Respiratory Examination Flashcards
On general inspection, what are you looking for in the patients surroundings?
Indicators of respiratory pathology (e.g. inhalers/ other drugs, nebulisers, oxygen delivery devices, sputum pot)
On general inspection of the patient, what are you looking for?
Weight loss, pain/ discomfort, breathlessness, positioning, use of accessory muscles
On general inspection of the patient, what are you listening for in their breathing/ speech? What may these indicate?
Audible inspiratory stridor indicating upper airway obstruction
Expiratory wheeze indicating asthma
Hoarseness indicating laryngitis, lung cancer (causing laryngeal nerve palsy), laryngeal cancer
Pattern of speech e.g. do they interrupt speech flow to take a breath?
Spontaneous coughing/ ask patient to cough and listen to the sound (dry or productive)?
On assessment of the hand, what are you looking/ feeling for?
Feeling for circulation (warmth and ventilation)
Finger clubbing
Tar staining
Flapping tremor
Fine tremor
Palpate radial pulse (rate and rhythm)
What are common respiratory causes of finger clubbing?
Lung cancer
Mesothelioma
Pulmonary fibrosis
Any chronic suppurative lung disease (e.g. bronchiectasis (late stages), empyema, cystic fibrosis)
What does a flapping tremor indicate? What other signs may accompany it?
Carbon dioxide retention
Also warm hands and bounding pulse
What can cause a fine tremor?
Use of beta-agonist inhalers or nebulisers
What does a tachycardia greater than 110/min in the context of asthma indicate?
Severe asthma attack
What can cause polycythaemia?
Chronic lung disease or smoking
What does pursed lips on expiration indicate and why?
Emphysema - patient trying to delay collapse of intrathoracic airways
What respiratory pathology may Horner’s syndrome indicate?
Pancoast tumour
On close inspection of the chest, what should you look for?
Scars Shape (asymmetry, deformity (e.g. kyphoscoliosis), increased AP diameter (barrel shaped) Pattern of breathing, use of accessory muscles, intercostal recession or undraping and posture
What is a barrel shaped chest with limited lateral expansion an indicator of?
Hyper-inflated chest and air trapping e.g. COPD (airflow obstruction)
What do prominent chest wall veins suggest?
SVC obstruction
What is the posture like in patients in respiratory distress related to airflow obstruction?
Fix their rib cage and shoulder girdle by supporting themselves with arms straight out on bed
What respiratory pathology might a raised JVP indicate?
Right heart failure secondary to chronic lung disease or pulmonary embolism
What should you check for if there is history of injury or possible pneumothorax?
Subcutaneous (“surgical”) emphysema (crackling sensation felt under skin leaving from a pneumothorax or rarely a ruptured oesophagus
Palpate for rib fractures
Look for swollen neck
Flail chest
Tenderness
Crepitus over broken ribs
How is mediastinal shift assessed?
Tracheal deviation and displaced apex beat
What pathologies cause the trachea to deviate towards the side of the pathology?
Fibrosis, absorption collapse of lung, pneumonectomy
What pathologies cause the trachea to deviate away from the side of the pathology?
Tension pneumothorax and pleural effusion
What might hyper resonant percussion indicate?
Emphysema, large bullae or pneumothorax
What might dull percussion indicate?
Collapse, consolidation, or fibrosis
What might “stony” or very dull percussion indicate?
Pleural effusion, haemothorax
What might dullness at the base of the lungs indicate?
Infection (consolidation), effusion, collapse (or a raised diaphragm)
If areas of the chest are found to be “stony”, what tests could be done to exploit this?
Either tactile vocal fremitus or vocal resonance (the latter is preferred)
How do you test for tactile vocal fremitus? What does increased or decreased fremitus indicate?
Palms of your hands on area of dullness and ask patient to say “99”
Increased fremitus = consolidation or fibrosis
Decreased fremitus = pleural effusion or collapse
How do you test for vocal resonance?
Auscultate area of dullness and ask patient to say “one, one, one” and then compare with other side
Increased resonance suggests consolidation or fibrosis
Decreased resonance suggests pleural effusion or collapse
Do the same again but ask patient to whisper
Whispering is not heard over a normal lung but in consolidation the sound is transmitted
What questions should you ask yourself as you auscultate?
- Are breath sounds present? Are they vesicular in nature?
- Are breath sounds equal on both sides?
- Are there any bronchial breath sounds?
- Are there any added sounds such as crackles, wheezes or pleural rub?
Does the inspiratory or expiratory component dominate in vesicular breath sounds?
Inspiratory
Is there normally a gap between inspiration and expiration?
No
Is there normally a gap between expiration and inspiration?
Yes
What causes decreased breath sounds?
When normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion)
When may bronchial sounds be heard?
When small airways or alveoli have been damaged e.g. consolidation
Describe bronchial sounds
Gradually increase through inspiration but stop near the end of inspiration (when air would normally be flowing round the alveoli i.e. there is gap between inspiration and expiration)
Expiratory component dominates
Describe the sound of crackles
High-pitched, discontinuous sounds similar to the sound when rubbing hair between fingers
What causes crackles?
Oedema or fibrosis
Describe the sound of wheezes
Generally high pitched and musical
What causes wheezes?
Small airway narrowing e.g. asthma
Describe the sound of friction/ pleural rub
Like creaking leather (low pitched)
What causes pleural rub?
Pleural inflammation e.g. pleurisy
What glands should be examined for lymphadenopathy?
Submental, submandibular, tonsillar, deep cervical chain scalene nodes
