Respiratory examination theory (geeky medics)

Question 1

What treatments or adjuncts found in the patient’s vicinity would be considered remarkable?

Answer 1

• O2
• Inhalers
• Nebulisers
• Sputum pots

Question 2

When examining from the end of the bed what patient signs could indicate SOB?

Answer 2

• Nasal flaring
• Pursed lips (maintains lung pressure preventing large airways from collapsing)
• Use of accessory muscles

Question 3

If the paitent is unable to speak in full sentences what could this indicate?

Answer 3

…

Question 4

If the patient has bluish/purple discolouration what does this indicate?

Answer 4

Cynaosis (oxygen saturation <85%)

Question 5

What other symptoms can be seen from a general inspection that could suggest respiratory patholgy?

Answer 5

• Chest wall abnormalities or asymmetries. e.g. barrel chest = COPD
• Cachexia = malignancy
• Cough. Productive or dry?
• Wheezing? Asthma / COPD / allergy related

Question 6

What does a low hand temperatur indicate?

Answer 6

• peripheral vasoconstriction / poor perfusion

Question 7

What sign on the hand could indicate the patient is a smoker?

Answer 7

Tar staining (increased risk of COPD / lung cancer)

Question 8

What does a bluish discolouration in the finger nails indicate?

Answer 8

Peripheral cynosis (O2 saturation <85%)

Question 9

What could clubbing of the fingernails indicate?

Answer 9

• lung cancer
• interstital lung disease (umbrella term for diseases effecting the interstitium. Idiopathic pulmonary fibrosis is the most common cause)
• bronchiectasis (abnormal widening of the bronchioles -> + mucus -> + infection)

Question 10

What is the normal adult ranges for breathing and pulse rate?

Answer 10

• 12-20 breaths/minute
• 60-100 beats/min

Question 11

What are you looking for when feeling for the pulse? What abnormal pulse can be found?

Answer 11

• rate and rhythm
• Pulsus paradoxus - pulse wave volume decreases with inspiration - COPD / Asthma

Question 12

What does a fine tremour in the hands indicate?

Answer 12

Can be a side effect of beta 2 agonist (e.g. salbutamol - causes smooth muscle relaxation)

Question 13

What does a flapping tremour indicate?

Answer 13

• CO2 retention - type 2 respiratory failure - COPD

Question 14

What is the difference between type I and type II respiratory failure?

Answer 14

• Type I involves low oxygen saturation and normal or low levels of CO2 saturation.
• Type II involves low oxygen saturation AND high levels of CO2 saturation

Question 15

What disease is implicated when inspecting the lower eyelid for conjucatival pallor? How is anaemia related to respiratory diseases?

Answer 15

• Anaemia
• …

Question 16

What is Horner’s syndrome and what are its signs?

Answer 16

• Horner’s syndrome may reflect serious disease to the chest or neck. Unilateral symptoms arise when the ipsilateral sympathetic trunk is damaged.
• ptosis (drooping of eyelid) / constricted pupil (miosis) / anhidrosis (inability to sweat properly) on affected side / enopthalmos (posterior displacement of the eyeball in the orbit)

Question 17

Why would you inspect the mouth and bottom of the tongue of the patient?

Answer 17

• blueish discolouration of the lips / inferior aspect of the tongue indicagtes central cynosis.

Question 18

What is cyanosis and what can cause it?

Answer 18

• Cyanosis is defined as a bluish discoloration, especially of the skin and mucous membranes, due to excessive concentration of deoxyhemoglobin in the blood caused by deoxygenation. Cyanosis is divided into two main types: Central (around the core, lips, and tongue) and Peripheral (only the extremities or fingers)
• Central cynosis is often due to a circulatory or ventilatory problem that leads to poor blood oxygenation in the lungs - present when arterial oxygen saturation <85%.
• Acute - asphyxiation
• Chronic - pnuemonia / COPD / hypoventilation

Question 19

How do you measure the JVP and what may a raised JVP indicate?

Answer 19

• number of cm from sternal angle to the upper border of the pulsation
• Internal jugular vein is located inbetween the two heads of the SCM
• pulmonary hypertension / hypervolemia (fluid overload)

Question 20

When inspecting the chest what scars could be present and what do they represent?

Answer 20

• mid-axillary = chest drains
• posterior chest = lobectomy

Question 21

When inspecting the chest what skin changes may be found?

Answer 21

• erythema (superficial redding of the skin due to dilation of blood cappilaries) / thickened skin - indication of recent of previous radiotherapy

Question 22

What could asymmetry of the chest indicate?

Answer 22

• major surgery:
  
  • pneumonectomy (removal of a lung or part of the lung)
  • thoracoplasty (removal of ribs from chest wall to permanently collapse the cavities can be done for patients with tuberculosis in the hope of putting the lung at rest and therefor inactivating the disease)

Question 23

What deformities of the chest can be found and what do they implicate?

Answer 23

• Barrel chest - COPD (occurs because the lungs are chronically overinflated with air, so the rib cage stays partially expanded all the time)
• Pectus excavatum (a congenital deformity of the anterior thoracic wall)
• Pectus carinatum (aka. pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs)

Question 24

What does tracheal examination show?

Answer 24

• A difference in the amount of space suggests deviation
• Tracheal deviation results from unequal intrathoracic pressure within the chest cavity - most commonly associated with traumatic pneumothorax

Question 25

What does cricosternal distance examination show?

Answer 25

• If the distance is <3 fingers - lung hyperinflation

Question 26

What can be found from an abnormal apex beat?

Answer 26

….

Question 27

What can an examination of chest expansion show?

Answer 27

• Reduced expansion (asymmetrically) can be caused by lung collaps / pneumonia
• What happens if both lungs collapse? There will be no asymmetrical difference?

Question 28

What areas should be percussed in a respiratory examination?

Answer 28

• Supraclavicular - lung apices
• Infaclavicular - …
• Chest wall - …
• Axilla - …

Question 29

What types of percussion notes are found and what do they indicate?

Answer 29

• Resonant - normal
• Dullness - increased tissue density - consolidation (lung tissue that is filled with dense material) / fluid / tumour / collapse
• Stony dullness - pleural effusion (excess fluid builds around the lung)
• Hyper-resonance - decreased tissue density - pneumothorax

Question 30

What two factors are assesed through ausculation?

Answer 30

• Quality - vesicular (normal) / Bronchial (harsh sounding) - consolidation
• Volume - quiet breath sounds suggest reduced air entry – consolidation / collapse / fluid

Question 31

What other sounds can be heard through auscultation?

Answer 31

• Wheeze - asthma / COPD
• Coarse crackles - pneumonia / fluid
• Fine crackles - pulmonary fibrosis

Question 32

What is achieved when asking the patient to say ‘99’ when aucultating?

Answer 32

• Vocal resonance - increased volume over an area suggests +tissue density - consolidation / fluid / tumour

Question 33

What lymph nodes are examined and what can they indicate?

Answer 33

• Anterior and posterior triangles / supraclavicular / axillary nodes
• Lymphadenopathy (disease affecting the lymph nodes) - infective/malignant pathology - TB / lung cancer

Question 34

What further procedures are needed for a complete examination?

Answer 34

• oxygen saturation (fraction of oxygen-saturatedhemoglobin relative to total hemoglobin)
• peak flow assesment (if asthmatic)
• CXR
• Arterial blood gas (measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery)