Respiratory Examination Flashcards
To remember the stages of a respiratory examination and learn the underlying pathology
What are you looking out for when ‘inspecting from the end of the bed’?
- oxygen
- nebulisers
- asthma inhalers
- peak flow
- intubation
- Cigarettes
What signs on the patient should be observed from general inspections
- Pain
- SOB
- Cyanosis
- Coughing
- Wheezing
- Nutritional state- cachexia/obesity
- Pink puffer- emphysema
- Blue bloater- bronchitis
- Chest deformities
- Scars on the chest wall or lower limbs (vein harvesting)
Anaemia Visible pulsations SOB Pallor Oedema Cyanosis Malar rash Oedema Nutritional state Syndromic features (Down’s, Marfan’s) Scars- Mitral valvotomy, Thoracotomy
What should be looked for when assessing the patients SOB during the general patient inspection?
- assess respiratory rate
- kussmaul breathing- deep and laboured breathing in acidotic
- pursed lips- COPD to increase intrathoracic pressure allowing for full exhalation
- Splinting diaphragm/use of accessory muscles
What are you looking for when inspecting the dorsum of the hands and what are these signs indicative of?
- Tar staining
- Capillary refill
- Peripheral cyanosis
- Tremor
- Coarse – CO2 retention
- Fine – Salbutamol effect
What respiratory conditions can clubbing be a sign of?
- Bronchial carcinoma
- Bronchiectasis
- Empyema
- Fibrosing alveolitis
What are you looking for when inspecting the palmar side of the hands?
- Tar staining
- Palmar erythema/warm – CO2 retention
- Peripheral cyanosis
- Tremor
- Coarse – CO2 retention
- Fine – Salbutamol effect
How long should capillary refill time be?
<3 seconds
What respiratory conditions could cause a fast and slow heart rate respectively?
Fast- B2 agonist effect
Slow- CO2 retention
What is pulsus paradoxus?
An abnormally large decrease in pulse volume during inspiration
What is Horners syndrome and what are the three main signs of it?
Interruption of sympathetic supply to the orbit results in:
- Ptosis- drooping or falling of the upper eyelid
- Miosis- excessive pupil constriction (specifically in one eye)
- Anhydrosis- inability to sweat normally
- red-eye
- enopthalmos
What are some common causes of Horner’s syndrome?
- Apical pulmonary disease – Pancoast’s syndrome (malignant neoplasm of the superior sulcus of the lung)
- Cervical lymphadenopathy
- Thyroid enlargement
- Central lesions – tumours/ demyelinating disease
What else should be observed on the face?
- Central cyanosis
- Oral thrush- side effect of steroid use
What is the order for palpating the cervical lymph nodes?
Anterior Cervical (both superficial and deep)- from the angle of the jaw to the top of the clavicle.
Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius, from the level of the mastoid bone to the clavicle.
Tonsillar: Located just below the angle of the mandible.
Sub-Mandibular: Along the underside of the jaw on either side.
Sub-Mental: Just below the chin.
Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the sternum.
What respiratory conditions will cause a raised JVP and why?
- Pulmonary hypertension and consequent Cor pulmonare (pulmonary heart disease)
The increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) results in the right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries. This leads to back pressure of blood in the right atrium, the vena cava and the systemic venous system.
- COPD
- Lung fibrosis
What would cause a deviation of the trachea towards the site of the lesion?
Collapse and consolidation of the lung caused by endobronchial obstruction (compensatory hyperinflation of other lung)
What would cause a deviation of the trachea away from the site of the lesion?
- Tension pneumothorax
- Pleural effusion
- Mass e.g. tumour
What can a cricosternal distance of <2cm indicate?
Can indicate chronically hyperexpanded chest wall seen in COPD
What 7 things should be inspected for on the chest?
- Surface markings – pneumonectomy scars including axilla (lateral thoracotomy)
- Deformity – scoliosis/ kyphosis
- Symmetry of chest movements
- ‘Barrel’ chest
- Pectus excavatum/ carinatum
- Surgical emphysema
- In drawing of intercostal muscles
How do you test for equal chest expansion?
- Ask patient to expire fully
- Grip patients chest on anterior chest wall
- Ask patient to inspire deeply
- Note deviation length and symmetry?
- Repeat beneath pectorals
Where should you percuss the lung?
At least 3 different levels from supraclavicular fossae to bases and the axilla
State some causes of dull percussion note?
- Lung consolidation
- Fibrosis
- Pleural effusion (stony dull)
- Pleural thickening
- Lung collapse
- Consolidation
State some causes of hyper-resonant percussion note?
- Pneumothorax
- Lung hyperinflation (as seen in COPD)
How should the patient breathe whilst you are auscultating their chest?
Breathing normally through a slightly open mouth
What does normal (vesicular) breathing sound like?
rustling leaves in the wind
What does bronchial breathing sound like?
High pitched blowing sound which can be heard when auscultating over trachea in normal breathing, with similar intensity in inspiration and expiration and a pause in between
When does bronchial breathing occur?
- Consolidation (commonest cause)
- Localised fibrosis
- Above a pleural effusion
What lung conditions cause reduced breath sounds?
- Pneumothorax
- Pleural effusion
- Emphysema
- Bronchial obstruction
What does a silent chest suggest?
Life threatening asthma due to severe bronchospasm
What is a monophic wheeze and what does it suggest?
Monophonic wheezes are loud, continuous sounds occurring in inspiration, expiration or throughout the respiratory cycle. The constant pitch of these sounds creates a musical tone.
Partial obstruction of a single airway e.g. tumour
What is a polyphonic wheeze and what does it suggest?
Polyphonic wheeze is the widespread narrowing of airways of differing calibre e.g. asthma, COPD hence a range of loud, muscial tones are heard
What does a fine end-inspiratory crackle suggest about the lung structure?
Pulmonary oedema or fibrosing alveolitis
What can a coarse and low picthed crackle indicate?
Issue lies more proximally in the airwyas e.g. bronchiectasis
What is pleural rub?
An abnormal lung sound which is caused by movement of visceral pleura over parietal pleura when both surfaces are roughened by an inflammatory exudate- heard on inspiration and expiration and sounds like a low-pitch harsh/grating noise.
State two causes of pleural rub?
- Adjacent pneumonia
- Pulmonary infarction
What do you ask the patient to repeatedly say whilst assessing for vocal resonance?
99/111
What causes increased vocal resonance?
consolodation
What causes decreased vocal resonance?
- pleural effusion
- pneumothorax
What is vocal resonance a sign of?
Vocal resonance a sign of lung density hence why increased vocal resonance is seen on lungs with a greater density than usual
What should you assess on the patients back?
- Inspect for scars and scoliosis/kyphosis
- Percuss and auscultate the lung bases
- Check for lung expansion on the back
What are some appropriate follow up examinations?
- Temperature chart
- Assess peak flow
- Pulse oximetry
- Inspect sputum
