Respiratory- The Phsyical Exam- Inspection And Hands/arms

Question 1

Inspection- hyperinflation (causes, mechanism to overcome)

Answer 1

• The normal shape and respiratory movements of the chest wall are significantly altered by the hyperinflation that accompanies chronic airflow obstruction
• They cause prolonged expiration relative to inspiration, and sometimes ‘pursed-lip’ breathing.
• Forceful inspiration at these very high lung volumes may cause indrawing of the intercostal spaces during mid-inspiration and the recruitment of muscles not normallyinvolved in breathing (‘accessory muscles’).
• These include the sternocleidomastoid muscles lifting the sternum, and the trapezius and the scalenes lifting the shoulder girdle.
• Patients some-time sit forwards and brace their arms on a surface, allowing them to use the pectoralis major to pull the ribs outwards during inspiration.

Question 2

Inspection- ILD, chest deformities and scoliosis/scarring

Answer 2

• interstitial disease causes small, stiff lungs, diminished thoracic volume and raises resting respiratory rate.
• Chest deformity may be congenital, as in pectus excavatum,or acquired, as in pectus carinatum.
• The latter is an inward displacement of the lower ribs with a prominent sternum,caused by severe airflow obstruction in early childhood, during rib cage development.
• Asymmetry of the chest may be secondary to scoliosis, scarring of lungs or surgical resection

Question 3

Hands and arms- finger clubbing

Answer 3

• Finger clubbing is due to overgrowth of soft tissue in the terminal phalanx, raising the nail bed of the underlying bone. It is palpable as a boggy fluctuation of the nail when pressure is applied just proximal to the nail
• Finding this in an adult patient should prompt consideration of lung cancer or pulmonary fibrosis.
• In younger patients, chronic suppurative lung disease, e.g. cystic fibrosis
• In somecases of lung cancer, finger clubbing is accompanied by hy-pertrophic pulmonary osteoarthropathy,with painful, tender swelling of the wrists and ankles.
• X-rays of the distal forearm and lower legs show subperiosteal new bone formation.

Question 4

Hands and arms- other features

Answer 4

• cyanosis
• tar staining in smoking
• small muscle wasting (T1 root damage by an apical lung tumour)
• yellow nail syndrome
• vasculitis in the nail bed

Question 5

Hands and arms- exam

Answer 5

• Examine the hands for finger clubbing, tar staining,nail discoloration and cyanosis.
• Ask the patient to hold their arms out straight with the wrists extended
• Measure the respiratory rate while feeling the pulse.
• Check for any tenderness in the distal forearm.
  Fine tremor of the outstretched hands is common in respiratory patients and usually due to the direct effect of high-dose beta-agonist bronchodilators on skeletal muscle
• Respiratory failure with CO2 retention is one of the causes of a coarse flapping tremor of the outstretched hands (asterixis).