Respiratory examination: Anterior and posterior Flashcards
What is the general order of the respiratory exam?
Look
Feel: Tracheal deviation, cricosternal distance, apex beat, auscultation, percussion, vocal resonance
When looking at the patient, how should you position them?
Lying supine (on back) on the bed at 45 degrees raised angle
What 3 types of respiratory signs do you look for in the respiratory exam?
Chest signs
Hand signs
Face signs
Before you start the respiratory examination, how should you ask the patient to expose their chest with 2 points?
- Ask patient if they would be comfortable with removing their shirt:
‘Would you be comfortable with removing you shirt so I can examine your chest?’ - Ask patient if they want a chaperone with them
What 8 general signs should you look for at the start of the respiratory exam?
Cyanosis
Wheezing
Pallor
Cough
Edema
Cachexia
Dyspnea
Flail chest
What is peripheral cyanosis and how do you identify it when looking at the patient in the respiratory exam, and what is the clinical significance?
Blue skin discolouration most obvious around lips, mouth, ears, distal extremities
Occurs when oxygen saturation is below 85%, causing increased conc of deoxyhaemoglobin which has blue colour
What is the clinical significance of flail chest and what are the 4 main signs in a respiratory exam?
Life-threatening condition where segment of rib cage breaks due to trauma and detaches from chest wall
Paradoxical movement of chest wall where broken segment draws in when patient inhales and chest expands, and segment moves out when patient exhales and chest shrinks
Dyspnea
Chest pain
Bruising in affected area
What 5 medical paraphernalias should you look for in the respiratory exam?
Oxygen delivery devices and masks
Sputum pot
Inhalers, nebulisers
Cigarettes, vapes
Prescriptions
What 8 hand signs should you look and feel for in the respiratory exam?
Peripheral cyanosis of the fingertips
Clubbing
Fine tremor
Flapping tremor
Tar staining
Temperature
Thenar and hypothenar muscle wasting
Radial and ulnar pulses
What does tar staining look like in a respiratory exam, and what does it indicate?
Brownish stains near fingertips and under nail beds
Indicates cigarette smoking
What does finger clubbing in a respiratory exam indicate, and give 5 conditions that can cause this?
Indicates hypoxemia
Pleural effusion
Lung cancer
Bronchiectasis
ILD
CF
How should you look for a fine tremor in the respiratory exam, and what does it indicate?
Ask patient to hold out their hands and look from the side
Indicates long-term beta-2 antagonist use eg. salbutamol inhaler
How should you look and feel for fingertip clubbing in a respiratory exam?
Looking: Fingers will look clubbed at the end
Feeling: Palpate the nail beds and nails, nail beds will be very soft and spongy and nails will float and bounce
What does a flapping tremor/asterixis look like and what causes it, in a respiratory exam?
Jerking hand movements when trying to extend wrist, that resemble bird wing flapping
Ask patient to extend their wrist and see if flapping occurs
CO2 retention in conditions like COPD
Where should you palpate the hand for temperature in a respiratory exam, and what does it indicate?
Palpate dorsal and palmar surfaces
Cold temperature: Poor peripheral perfusion
Hot temperature and sweating: CO2 retention
After you have measures the radial and ulnar pulses in the respiratory exam, what should you measure?
Respiratory rate
What 3 face signs should you look for in the respiratory exam?
Facial plethora
Conjunctival pallor
Central cyanosis of the tongue
How do you look for facial plethora in a respiratory exam, and what 2 conditions can it indicate?
Reddened, flushed skin
Indicates secondary polycythemia or CO2 retention conditions eg. COPD
How do you look for conjunctival pallor in a respiratory exam, and what condition can it indicate?
Ask patient to pull down lower eyelid and look for paleness
Indicates anaemia
How do you look for central cyanosis of the tongue?
Ask patient to stick out tongue and look for purple/blue colour
When palpating the patient’s neck, what 2 things do you feel for in the respiratory examination?
Tracheal deviation
Cricosternal distance
How do you feel for tracheal deviation in the respiratory exam?
- Ask patient to position chin slightly downwards to relax neck muscles
- Warn patient that this can feel slightly uncomfortable and that you’ll gently palpate neck
- Start palpating at suprasternal notch then move up and place a finger on each side of trachea
- Feel if distance between each side of trachea and SCM muscle is symmetrical, asymmetry indicates deviation
Give 4 causes of tracheal deviation?
Trachea deviated towards areas with lower pressure and away from areas with higher pressure
Deviation away: Pneumothorax, pleural effusion
Deviation towards: Lobar collapse, pneumonectomy
What is the cricosternal distance?
Distance between suprasternal notch and inferior border of cricoid cartilage
In men, the cricoid cartilage is the adam’s apple
How do you measure the cricosternal distance in a respiratory examination, and what is the normal distance?
- Warn patient that this might be slightly uncomfortable
- Use fingertips to measure distance between suprasternal notch and inferior border of cricoid cartilage
- Normal distance is 3-4 fingertips, less indicates hyperinflation
In the respiratory examination, what should you palpate first on the chest, and what abnormality are you checking for?
Apex beat
Displaced apex beat indicates cardiomegaly
Where is the apex beat located, and how do you check for a displaced apex beat?
Located on 5th intercostal space/mid-clavicular line, under nipple
- Place fingers horizontally and feel for beat
What are the 3 main respiratory causes of a displaced apex beat?
Cardiomegaly due to COPD, ILD
Pneumothorax
Large pleural effusion
How do you palpate chest expansion in the anterior respiratory exam?
Upper chest: Place hands on shoulders and ask patient to take deep breaths in and out, see if hands move symmetrically
Lower chest: Place hands on chest under mid-clavicular line with thumbs lightly fixed and pinky fingers firmly fixed at costal margins. Ask patient to take deep breaths in and out and see if hands move symmetrically
How do you palpate chest expansion in the posterior respiratory exam?
Place hands flat on back with thumbs under inferior border of scapula and pinky fingers firmly fixed on lateral thorax
Ask patient to take deep breaths in and out and see if hands move symmetrically
Give 3 causes of asymmetrical/unilateral chest expansion in the respiratory exam?
Pneumonia
Pneumothorax
Pleural effusion
Reduced chest expansion on affected side
Give 2 respiratory causes of bilateral reduced chest expansion?
Asthma
COPD
Which 6 landmarks do you percuss in the respiratory exam?
Supraclavicular
Infraclavicular
Supramammary
Inframammary
Upper axillary
Lower axillary
Which 6 landmarks do you auscultate in the respiratory exam?
Supraclavicular
Infraclavicular
Supramammary
Inframammary
Upper axillary
Lower axillary
Which 6 landmarks do you check for vocal resonance in the respiratory exam?
Supraclavicular
Infraclavicular
Supramammary
Inframammary
Upper axillary
Lower axillary
When looking at the patient, what should you look for in their general posture?
Kyphoscoliosis
What neck sign should you look for in the respiratory exam, and what does it indicate?
Jugular Venous Pressure (JVP) elevation
Elevation caused by venous hypertension due to right-sided heart failure
How do you look for JVP elevation in a respiratory exam, and what further investigation could you do?
- Ask patient to look to the side or over their shoulder
- Bend down so that you are in line with patient’s JVP and look for pulsation above the clavicle
- Negative: Say that the jugular vein pressure is not visibly elevated
Positive: Say that the jugular vein pressure is visibly elevated, could be due to right-sided heart failure which also causes venous hypertension
- Ask examiner if they would like you to illicit the hepatojugular reflex
Both: Inspection, Percussion, auscultation, vocal resonance
