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Phase 2B > Respiratory examination > Flashcards

Respiratory examination Flashcards

1
Q

what clinical signs should be looked for during general inspection?

A
  • age
  • cyanosis
  • SOB
  • cough
  • wheeze
  • stridor
  • pallor
  • oedema
  • cachexia
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2
Q

what is cyanosis?

A

bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood

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3
Q

what are signs of SOB?

A

nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession, tripod session, inability to speak in full sentences

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4
Q

what is wheeze?

A

a continuous, coarse, whistling sound produced in the respiratory airways during breathing; associated with asthma, COPD, bronchiectasis

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5
Q

what is stridor?

A

high-pitched extrathoracic breath sound resulting from turbulent airflow through narrowed upper airways; causes include foreign body inhalation and subglottic stenosis

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6
Q

what objects and equipment are looked for in general inspection?

A
  • oxygen delivery devices
  • sputum pot (volume and colour)
  • ECG leads, medications, catheters, IV access
  • cigarettes or vaping equipment
  • mobility aids
  • vital signs
  • FBC
  • prescriptions
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7
Q

what should be looked for in hand inspection?

A
  • colour
  • tar staining
  • skin changes
  • joint swelling or deformity
  • finger clubbing
  • fine tremor
  • asterixis
  • temperature
  • heart rate
  • respiratory rate
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8
Q

what is pulsus paradoxus?

A

pulse wave volume decreases significantly during the inspiratory phase; late sign of cardiac tamponade, severe acute asthma and severe exacerbations of COPD

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9
Q

how do you measure the JVP?

A
  1. position the patient in a semi-recument position (45deg)
  2. ask the patient to turn their head slightly to the left
  3. inspect for evidence of the EJV (double waveform pulsation)
  4. measure the JVP by assessing the vertical distance between the sternal angle and the top of the EJV (should be no greater than 4cm)
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10
Q

where is the EJV located?

A

runs from the angle of the mandible to the middle of the clavicle superior to the sternocleidomastoid muscle

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11
Q

how do you measure the JVP?

A

assess the vertical distance between the sternal angle and the top of the EJV (should be no greater than 4cm)
- hepatojugular reflux test

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12
Q

what should you inspect in the face?

A
  1. plethoric complexion
  2. swelling
  3. eyes
  4. mouth
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13
Q

what should you inspect for in the eyes?

A
  • conjunctival pallor
  • ptosis, miosis and enophthalmos
  • Horner’s syndrome
  • chemosis
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14
Q

what should you inspect for in the mouth?

A
  • central cyanosis
  • oral candidiasis
  • dental caries may cause lung abscess by inhalation of debris
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15
Q

what is central cyanosis?

A

bluish discolouration of the lips and/or tongue associated with hypoxaemia

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16
Q

what should you inspect for in the chest?

A
  • shape
  • symmetry
  • scars
  • muscle wasting
  • chest vs diaphragmatic breathing
  • use of accessory muscles
  • recession
  • chest wall deformities
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17
Q

what does the median sternotomy scar represent?

A
  • located in the midline of the thorax

- used for cardiac valve replacement and CABG

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18
Q

what does the axillary thoracotomy scar represent?

A
  • located between the posterior border of the pectoralis major and the anterior border of the latissimus dorsi muscles, through the 4th or 5th intercostal space
  • used for insertion of chest drains
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19
Q

what does the posterolateral thoracotomy scar represent?

A
  • located between the scapula and mid-spinal line, extending laterally to the anterior axillary line
  • used for lobectomy, pneumonectomy and oesophageal surgery
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20
Q

what does the infraclavicular scar represent?

A
  • located in the infraclavicular region

- used for pacemaker insertion

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21
Q

what are examples of radiotherapy-associated skin changes?

A

xerosis, scale, hyperkeratosis, depigmentation, telangiectasia

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22
Q

what are examples of chest wall deformities?

A
  • asymmetry
  • pectus excavatum
  • pectus carinatum
  • hyperexpansion
  • barrel chest
  • severe kyphoscoliosis
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23
Q

what is pectus excavatum?

A

caved-in or sunken appearance of the chest

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24
Q

what is pectus carinatum?

A

protrusion of the sternum and ribs (pigeons chest) and/or Harrison’s sulci

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25
Q

what structures should be closely inspected?

