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Clinical Examinations > Respiratory Examination > Flashcards

Respiratory Examination Flashcards

1
Q

State the 7 stages/sections of your respiratory examination

A
  1. Introduction & preparation
  2. General inspection
  3. Hands & arms
  4. Head & neck
  5. Chest: inspection, palpation, percussion, auscultation
  6. Legs
  7. Completing the examination
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2
Q

Describe what you must do in the introduction/preparation stage of your respiratory examination

A
  • Introduce yourself: name, role
  • Explain & consent: explain examination, offer chaperone, obtain consent, check for any pain
  • Check patient details: name, DOB
  • Wash hands
  • Position patient appropriately (45o and exposed neck and chest)
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3
Q

Describe what you must do in the general inspection stage of your respiratory examination

A

Inspect patient from end of bed, look for:

  • Obvious discomfort/pain
  • Colour
  • Evidence of dysnpoea?
  • Audible whee
  • Breathing: breathing pattern, pursed lip breathing, accessory muscle use, splinting of diaphragm, expiratory phase duration
  • Coughing
  • Cyanosis
  • Pink puffer
  • Blue bloater
  • Surroundings: oxygen, nebulisers, inhaler, peak flow
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4
Q

Describe what you must do in the hands & arms section of your respiratory examination

A
  • Inspection of hands: clubbing, tar staining, peripheral cyanosis, tremor, hypercapnic flap
  • Inspection: radial pulse
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5
Q

Describe what you must do in the head & neck section of your respiratory examination

A
  • Inspection of neck: JVP
  • Inspection of head: conjunctival pallor, central cyanosis, oral candidiasis, horner’s syndrome
  • Palpation of lymph nodes:submental, submandibular, pre-auricular, post-auricular, occipital, anterior cervical, posterior cervical, supraclavicular
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6
Q

Desribe what you must do in the chest stage of you respiratory examination

A
  • Inspection: movement, asymmetry, scars, shape/deformities, accessory muscle use, splinting of diaphragm
  • Palpation: tracheal palpation, chest expansion, apex beat, surgical emphysema
  • Percussion: all areas
  • Auscultation: breath sounds, vocal resonance

****DO IN ZIG-ZAG PATTERN FOR BOTH FRONT & BACK.

  • Extra note for back inspection: deformity of spine, sacral oedema
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7
Q

Describe what you must do in the legs stage of your respiratory examination

A
  • Inspection: calf swelling, superficial collateral non-varicose veins -any of these may indicate DVT (may make you think about PE risk)
  • Palpation: checking for DVT therefore check for tenderness & pitting oedema
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8
Q

Describe what you must do in the completing the examination part of the respiratory examination

A

Say that you would:

  • Temperature
  • Peak flow
  • Examine sputum

You may also be required to:

  • Present your fndings
  • Suggest diagnoses (max marks for 3)
  • Suggest appropriate next steps
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9
Q

What is the appropriate position to have your patient in when starting your respiratory examination?

A
  • Led at 45o
  • Neck and chest exposed
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10
Q

What is Kussmaul breathing and what is it suggestive of?

A
  • Kussmaul breathing is deep, laboured breathing
  • Suggestive of metabolic acidosis (e.g. due to DKA, organ failure, sepsis, seizures, toxins, long term use alcohol, some cancers)
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11
Q

What type of breathing is this?

A

Kussmaul breathing

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12
Q

What is pursed lip breathing indicative of?

*Can you explain why patients with this condition do this?

A
  • Pursed lip breathing is indicative of COPD
  • Patients purse their lips to increase intrathoracic pressure to help keep airways open for longer during expiration. Emphysema destroys elastic walls of alveoli hence there is a loss of radial traction keeping bronchioles open
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13
Q

What is splinting of the diaphragm?

A
  • Splinting is when a person reduces movement because the movement causes pain. Hence, splinting of diaphragm is when a patient has reduced movement of diaphragm (because movement causes pain)
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14
Q

Describe the appearance of a pink puffer

A
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15
Q

Patients with what condition can be described as pink puffers or blue bloaters?

