Respiratory Examination Flashcards
Introduction
Introduce yourself Confirm patient name and DOB Ask how they'd like you to address them Explain what you plan to do, gain consent Are they in any pain PPE, handwashing Adjust bed to 45 degrees
Step 1 General inspection (clinical signs)
- what might you find
- what does this mean
Age
- young => asthma, CF?
- old => COPD, ILD, malignancy
Complexion
- pallor => anemia (haemorrhagic/chronic disease), poor perfusion (CCF)
- cyanosed => poor circulation (peripheral VC, inadequate oxygenation)
Habitus
- pedal/abdomen edema => RV failure, cor pulmonale
- cachexic => malignancy, end stage COPD
Breathing
- SOB, can’t speak in full sentences, tripod, accessory muscle use => asthma, pulmonary edema, pulmonary fibrosis, lung cancer, COPD
- stridor => foreign body inhalation, subglottic stenosis
- wheeze => asthma, COPD, bronchiectasis
Cough
- productive => pneumonia, bronchiectasis, COPD, CF
- dry => asthma, ILD
Step 1 General inspection (objects, equipment)
- what might you find
- what does this mean
O2 delivery, ventilation
- nasal prongs, venturi, non rebreathe
- CPAP, BiPAP?
Sputum pot colour and contents
- white => COPD exacerbation
- yellow, green => bacterial infection (pneumonia?)
Medical equipment
- ECG
- medications (nebulisers, inhalers, catheters, IVs)
Charts
-NEWS, fluid balance, drug charts
Mobility
-wheelchairs, frames
Cigarettes, vapes
-COPD, lung cancer?
Step 2 Hands, general observations
- what might you find, look for
- what does this mean
Colour
- cyanosis => hypoxemia
- tar stains => smoker (COPD, lung cancer?)
- bruising, thin skin (long term steroid use) => asthma, COPD, ILD?
- joint swelling, deformity => RA with pleural effusions, pulmonary fibrosis
Step 2 Hands
-what is clubbing indicative of?
Cancer
-squamous
-mesothelioma (caused by asbestos)
Chronic suppuration
- bronchiectasis
- ILD
- empyema
Cystic fibrosis
Chronic autoimmune
-sarcoidosis
Step 2 Hands
-what can tremor and flap tell you
Fine tremor => B2ag use
Asterixis => CO2 retention (T2RF, COPD)
Step 2 Hand palpation
- what info can you get from this
- what does this tell you
Temperature, should be symmetrically warm
- cool => poor peripheral perfusion
- excessively warm => CO2 retention?
HR
- bounding => CO2 retention
- pulsus paradoxus (pulse wave volume decreases significantly on inspiration) => cardiac tamponade, severe acute asthma, COPD
RR
- bradypnoea => opiate OD?
- tachpnoea => acute asthma?
- asymmetrical => expiration prolonged in COPD exacerbations
Step 3 Neck, JVP
- how would you measure this
- what is abnormal and what does this mean?
45, turn head to left
- look for biphasic flicker in supraclavicular fossa
- measure the vertical distance between sternal angle and top of pulsation (up to 4cm)
Raised => venous HTN (cor pulmonale due to COPD, ILD)
Hepatojugular reflex
NORMALLY JVP REMAINS CONSTANT OR TEMPORARILY RISES
-sustained rise => decreased venous return
Step 4 Face, general observations
- what might you find
- what does this mean
Plethoric (congested red face) => polycythemia (COPD), CO2 retention (T2RF)
Step 4 Face (eyes)
- what might you find
- what does this mean
Conjunctival pallor => anemia
Ptosis, miosis (excess pupil constriction), enopthalmos (retraction of eye into orbit) => Horners syndrome (sympathetic trunk damaged <= pancoast tumour compression)
Step 4 Face (mouth)
- what might you find
- what does this mean
Central cyanosis => hypoxemia
Oral candida above erythmatous mucosa => steroid inhaler use, immunosuppresion
Step 5 Chest (inspection)
- what might you find
- what might this be indicative of?
Scars
Radiotherapy associated skin changes (lung cancer)
-dry skin, scale, hyperkeratosis
-depigmentation, telangiectasia
Asymmetry => pneumonectomy, thoracoplasty
Pectus excavatum, carinatum
Hyperexpansion (wider and taller than normal) => asthma, COPD
Step 6 Trachea
- how would you assess its position
- what could this tell you
Warn patient before hand, might be painful
Dip index finger into thorax next to trachea, gently apply pressure
Compare this space to other side
Deviation away => tension pneumothorax, large pleural effusions
Deviation towards => lobar collapse, pneumonectomy
Step 6 Trachea
Cricosternal distance
-how would you assess this
-what could this tell you
Distance between suprasternal notch and cricoid cartilage
-3-4 finger distance is normal
Smaller => hyperinflation (asthma, COPD)
Step 7 Chest palpation
- what would you assess
- what would this tell you
Apex beat
-displaced => LVH (pulmonary HTN, COPD, ILD), large pleural effusion, tension pneumothorax
Symmetrical reduced chest expansion => pulmonary fibrosis
Asymmetrical reduced chest expansion => pneumothorax, pneumonia, pleural effusion
Step 8 Chest percussion
- what are you looking for
- what can this tell you
NORMALLY RESONANT
Dullness => consolidation, tumour, lobar collapse
Stony dullness => pleural effusion
Hyper resonant => pneumothorax
Vocal fremitus
- increased resonance => consolidation, tumour, lobar collapse
- decreased resonance => fluid, air outside lung (pleural effusion, pneumothorax)
Step 9 Chest auscultation
- what would you find
- what does this mean
Quality
- vesicular => normal
- bronchial => harsh sounding, inspiration, expiration equal (consolidation)
Volume
-quiet => reduced air entry (pleural effusion, pneumothorax
Added sounds
- wheeze => coarse (asthma, COPD, bronchiectasis)
- stridor => high pitched from turbulent flow (foreign body inhalation, subglottis stenosis)
- coarse => discontinuous brief popping (pneumonia, bronchiectasis, pulmonary edema)
- fine crackles => Velcro (pulmonary fibrosis)
Step 10 lymph node palpation
- which ones would you palpate
- what are you looking for
Examine from behind the patient
Tilt chin downwards slightly
-inspect for lymphadenopathy/abnormalities
-use both hands to assess symmetry in both sides
-use pads of fingers to roll nodes over surrounding tissue
Submental, submandibular Preauricular, postauricular Superficial, deep cervical Anterior, posterior chain Occipital Supraclavicular
Lung cancer with mets
TB
Sarcoidosis
Step 11 Posterior chest
- what are you doing
- what are you looking for
Ask patient to hug their knees
- inspect
- expansion
- percussion, vocal fremitus
- auscultation
Same as anterior thorax
Step 12 Peripheral edema
- what are you testing
- what does this mean
Pitting sacral, pedal edema (RVF)
Erythema nodosum (swollen fat under skin causing bumps and patches) => sarcoidosis, TB, pneumonia,
Signs of DVT
Completion of examination
Further examinations
SaO2 Sputum sample if coughing Peak flow CXR if abnormalities found ABG CV exam to rule out CV causes
