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Generic Clinical Skills > The respiratory exam > Flashcards

The respiratory exam Flashcards

1
Q

What are the things we check when doing a respiratory exam?

A
  1. Sputum
  2. Haemoptysis
  3. Cough
  4. Dyspnoea
  5. Wheeze
  6. Pain
  7. Stridor
  8. Hoarseness
  9. Physical exam
  10. Hands
  11. Face and mouth
  12. Trachea
  13. Chest inspection/palpitation/auscultation
  14. Physical signs
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2
Q

What is sputum?

A

Sputum or phlegm is the mucousy substance secreted by cells in the lower airways (bronchi and bronchioles) of the respiratory tract

large volume yellow/green opaque -purulent, bronchiectasis
foul smelling, dark - lung abscess w/ anaerobic bacteria
pink frothy - from trachea - pulmonary oedema

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3
Q

What is Haemoptysis ?

A

coughing up blood from the lungs or bronchial tubes. It can range from small flecks of blood to a lot of blood.
sinister sign of lung disease.
mild <20 mL in 24 hrs
massive > 250 mL in 24 hrs
common causes are carcinoma, cystic fibrosis, bronchiectasis and tuberculosis

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4
Q

What do we look at in regards of cough?

A

Note: duration, character (including changes in pattern)

Change in character of chronic cough - may indicate new problem ie infection, cancer

Sound of cough can be indicative :
inflam of epiglottis - barking
tracheal compression by tumour - loud and brassy
recurrent laryngeal nerve involvement - hollow as vocal chords don’t close

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5
Q

What are some of the acute causes of cough?

A

Fever
URTI
acute bronchitis
pneumonia

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6
Q

What are some the chronic causes of cough?

A

w/ wheezing - asthma
dry irritating cough - GORD, reflux, acid irritation of lungs
late feature of interstitial fibrosis
ACE inhibitors, coughing when laying flat
purulent sputum, bronchiectasis

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7
Q

What is Dysponea?

A

Breathlessness.
Abnormal amount of work required for breathing
Due to respiratory or cardiac disease

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8
Q

What do we look at and what are some examples when it comes to Dysponea?

A
  • Timing of onset, severity, pattern aid dx
  • Graded I-IV MMRC grading system
  • Dyspnoea + wheeze + airway disease ie asthma, COPD

Duration and variability are imp

  • Gradual worsening > pulmonary fibrosis
  • rapid onset > acute resp infection, pneumonitis or hypersensitivity
  • daily variations > asthma
  • rapid onset + sharp pain>pneumothorax

Other considerations - anxiety (sighing, inability to get a big enough breath) or obesity + lack of physical fitness (at moderation exertion)

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9
Q

What is a wheeze and when do we hear it?

A

Continue whistling noise
Asthma, COPD, airway obstruction by a foreign body or tumour
Maximal during expiration and prolonged expiration

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10
Q

When is there pain with breathing?

A
  • Diff from myocardial ischemia
  • Pleura, central airways have pain fibres
  • Pleural pain - pleuritic nature - sharp, made worse on inspiration, coughing, localised to on side of chest, dyspnoea associated
  • sudden onset lobar pneumonia, PE, infarction, pneumothorax
  • All three life threatening - medical emergency
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11
Q

When do we hear stridor?

A

obstruction of larynx, trachea, large airways
rasping, croaking noise, loudest of inspiration
e.g. anaphylaxis, foreign body, inflammation, tumour, lymph nodes pressing into trachea, post tracheostomy

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12
Q

When do we hear hoarseness?

A

laryngitis, recurrent laryngeal nerve palsy (can be secondary to lung carcinoma) , laryngeal carcinoma
Non respiratory causes ie hypothyroidism

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13
Q

What are the limits for expiratory rates?

A 
Respiratory rate (adult) 
16-25 – normal 
> 25 tachypnoea
< 8 bradypnoea
Covert assessment as can be changed voluntarily
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14
Q

What are 4 common signs of the hands that can be seen when there is respiratory issues?

A
  1. Finger Clubbing
    Common (80% of cases)
    NB: hypertrophic pulmonary osteoarthropathy (HPO)
    Not seen in COPD
  2. Finger staining
    Indicator smoking status but not frequency
  3. Wasting and Weakness
    Small muscles of hand and difficulties in finger abduction
  4. Tremor
    Severe CO2 retention
    Inability to maintain dorsiflexion in wrists
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15
Q

Where do we cyanosis in the face/mouth?

A

Central cyanosis – tongue

  • Severe hypoxaemia
  • Deoxy Hb 50g/L or < 90% O2 saturation

Lips

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16
Q

What are the intraoral findings in COPD/respiratory disease?

A

Pharyngeal and tonsillar inflammation
Pericoronitis
Caries, perio causing dental abscess

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17
Q

What are 3 other signs of respiratory issues?

A

-Sleep Apnoea
Reduction in velopharyngeal space
Large neck circumference, Class II
-Sinusitis – palpate for tenderness over sinuses
-Red leathery wrinkled skin – chronic smoker

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18
Q

What are the steps in assessing the trachea?