A

COPD

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16
Q

Describe the appearance of a blue bloater

A
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17
Q

Explain why, scientifically, someone with chronic bronchitis may present as a blue bloater)

A

Chronic bronchitis can cause someone to be a ‘blue bloater’

  • Blue: cyanosis
  • Bloated: right sided heart failure (cor pulmonale) due to pulmonary vasculature remodelling. May also be due to hypoxic pulmonary vasoconstriction? Right sided heart failure causes peripheral oedema.
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18
Q

Explain, scientifically, why someone with emphysema may present as a pink puffer

A
  • Pink: CO2 retention & increased work of muscles?
  • Pufing: due to pursed lip breathing
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19
Q

State and describe 3 complications which may be experienced by blue bloaters

A
  • Secondary polycythaemia vera (due to hypoxia)
  • Pulmonary hypertension (due to vascular remodelling and hypoxic pulmonary vasoconstriction)
  • Cor pulmonale (from pulmonary hypertension)
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20
Q

State and describe 2 complications which may be experienced by ‘blue bloaters’

A
  • Pneumothorax (due to rupture of large bullae)
    *
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21
Q

Describe how you would test to see if your patient has a hypercapnic flap

A
  • Elevate arms with elbows straight
  • Cock wrist back (full wrist extension)
  • Ask patient to close eyes
  • Observe for at least 10 seconds
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22
Q

What is flapping tremor- also known as asterixis- indicative of?

A

CO2 retention (e.g. in metabolic encephalopathy)

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23
Q

State one possible cause of a fine tremor

A

B2 agonist

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24
Q

What should the JVP be below (in cm)?