A
  1. hands
  2. JVP
  3. hepatojugular reflux test
  4. face
  5. eyes
  6. mouth
  7. chest
26
Q

what should be done in palpation?

A
  1. assess tracheal position
  2. assess cricosternal distance
  3. palpate the apex beat
  4. assess chest expansion
27
Q

how can you assess tracheal position?

A
  1. warn patient of discomfort
  2. ensure patient’s neck muscles are relaxed by asking them to point their chin slightly downwards
  3. dip your index finger into the thorax beside the trachea
  4. gently apply side pressure to locate the border of the trachea
  5. compare this space to the other side of the trachea using same process
  6. a difference in the amount of space between the sides suggests the presence of tracheal deviation
28
Q

when will the trachea deviate away from the cause?

A

pneumothorax and large pleural effusions

29
Q

when will the trachea deviate towards the cause?

A

lobar collapse and pneumonectomy

30
Q

how can you assess cricosternal distance?

A

cricosternal distance is the distance between the inferior border of the cricoid cartilage and the suprasternal notch

  1. measure the distance between the suprasternal notch and cricoid cartilage using your fingers
  2. healthy distance is 3-4 fingers
  3. distance < 3 fingers suggests lung hyperinflation
31
Q

how can you palpate the apex beat?

A
  1. palpate it with your fingers horizontally across the chest
  2. should be located in 5th intercostal space in the midclavicular line
32
Q

what are respiratory causes of a displaced apex beat?

A

right ventricular hypertrophy (pulmonary hypertension, COPD, ILD), large pleural effusion, tension pneumothorax

33
Q

how can you assess chest expansion?

A
  1. place your hands on the patient’s chest, inferior to the nipples
  2. wrap your fingers around either side of the chest
  3. bring your thumbs together in the midline, so that they touch
  4. ask patient to take a deep breath in
  5. observe the movement of your thumbs
  6. in healthy people they should move symmetrically upwards/outwards during inspiration and symmetrically downwards/inwards during expiration
  7. reduced movements of one of your thumbs indicates reduced chest expansion on that side
34
Q

what is normal/abnormal chest expansion?

A

normal = 3-5cm

abnormal <2cm

35
Q

what are respiratory causes of symmetrical reduced chest expansion?

A

pulmonary fibrosis reduces lung elasticity, restricting expansion

36
Q

what are respiratory causes of asymmetrical reduced chest expansion?

A

pneumothorax, pneumonia, pleural effusion

37
Q

what areas should be percussed?

A
  1. supraclavicular region (lung apices)
  2. infraclavicular region
  3. chest wall (3-4 locations bilaterally)
  4. axilla
  5. tactile vocal fremitus
38
Q

how should you perform percussion technique?

A
  • place your non-dominant hand on the patient’s chest wall
  • position your middle finger over the area you want to percuss, firmly pressed against the chest wall
  • with your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger using a swinging movement of the wrist
  • the striking finger should be removed quickly, otherwise you may muffle the resulting percussion note
  • consider the surface marking of the lungs and their fissures whilst percussing
  • start at the apices, and percuss from side to side anteriorly. ensure you percuss every lobe (including right middle)
39
Q

what are types of percussion note?

A

resonant, dullness, stony dullness, hyperresonance

40
Q

what does dull percussion suggest?

A

increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse)

41
Q

what does hyper-resonant percussion suggest?

A

the opposite of dullness, suggesting decreased tissue density (e.g. pneumothorax)

42
Q

how can you assess tactile vocal fremitus?

A
  1. involves palpating over different areas of the chest wall whilst patient repeats a word/number consistently
  2. presence of increased tissue density or fluid affects the strength at which the patient’s speech is transmitted as vibrations through the chest wall
  3. ask patient to say 99 repeatedly at same volume and tone
  4. palpate chest wall on both sides, using the ulnar border of your hand
  5. cover all major regions of the chest wall, comparing each side
43
Q

what does increased vibration in tactile vocal fremitus suggest?

A

suggests increased tissue density (e.g. consolidation, tumour, lobar collapse)

44
Q

what does decreased vibration in tactile vocal fremitus suggest?

A

suggests presence of fluid or air outside of the lung (e.g. pleural effusion, pneumothorax)

45
Q

what is an alternative to assessing tactile vocal fremitus?

A

vocal resonance

46
Q

how do you perform auscultation technique?

