiration)
- External intercostals (for inspiration)
b) - Scalenes – elevates the upper ribs.
- Sternocleidomastoid – elevates the sternum.
- Pectoralis major and minor – pulls ribs outwards.
- Serratus anterior – elevates the ribs (when the scapulae are fixed).
- Latissimus dorsi – elevates the lower ribs.
c) - Anterolateral abdominal wall – increases the intra-abdominal pressure, pushing the diaphragm upwards into the thoracic cavity.
Internal intercostal – depresses the ribs.