A

JVP should be below 4cm

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25
What is surgical emphysema?
Air/gas in subcutaneous tissue which can cause: * Pain/discomfort * Swelling (skin coloured) * Crepitus (crackling sound- like a crisp packet- under skin)
26
How do you test for vocal resonance?
27
Describe how you test for tacile vocal fremitus
* Ask patient to say 99 each time hands placed on chest * Place medial side of each and on either side of chest and perform in at least 3 areas
28
If, when testing vocal resonance, you hear the word '99' better on one side, what could this indicate?
29
If calf swelling is unilateral, where abouts on the leg should you measure?
30
What is the cricosternal distance? What is the normal distance? What does a reduced cricosternal distance indicate?
* Distance from lower border of cricoid cartilage to the sternal notch * \>2cm (should be about 3-4 fingers) * Hyperexpanded chest (can be seen in COPD or asthma)
31
Give a brief summary of a structure you could use to present your examinatino findings
1. I performed ____ on a _____ year old ___ who presented with \_\_\_\_ 2. They appear \_\_\_(general inspection findings) \_\_\_\_ 3. On inspection of hands... 4. In head and neck.... 5. In chest.... 6. Observations were.... 7. My differentials are... 8. In summary, I believe the cause is.... 9. To complete my examination I would....
32
What does this image show?
Clubbing
33
How do you check for clubbing? *(4)* *HINT: think ABCD*
* **Loss of Schamroth's window** *(due to loss of angle between nail & nailbed)* * **Boggy nailbed** * **Increased longitudinal curvature** * **Drumstick appearance of fingertips**
34
Clubbing is a non-specific sign of systemic disease; true or false?
True
35
State some respiratory conditions in which clubbing is seen
* Inflammation: **cystic fibrosis, bronchiectasis** * Malignancy: **all except small cell** * Infection: **empyema, abscess**
36
State some other non-respiratory causes of clubbing
37
What does this image show?
Tar staining
38
What does this image show?
Peripheral cyanosis
39
Describe Raynauds phenomenom
Vasospams of arteries often triggered by cold. Colour change goes: * **Pale/white** * **Blue** (cyanosis) * **Red** (hyeraemia mediated by anaearobic metabolites causing vasodilation) *\*Fingers will feel cool and numb*
40
State some causes of peripheral cyanosis
* Peripheral: peripheral arterial disease, Raynauds, venous obstruction * Cardiac: shock, heart failure, hypotension * Respiratory: any that leads to decreased saturations * Haemoglobinopathy:
41
What does this image show?
Horner's syndrome *(partial ptosis, miosis & ahidrosis)*
42
What respiratory pathology does Horner's syndrome indicate?
Pancoast tumour (apcial pulmonary neoplasm that compresses surroudning structures)
43
Other than Horner's syndrome, state some other symptoms/consequences of a pancoast tumour
* **Pain, paraesthesia, weakness** *(compression of brachial plexus)* * **Hoarseness of voice, bovine cough** *(compression of recurrent laryngeal nerve)* * **Venous oedema or arterial ischaemia** *(compression of subclavian vessels*
44
What does conjuncival pallor indicate?
Anaemia
45
46
What does this image show?
Left shows central cyanosis
47
Central cyanosis is usually the manifestation of severe respiratory, cardiac or neurological/MSK pathology; state some examples of causes of central cyanosis from each of the above categories
_Respiratory_ * Acute: * Tension pneumothorax * Life-threatening asthma * Chronic: * End stage COPD _Cardiac_ * Congenital heart defects which mix oxygenated and dexoygenated blood _Neurological MSK:_ * Sedation * Neuromusular junction conduction impairing agents * Guillain-Barre syndrome
48
Remind yourself of difference, in terms of pathology, between peripheral and central cyanosis
* Peripheral: decreased blood flow * Central: decreased oxygen saturations
49
What does this image show?
Oral candidiasis
50
How can you differentiate between oral candidiasis and other causes such as oral hairy leukoplakia and oral lichen planus?
* In oral candidiasis the white lesions can be scrapped off leaving a raw area
51
When is oral candidiasis often seen in respiratory patients?
With inhaled corticosteroid use. Gargling with salt water after use can help to prevent candidiasis
52
What causes: a. ) Oral hairy leukoplakia b. ) Oral lichen planus
* Oral hairy leukoplakia= EBV infection * Oral lichen planus= chronic inflammatory condition that affects mucous membranes in mouth *
53
What does this image show?
Oral lichen planus
54
What does this iamge show?
Oral hairy leukoplakia
55
State two ways in which you can confirm whether the pulsation you are seeing is the JVP
* Palpate and ensure pulse is biphasic * Hepatojugular reflux
56
State 5 possible causes of raised JVP
* Right ventricular failure * Tricuspid disease * Fluid overload * PE * Obstruction to blood flow e.g. SVC obstruction (RARE)
57
State 3 possible causes of cervical lymphadenopathy
* Infection: **glandular fever** * Inflammation: **Sjogren's syndrome** * Malignancy: **tonsil, tongue etc...**
58
State some causes of tracheal deviation
* Pulling: **lung collapse, pneumonectomy** * Pushing: **tension pneumothorax, thyroid mass**
59
What does this image show?
* Barrel chest *(AP to transverse diameter ratio is closer to 1:1 wherease is should be 1:2)*
60
What does this image show? What has happened to sternum? When is it usually noticed?