A

Positioning
Be gentle
Forefinger superior and backwards of suprasternal notch
Similar gap on either side
Displacement to one side suggests upper lobe lung disease

position changes: Towards affected side - Upper lobe collapse
Upper lobe fibrosis
Pneumonectomy
Away from affected side – massive pleural effusion, tension pneumothorax
Upper mediastinal masses ie retrosternal goitre

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19
Q

What is Kyphosis?

A

ant exaggerated curvature of spine

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20
Q

What is Scoliosis?

A

lateral bowing of spine

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21
Q

What is Kyphoscoliosis?

A

asymmetrical deformity; Marfan’s or poliomyelitis

22
Q

What are the 5 steps of chest inspection?

A

1.Scars on chest wall – hx of chest drains, lymph node biopsies, pneumonectomy
2.Erythema, thickened skin + defined borders – radiation therapy
3.Subcutaneous emphysema – crackling on palpation of skin
4. Curvatures
5. Movements (Movement of chest wall – looking down clavicles – even expansion both sides,
Unilateral reduced movement – pleural effusion, pneumothorax, collapse, consolidation
Bilateral reduced movement – COPD, interstitial lung disease)

23
Q

How to palpate for movement of the chest?

A
  1. Place hands on chest walls with fingers extending either side of chest
  2. Thumbs meet in the middle, not touching chest
  3. Inspiration – thumbs move apart ~ 5 cm symmetrically
  4. COPD – from in front of pt, hands along costal margins, thumbs close to xiphisterum region
    Overinflated chest wont inflate further
24
Q

Why should we palpate for apex beat?

A

May be helpful, displacement to one side – pleural effusion, tension pneumothorax
Impalpable in COPD and 50% of people

25
Q

How to palpate for Vocal fremitus?

A

Palpable vibration on chest wall
Palm of hand either side chest wall, pt says ‘ninety-nine’
Two comparable areas front and back
Tricky to interpret
May not be noted in higher pitched voices
Vocal resonance can indicate similar signs

26
Q

How to palpate the ribs?

A

Press gently AP, ML
Localised pain – fracture
Costochondral joints – costochondritis

27
Q

How to percuss the chest?

A

-L hand chest wall, fingers slight, strike R middle finger on L middle finger slightly parted
-Symmetrical areas ant, post, axillary regions
-Supraclavicular fossa – apex of lung
-Post percussion – wrap elbows around front of chest (scapulae moves forward)
:Resonant – normal
:Dull note – solid structures – liver, consolidation, collapse
:Stony dull – fluid filled – pleural effusion
:Hyperresonance – hollow – bowel, pneumothorax

28
Q

What 4 features do we look for when auscultating the chest for breath sounds?

A
  1. Quality
  2. Intensity
  3. Additional Sounds
  4. Vocal resonance
29
Q

What do we look for when checking quality of breath sounds?

A 
No gap bw inspiratory, expiratory 
Bronchial 
-Turbulence in large airways 
-Hollow, blowing
-Exp higher intensity
-R upper chest more pronounced
consolidation
30
Q

What do we look for when checking intensity of breath sounds?

A

Reduced – COPD, pleural effusion, pneumothorax, pneumonia, neoplasm, pulmonary collapse

31
Q

What do we look for when checking additional sounds of breath sounds?

A

Wheeze (continuous) – heard on insp/exp, more on exp
-High pitch – asthma, low pitch – COPD
Crackles
-Loss of stability peripheral airways, collapse on exp
-Early inspiratory crackles: Small airways disease ie COPD
-Late or pan inspiratory crackle – Velcro, pulmonary fibrosis
-Medium crackles – LVF
-Coarse crackles – bronchiectasis, secretion retention
-Pleural friction rub – as lungs expand/contract

32
Q

What do we look for when checking Vocal resonance of breath sounds?

A

Low pitch – booming quality, high pitch – subdued – consolidation

33
Q

What are 3 physical examinations?

A
  1. Heart
    - Previous seminars
    - JVP
  2. Abdomen
    - Liver for ptosis
    - Enlargement secondary to tumour deposits
  3. Pemberton’s sign
    - Superior vena cava obstruction
34
Q

How does Consolidation (Inflammation of lungs) present?

A
  • General signs: Cough – dry, painful, Fever, Dyspnoea
  • Inspection/palpation:Reduced expansion AS (affected side)
  • Percussion: Dull
  • Auscultation: Bronchial BS inc vocal resonance, vocal fremitus, Pan inspiratory crackles

-Other signs:

35
Q

How does Atelectasis (Region of lung collapse distal to bronchial obstruction) present?

A

-General signs:
-Inspection/palpation:Trachea displacement AS
Reduced expansion AS
-Percussion: Dull
-Auscultation: Reduced or absent BS

-Other signs:

36
Q

How does Pleural Effusion (Collection of fluid in pleural space) present?

A

-General signs:
-Inspection/palpation: Trachea displaced away from AS
Reduced expansion AS
-Percussion: Stony dull
-Auscultation: Reduced or absent BS,
Reduced vocal resonance

-Other signs:

37
Q

How does Pneumothorax

(Air enters space bw chest wall and lung) present?

