Respiratory examination Flashcards
What are the possible causes of tracheal deviation?
Pushed away from pleural effusion or tension pneumothorax
Pulled towards fibrosis, a collapsed lung or a surgically removed lung
What are vesicular breathing sounds?
Normal breathing sounds of laminar airflow
What is the peak expiratory flow rate test?
Where the patient inhales to vital capacity, then exhales quickly and forcefully into peak flow meter to determine their FEV1. This can detect airway obstruction for assessment of asthma
In an absolute emergency, where’s the best place to make an incision if the patient cannot breath?
The cricothyroid membrane (an emergency tracheotomy)
Describe the process of a chest drain for pleural effusion
The patient should be sat at 45º and the drain is usually inserted in the 5th intercostal space in the mid-axillary line (in the safe triangle)
What clinical signs do you look for on inspection of the patient from the end of the bed?
Age Cyanosis SOB Cough Wheeze Stridor Pallor Oedema Cachexia
Why is age important to note on inspection?
Younger patients are more likely to have asthma or cystic fibrosis, while older patients are more likely to have COPD, interstitial lung disease or malignancy
What is the cause of cyanosis?
It’s due to either poor circulation or inadequate oxygenation of the blood
What could cause SOB?
Causes could be asthma, pulmonary oedema, pulmonary fibrosis, lung cancer and COPD
What causes coughs?
Productive coughs are associated with pneumonia, bronchiectasis, COPD and CF. A dry cough may suggest asthma, interstitial lung
disease or COVID19
What causes wheezing?
Wheezing’s often associated with asthma, COPD and bronchiectasis
What is stridor?
A high-pitched extra-thoracic breath sound due to turbulent airflow through narrowed airways
What causes stridor?
Stridor can be caused by foreign body inhalation or subglottic stenosis
What can pallor suggest?
Anaemia or poor perfusion from congestive cardiac failure
How does oedema typically present?
Swelling of the limbs- pedal oedema- or of the abdomen- ascites.
What’s oedema commonly associated with?
Right ventricular failure
What is cachexia?
Ongoing muscle loss that is not entirely reversed with nutritional supplementation
What is cachexia associated with?
Underlying malignancy e.g. lung cancer, and other end-stage respiratory diseases like COPD
What objects/equipment would you note on general inspection of the room?
Oxygen delivery devices (Venturi mask, non-rebreathing mask, nasal cannulae A sputum pot ECG leads, medications, catheters Cigarettes or vaping equipment Mobility aids like wheelchairs Vital signs
What 5 things do you look for on inspection of the patient’s hands in a respiratory examination?
Cyanosis Tar staining Skin changes like bruising and thinning of the skin Joint swelling or deformity Finger clubbing
What can bruising and thinning of the skin be associated with?
Long-term steroid use, e.g. for asthma, COPD or ILD
Why do you assess for a fine tremor in the patient’s hands?
A fine tremor is typically associated with beta-2 agonist use
What is asterixis?
A type of negative myoclonus characterised by irregular lapses of posture (CO2 retention flap) from conditions that result in type 2 respiratory failure (e.g. COPD)
What do you palpate the hands for initially?
Temperature
Cool hands may suggest poor peripheral perfusion
Excessively warm and sweaty hands can be associated with CO2 retention
What is pulsus paradoxus?
When pulse wave volume decreases significantly during inspiration. This is a late sign of cardiac tamponade, severe acute asthma and severe exacerbations of COPD
How do you assess breathing rate of the patient?
Continue palpating their radial pulse but bring their hand across their chest so as to feel the expansions of the chest without making it obvious that you are assessing their breathing rate
What is normal respiratory rate?
12-20 breaths per minute
What do you do after assessing pulse rate and respiratory rate?
Assess JVP and the hepatojugular reflux test
What is a plethoric complexion of the face?
A congested red-faced appearance associated with polycythaemia (e.g. COPD) and CO2 retention
What relevant signs do you look for in the patient’s eyes?
Conjunctival pallor for anaemia
Ptosis, miosis and enophthalmos for Horner’s syndrome
What is Horner’s syndrome?
Horner’s syndrome occurs when the sympathetic trunk is damaged by pathology such as lung cancer affecting the apex of the lung (e.g. Pancoast tumour)
What signs do you look for in a patient’s mouth for a respiratory examination?
Central cyanosis- hypoxaemia
Oral candidiasis- a fungal infection commonly associated with steroid inhaler use. Characterised by pseudomembranous white slough which can be wiped away to reveal underlying erythematous mucosa
What do you look for on inspection of the chest?
Scars and chest wall deformities
What is an axillary thoracotomy scar likely to be from?
Insertion of chest drains
What causes tracheal deviation?
The trachea deviates away from pneumothorax and large pleural effusions, but towards lobar collapse and pneumonectomy
What are the 3 respiratory causes of a displaced apex beat?
Right ventricular hypertrophy e.g. in pulmonary hypertension, COPD or ILD)
Large pleural effusion
Tension pneumothorax
What do you do after palpating the apex beat?
Assess chest expansion with the thumb technique
What is the respiratory cause of symmetrical reduced chest expansion?
Pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion
What are the 3 respiratory causes of asymmetrical reduced chest expansion?
Pneumothorax, pneumonia and pleural effusion
After assessing chest expansion, you percuss the chest. What are the 4 areas to percuss on each side?
Supraclavicular region (for lung apices
Infraclavicular region
Chest wall- 3-4 locations bilaterally
Axilla
What causes dullness on percussion?
Increased tissue density, possibly due to cardiac dullness, consolidation, a tumour or lobar collapse
What causes stony dullness on percussion?
An underlying pleural effusion
What causes hyper resonance?
Decreased tissue density, e.g. pneumothorax
What do you do after percussion of the chest?
Auscultate for breathing sounds
What are bronchial breath sounds?
Harsh-sounding breathing on inspiration and expiration, which are equal. This is associated with consolidation
After auscultation of breathing sounds, what do you do in the respiratory examination?
Vocal resonance- patient says 99 when you place your stethoscope on the same areas you percussed
What does decreased volume over an area suggest?
The presence of fluid or air outside the lung (pleural effusion, pneumothorax)
What does increased volume over an area suggest?
Increased tissue density (e.g. consolidation, tumour or lobar collapse)
What do you do having assessed vocal resonance?
Palpate the patient’s lymph nodes
What are 3 respiratory causes of lymphadenopathy?
Lung cancer with metastases
Tuberculosis
Sarcoidosis
After assessing the patient’s lymph nodes, what do you do?
Assess the posterior chest- inspection, chest expansion, percussion, auscultation and vocal resonance
Having assessed the patient’s posterior chest, what do you do to finish the examination?
Check for pitting sacral and pedal oedema. Assess the calves for signs of DVT
What are 6 possible further investigations?
Check oxygen saturation Take a sputum sample Perform a peak flow assessment Request a chest x-ray Take an ABG Perform a full cardiovascular examination
