Respiratory System 1 - Inspection and Palpation of the Thorax Flashcards
Inspects for systemic manifestations of lung disease, wasting, voice changes, central or peripheral cyanosis, clubbing, asterixis, nicotine staining, use of accessory muscles, etc.
“First, I’ll be inspecting for systemic manifestations of lung disease.”
“I’m noting that my patient’s lips are pink and well perfused. I do not see any signs of malar flush, which is indicative of increases CO2 retention. Can you please open your mouth and lift your tongue? Ok, you can close your mouth. I did not see any signs of central cyanosis around the lips and tongue. If central cyanosis was present this could indicate hypoxia.”
“Can I please see your fingers? There are no signs of nicotine staining, which is indicative of smoking. Next, can you make a heart with your fingers for me (demonstrate to patient what you would like them to do)? Ok, I do not see Schamroth’s window which is negative for clubbing (explain findings-should see Schamroth’s window which is negative for clubbing in a healthy patient). If clubbing were present, it would be indicative of cystic fibrosis, or lung abscess. I’m also noting that I do not see any signs of peripheral cyanosis in the hands and nail beds and feet which would be due to deoxygenation.”
“Additionally, I’m noting no use of accessory muscles such as the SCM or scalene muscle (indicative of respiratory distress due to COPD), and no visible wasting (muscle loss), and the patient isn’t experiencing any voice changes (ask patient if they’ve experienced changes in their voice; also, be observant when they are answering your questions).” “Next, I’ll check for asterixis, which is tremor of the hand when the wrist is extended (sometimes said to resemble a bird flapping its wings). Can you please hold your hands out for me, and extend your wrist? I’m noting no signs of asterixis which can be caused by hepatic encephalopathy (includes a spectrum of neuropsychiatric abnormalities due to liver failure like cirrhosis).”
Inspects the neck for tracheal deviation. Describes what a tracheal deviation may indicate
“Next, I will inspect the neck for tracheal deviation. Place 2 fingers on either side of the sternal head. With the middle finger, feel down the midline of the neck for the trachea. I’m noting that the trachea is positioned in the midline which is normal. If the trachea was deviated AWAY from the effected lung, it would be indicative of tension pneumothorax or pleural effusion. If the trachea was deviated TOWARD the effected lung, it would be indicative of spontaneous pneumothorax or atelectasis (collapse of lung/lobe of lung).”
● During inspection/exam/physical, DON’T TALK while performing. Do the procedure, then talk or talk then do the procedure. However, DO NOT TALK while performing the procedure.
Inspects the chest wall looking for deformities, scars, shape, intercostal retraction, symmetrical movements, etc. Describes signs of respiratory distress
“I will now be inspecting the chest wall (look at front then look at back, then ask patient to take a deep breath to look for intercostal retractions). I do not see any scars from past surgeries, no deformities (pectus carinatum or excavatum or barrel chest), and no signs of bruises which would be indicative of trauma/rib fracture. I’m also noting bilateral rise and fall of the chest wall (symmetrical movements of the chest wall).”
“The patient doesn’t appear to be in respiratory distress. There is no use of accessory muscles such as the SCM or scalene muscles for breathing, and no nasal flaring or labored breathing. If accessory muscle were being used this would be indicative of COPD. I do not hear wheezing on expiration which is indicative of asthma, or lower airway obstruction. There is no stridor (high-pitched wheezing) on inspiration, indicative of upper airway obstruction in the larynx or trachea. The patient isn’t bending over gasping for breath (tripoding)”
RR= >20 breaths/min
Palpates for chest wall tenderness, crepitus, chest expansion.
“Next, I’m going to palpate the chest wall for tenderness, crepitus, and chest expansion (use one hand). Please tell me if I hurt you in any way. I’m noting that I do not feel any intercostal tenderness which would be indicative of inflamed pleura or costochondritis.”
“I’ll be moving to the back of the patient to check for chest expansion. I’m going to place my fingers along the 10th rib, folding a bit of skin (find 12th rib then go up to the 10th). Can you breathe in (inhale) and a deep breath out for me (exhale) for me? (Do twice). Ok, I’m noting that the patient has equal, bilateral symmetrical chest expansion- even deviation of ~ 2cm which is normal. If chest expansion was asymmetric, that would be indicative of CF (cystic fibrosis) or collapsed lung. -deviation <2cm: restrictive lung disease: cystic fibrosis.”
Checks the A/P diameter of the chest. Describes the significance of a positive finding
“I am now going to check for the anteroposterior (A/P) diameter of the chest. Place one hand in front of the patient, on the xiphoid process and the other hand at the back parallel to that-look for vertebrae (you’re standing at the side). Without moving your hands, move to the back and compare with lateral diameter. I’m noting that the AP diameter > lateral diameter, this would be indicative of barrel chest which can be due to COPD or aging.”
Normal: 70-90% with anything over 0.9 is COPD
Checks tactile fremitus. Describes the findings in lobar pneumonia, pleural effusion, pneumothorax, asthma and chronic obstructive pulmonary disease (COPD)
“Lastly, I’ll be checking tactile vocal fremitus (palpable chest vibration and resonance sounds that are transmitted through bronchopulmonary tree to the chest wall as the patient is speaking; asking patient to cross hands over chest).”
“I’ll be using the ulnar surface of my hand to feel areas of your chest, in order to feel these transmitted vibrations. Is that ok? Can you repeat “99” whenever you feel my hand on your chest, until I tell you to stop.” Check for vibration intensity bilaterally; feel all 3 lobes of the right lung and 2 lobes of the left lung. Repeat on the back
“Ok, I’m noting that fremitus is present and normal.” Decreased fremitus could be indicative of COPD, asthma, pleural effusion, pneumothorax. Increased fremitus could be indicative of lobar pneumonia
