Pulmonary Exam Flashcards
(7 cards)
Hands
Inspect the hands:
Tar staining on fingers (or nicotine patches on body)- smoker – increased risk of COPD / lung cancer
Clubbing – lung cancer / interstitial lung disease / bronchiectasis
Peripheral cyanosis – bluish discolouration of nails – O2 saturation <85%
Features of rheumatological disease (e.g. joint swelling/tenderness) – rheumatological diseases (e.g. rheumatoid arthritis) can be associated with pleural effusions and pulmonary fibrosis
Skin changes – bruising and thinning of the skin are associated with long-term steroid use (ILD / asthma / COPD)
Asess - 2
Assess temperature – ↓ temperature suggests peripheral vasoconstriction / poor perfusion
Palpate pulse – rate and rhythm
Assess respiratory rate – normal adult range = 12-20 breaths per minute
Pulsus paradoxus – pulse wave volume decreases with inspiration – asthma / COPD
Fine tremor – can be a side effect of beta 2 agonist use (e.g. salbutamol)
Flapping tremor – CO2 retention – type 2 respiratory failure – e.g. COPD
Types of percussion note
Resonant – this is a normal finding
Dullness – this suggests increased tissue density – consolidation / fluid / tumour / collapse
Stony dullness – this suggests the presence of a pleural effusion
Hyper-resonance – the opposite of dullness, suggestive of decreased tissue density – e.g. pneumothorax
Auscultation
Ask the patient to take deep breaths in and out through their mouth.
Assess quality:
Vesicular (normal)
Bronchial (harsh sounding – similar to auscultating over the trachea – inspiration and expiration are equal and there is a pause between) – associated with consolidation
Assess volume:
Quiet breath sounds suggest reduced air entry – consolidation / collapse / pleural effusion
State reduced breath sounds rather than reduced air entry when presenting
Added sounds:
Wheeze – asthma / COPD
Coarse crackles – pneumonia / bronchiectasis / fluid overload
Fine crackles – pulmonary fibrosis
Vocal resonance:
Ask patient to say “99” repeatedly and auscultate the chest again
Increased volume over an area suggests increased tissue density (especially if there is a dull percussion note over the same area) – consolidation / tumour / lobar collapse
Decreased volume over an area (especially if there is an associated dull percussion note) suggests fluid outside of the lung (pleural effusion)
Lymph nodes
Palpate the following areas:
Anterior and posterior triangles
Supraclavicular region
Axillary region
Lymphadenopathy may indicate infective/malignant pathology – lung cancer / tuberculosis / sarcoidosis
Assess the posterior chest
Repeat inspection, chest expansion, percussion and auscultation on the posterior aspect of the chest.
Spend more time assessing the posterior aspect of the chest as this is where you are likely to find clinical signs.
Assess chest expansion
Percuss the posterior chest wall
Auscultate the posterior chest
Assess vocal resonance
Assess for sacral oedema
Assess for pedal oedema
Assess for signs of a deep vein thrombosis
1
Examine the sacrum for oedema (fluid overload in cor pulmonale)
Examine the legs:
Pitting oedema (fluid overload in cor pulmonale) Assess the calves for signs of deep vein thrombosis Inspect for evidence of erythema nodosum (associated with sarcoidosis)
Head and neck
Conjunctival pallor – ask patient to lower an eyelid to allow inspection – anaemia is associated with pallor
Horner’s syndrome – ptosis / constricted pupil (miosis) /anhidrosis on affected side / enophthalmos
Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue
Jugular venous pressure (JVP) – a raised JVP may indicate pulmonary hypertension / fluid overload
Ensure the patient is positioned at 45°
Ask patient to turn their head away from you
Observe the neck for the JVP – located inline with the sternocleidomastoid
Measure the JVP – number of centimetres measured vertically from the sternal angle to the upper border of pulsation