A
  1. ask patient to relax and breathe deeply in and out through their mouth
  2. position the diaphragm over all locations
  3. listen to breathing sounds during inspiration and expiration
  4. assess quality and volume of breath sounds and note any added sounds
  5. auscultate each side in turn
47
Q

what areas should be auscultated?

A
  1. clavicle to 6th rib, mid-clavicular line
  2. axilla to 8th rib, mid-axillary line
  3. vocal resonance
48
Q

what should you listen for in chest auscultation?

A
  • vesicular breathing
  • bronchial breathing
  • quiet breath sounds
  • wheeze
  • stridor
  • coarse crackles
  • fine end-inspiratory crackles
  • pleural rub
49
Q

what is bronchial breathing?

A

harsh-sounding, inspiration and expiration are equal and there is a pause inbetween; associated with consolidation

50
Q

what are coarse crackles?

A

discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema

51
Q

what are fine end-inspiratory crackles?

A

often described as sounding similar to the noise generated when separating velcro; associated with pulmonary fibrosis

52
Q

how can you assess vocal resonance?

A
  1. ask patient to say 99 repeatedly at same volume and tone
  2. auscultate all major regions of the anterior chest wall, comparing each side
  3. allows discrimination between dullness to percussion from pleural effusion and that from consolidation
53
Q

how does vocal resonance discriminate between pleural effusion and consolidation?

A
  • this technique allows discrimination between dullness to percussion from pleural effusion and that from consolidation.
  • voice sounds, which are created in the larynx, are transmitted more effectively across an area of consolidation.
  • transmission is reduced across a pleural effusion or pneumothorax
54
Q

what does increased volume in vocal resonance suggest?

A

increased tissue density (e.g. consolidation, tumour, lobar collapse)

55
Q

what does decreased volume in vocal resonance suggest?

A

presence of fluid or air outside the lung (e.g. pleural effusion, pneumothorax)

56
Q

how can you palpate the lymph nodes?

A
  1. position the patient sitting upright and examine from behind if possible. ask them to tilt their chin slightly downwards to relax the neck muscles and aid palpation of lymph nodes. ask them to relax their hands in their lap
  2. inspect for any evidence of lymphadenopathy or irregularity of the neck
  3. stand behind the patient and use both hands to start palpating the neck
  4. use the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue to assess them. note any asymmetry in size, consistency and mobility of lymph nodes
  5. start in the submental area and progress through the various lymph node chains
  6. be careful when examining the anterior cervical chain that you don’t compromise cerebral blood flow due to carotid artery compression; examine one side at a time
57
Q

what lymph nodes should be palpated?

A
  1. submental
  2. submandibular
  3. preauricular
  4. postauricular
  5. superficial cervical
  6. deep cervical
  7. posterior cervical
  8. supraclavicular
58
Q

what is an example of logical systematic examination of the lymph nodes?

A
  1. start under the chin (submental), move posteriorly palpating beneath the mandible (submandibular), turn upwards at the angle of the mandible and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes)
  2. follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process
  3. ask the patient to tilt their head (bring their ear towards the shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes)
59
Q

what are respiratory causes of lymphadenopathy?

A
  • lung cancer with metastases
  • TB
  • sarcoidosis
60
Q

how do you assess the posterior chest?

A
  1. with the patient sitting forwards, ask them to fold their arms across their chest so their hands are touching the opposite shoulder; this results in rotation of the scapulae to better expose the underlying chest wall for assessment
  2. assess the posterior chest including inspection, chest expansion, percussion, tactile vocal fremitus and auscultation
  3. allow adequate time
61
Q

what are the final steps for a respiratory examination?

A
  1. assess for evidence of pitting sacral and pedal oedema (e.g. CHF)
  2. assess the calves for signs of DVT (e.g. swelling, increased temperature, erythema, visible superficial veins) as the patient may have SOB secondary to PE
  3. palpate ankles for oedema
  4. check sputum pot (volume, consistency, colour, odour, any haemoptysis)
  5. inspect for evidence of erythema nodosum, which can be associated with sarcoidosis
  6. assess peak flow (state you would do this in the OSCE)
62
Q

what further assessments and investigations should be suggested at the end of a respiratory examination?

A
  1. check oxygen sats and provide supplemental oxygen if needed
  2. check other vital signs including temp and BP
  3. take sputum sample
  4. perform peak flow assessment
  5. request CXR
  6. take ABG
  7. perform full cardiovascular examination

Phase 2B (9 decks)

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