A
  • General signs:
  • Inspection/palpation: Reduced expansion AS
  • Percussion: Resonant, Hyper resonant if large
  • Auscultation: Reduced or absent BS

-Other signs:

38
Q

How does Tension pneumothorax (Communication bw lung and pleural space) present?

A

-General signs:
-Inspection/palpation:Trachea displaced away from AS,
Reduced expansion AS
-Percussion:Hyper resonant
-Auscultation: Absent BS, Absent vocal resonance
-Other signs:

39
Q

How does Bronchiectasis (Pathological dilation of bronchi; impaired clearance) present?

A
  • General signs: Fever, Sinusitis, Purulent sputum, Haemoptysis, Clubbing, Cyanosis
  • Inspection/palpation:
  • Percussion:
  • Auscultation: Coarse pan, inspiratory crackles

-Other signs:

40
Q

How does Bronchial Asthma (airway narrowing via bronchospasms) present?

A

-General signs: Wheeze, Dry cough, Dyspnoea
-Inspection/palpation:Use of accessory muscles
Hyperinflated chest
-Percussion: resonant
-Auscultation: Reduced or silent

-Other signs:

41
Q

How does COPD (Chronic airflow limitation - Emphysema) present?

A
  • General signs: Unforced wheeze, Pursed lips
  • Inspection/palpation: Barrel chest, Use of accessory muscles, Reduced expansionhyperinflated chest
  • Percussion: Hyper resonant, Reduced liver dullness
  • Auscultation: Early inspiratory crackles, Reduced BS

-Other signs:

42
Q

How does Chronic Bronchitis (Sputum production 3/12 for 2 consecutive years) present?

A
  • General signs:
  • Inspection/palpation: Hyperinflated chest, Reduced expansion
  • Percussion: Hyper resonant
  • Auscultation: High or low pitch wheezes, Early inspiratory crackles

-Other signs:

43
Q

How does ILD/Pulmonary Fibrosis

(Fibrosis of lung parenchyma) present?

A
  • General signs: Dry cough, Clubbing, Dyspnoea
  • Inspection/palpation:Reduced expansion AS
  • Percussion: Dull in severe cases
  • Auscultation: Velcro like, Pan inspiratory crackles

-Other signs: Other CT disorders ie. Sjogrens, SLE

44
Q

How does TB (primary or post primary) present?

A
  • General signs: Horner’s syndrome (recurrent laryngeal nerve involvement)
  • Inspection/palpation: Superior vena cava obstruction (Pemberton’s sign)
  • Percussion: Unreliable due to random distribution of infection, variations in severity in different regions
  • Auscultation: Unreliable due to random distribution of infection, variations in severity in different regions
  • Other signs:
45
Q

How does Carcinoma of lung present?

A
  • General signs: Haemoptysis, Clubbing, Pneumonia, lobar collapse
  • Inspection/palpation:Tender ribs, Axillary, supraclavicular lymphadenopathy
  • Percussion:
  • Auscultation: Inspiratory wheeze

-Other signs:

46
Q

What is the difference between phlegm, mucous and sputum?

A

Phlegm: mucus produced in the lungs and lower respiratory tract. It is most noticeable when a person is acutely sick or has a longstanding health condition. Mucus forms a protective lining in certain parts of the body, even when a person is well.

Mucous: a normal, slippery and stringy fluid substance produced by many lining tissues in the body.

Sputum: a mixture of saliva and mucus coughed up from the respiratory tract, typically as a result of infection or other disease and often examined microscopically to aid medical diagnosis

47
Q

Why do smokers cough?

A
  • reactive airway

- damage to cilia decreasing normal clearance

48
Q

What can be given for a chronic cough(medications)? antitussive

A

cough regulated by airway vagal afferent nerves, cough center in the medulla and the efferent nerves

  1. codeine - Narcotic antitussives such as codeine reveal the antitussive effect primarily via the μ-opioid receptor in the central nervous system (CNS) (also in vagal nerve and cortex). The κ-opioid receptor also seems to contribute partly to the production of the antitussive effect of the drugs.
    Chronic cough more resistant to narcotic antitussive.
  2. pseudoephedrine (not cough but can reduce mucous amount). decreases cough reflex and secretions
  3. Antihistamines. peripheral indirect mechanism involving cholinergic mechanisms
49
Q

What is aspiration pneumonia?

A

Aspiration pneumonia is a complication of pulmonary aspiration. Pulmonary aspiration is when you inhale food, stomach acid, or saliva into your lungs. can have fever and cough.

Typically for ICU or long in stay patients, often use Chx rinse.

50
Q

What are tonsil crypts?

A

deeper anatomical crypts can collect debris but not an indication for a tonsillectomy. Can use betadine, difflam C. can appear yellow but not indication of infection.

51
Q

URI can cause pericoronitis

A

Meurman BJM. Respiratory tract infection may precipitate and occur concomitantly with acute pericoronitis. Third molar surgery for pericoronitis, on the other hand, may trigger respiratory tract infection.

Generic Clinical Skills (10 decks)

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