* **Pectus excavatum** ("funnel chest") * Occurs when sternum is sunk into chest wall * May be noticed at birth
61
What does this image show? What has happened to sternum? When does it usually present?
* Pectus carinatum ("pigeon chest") * Occurs when sternum grows outwards * Usually noticed during growth spurt of puberty
62
What does the CXR show?
Surgical emphysema
63
What causes surgical emphysema? How does it feel to touch?
* Gas in subcutaneous tissue * On palpation crepitus (crackling) is felt
64
State some causes of surgical emphysema
* Trauma * Surgery * Drainage * Fistula with gas containing organ
65
What is the apex beat?
Point of maximal impulse during ventricular contraction
66
Where is the apex beat usually found?
Left 5th ICS, mid-clavicular line
67
State the 7 thoracic incisions you need to know
1. Median sternotomy 2. Infraclavicular 3. Left inframammary 4. Left anterolateral thoracotomy 5. Right anterolateral thoracotomy 6. Clamshell thoracotomy 7. Posterolateral thoracotomy
68
Describe where a median sternotomy incision is State some surgeries which may use a median sternotomy
* Number 1 on image *(middle of sternum)* * Access anterior mediastinal structures e.g. **CABG, open aortic or mitral valve replacement**
69
Describe where an infraclavicular thoracic incision is What surgeries may use this incision?
* Number 2 on image *(under clavicle)* * Insert pacemaker
70
Describe where an inframammary scar is What surgeries may use this incision?
* Number 3 on image *(under breast)* * Breast augmentation or mitral valvotomy
71
Describe where a left anterolateral thoracotomy incision is What surgeries may use this incision?
* Number 4 on image *(mid axillary line to lateral sternal border)* * May suggest emergency surgery to: * Cardiac massage in resuscitation * Repair coarctation of descending aorta * Repair anterior penetrating thoracic injury
72
Describe where a right anterolateral thoracotomy incision is What surgeries may use this incision?
* Number 5 on image *(right mid axillary line to lateral sternal edge)* * To access: * Aortic valve * Ascending thoracic aorta * Anterior penetrating thoracic injury
73
Describe where a clamshell thoracotomy incision is What surgeries might use this incision?
* Number 6 on image *(combination of left and right anterolateral thoracotomy)* * Suggests emergency surgery e.g. cardiac massage in resuscitation or repair of anterior penetrating thoracic injury
74
Describe where a posterolateral thoracotomy incision is What surgeries might use this incision?
* Number 7 on image *(mid spinal line to anterior axilla line)* * Used to access: * Lungs: lobectomy, pneumonectomy or transplant * Oesophagus: oesophagectomy *(requires rooftop incision aswell)*
75
Describe vesicular breath sounds
* Normal breathing * Soft, non-musical * Inspiratory is longer than expiratory * No gap between
76
State 2 broad causes of diminished breath sounds For each of these broad causes give some specific example conditions
_Decreased sound generation_ * Hypoventilation * Bronchospasm * Bronchial obstruction _Decreased transmission_ * Pneumothorax * Pleural effusion
77
Describe bronchial breathing
* Mimics normal trachea sound * Soft, non-musical * Inspiration and expiration * Gap inbetween
78
State some reasons you may hear bronchial breath sounds (3)
* Consolidation (e.g. pneumonia) * Fibrosis * Just above a pleural effusion
79
Describe stridor
* Musical * High pitched * Can be heard at end of bed or over upper airway
80
A stridor suggests a large airway obstruction; state what each of the following specifically suggests: * Inspiratory stridor * Expiratory stridor * Biphasic stridor
* Inspiratory stridor: *extra-thoracic obstruction* * Expiratory stridor: *intra-thoracic obstruction* * Biphasic stridor (both insp & exp): *fixed lesion usually at level of vocal cords e.g. croup, bilateral vocal cord paralysis*
81
Describe a wheeze
* Musical, high pitched * Usually on expiration (but may be heard on inspiration)
82
If a wheeze is... * Localised and monophonic * Widespread and polyphonic ... what does it suggest?
* Localised & monophonic: foreign body or tumour * Widespread & polyphonic: bronchospasm due to airway or COPD
83
State two other words for crackles
* Crepitations * Rales
84
Compare fine and coarse crackles
_Fine crackles_ * Sounds like velcro being torn * Short/explosive * Heard mid to end inspiration * Unaffected by coughing * May be gravity dependent (dependent on cause) _Coarse crackles_ * Short, explosvie * Low pitched * Heard throughout expiration (and occasionally inspiration) * May change or disappear on coughing
85
State 2 possible causes of fine crackles
* Pulmonary oedema * Interstitial lung diseases
86
State 2 possible causes of coarse crackles
Coarse crackles represent intermittent airway opening and may relate to secretions: * Bronchiectasis * Pneumonia
87
What does a pleural friction rub sound like? When is it heard?
* Like crunching snow under your foot * Biphasic
88
A pleural friction rub indicates pleural inflammation; state some possible causes of pleural inflammation
* Infection * Pulmonary infarction due to PE * Malignancy
89
For each of these conditions (pneumothorax, consolidation, effusion, collapse) state what you would find for each of the following on examination: * Expansion * Percussion * Resonance/fremitus * Auscultation
90

Clinical Examinations (16 decks)

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