Respiratory Exam

Question 1

Angle of Louis

Answer 1

Manubriosternal junction

Question 2

Respiration

Answer 2

Movement of air back and forth from the alveoli to the outside environment, gas exchange across the alveolar pulmonary capillary membranes, and circulatory system transport of oxygen to, and carbon dioxide from, the peripheral tissues. Purpose is to keep the body adequately supplied with O2, and protected from accumulation of CO2

Question 3

Ventilation

Answer 3

Purpose is to move air in and out of the lungs through inspiration and expiration. Volume of air exchanged in one ventilation cycle is referred to as tidal volume.

Question 4

Inspection (Resp. Exam)

Answer 4

Breathing: rate, depth, pattern, audible sounds (grunting, wheezing, etc), distress
Thorax: shape and symmetry, AP diameter, spinal curvature (lordosis, scoliosis, kyphosis)
Other: clubbing, mediastinal and tracheal position

Question 5

Palpation (Resp. Exam)

Answer 5

Respiratory expansion using hands, tactile fremitus (symmetry), any painful areas?

Question 6

Percussion (Resp. Exam)

Answer 6

Over intercostal spaces, lung fields comparing side to side, diaphragmatic excursion

Question 7

Auscultation (Resp. Exam)

Answer 7

Breath sounds using diaphragm, deep breathing with mouth open, adventitious sounds, timing, location, number and change, vocal fremitus

Question 8

Assessment of respiratory rate and pattern

Answer 8

Mouth/nose breather, pattern, Kussmaul, Cheyne-Stokes, hyperpnic, apnic, bradypnic, etc.

Question 9

General percussion notes elicited on the chest

Answer 9

Flatness: soft intensity, high pitch, short duration (large pleural effusion)
Dullness: medium intensity, medium pitch, medium duration (lobar pneumonia)
Resonance: Loud intensity, low pitch, long duration (simple chronic bronchitis, normal lung)
Hyperresonance: Very loud intensity, lower pitch, longer duration (emphysema, pneumothorax)
Tympany: Loud intensity, high pitch (large pneumothorax)

Question 10

Tracheal breath sounds

Answer 10

Location: Trachea, neck
Sound: Relatively high pitched, harsh, ‘darth vader’ equal inspiration and expiration

Question 11

Bronchial breath sounds (Tubular)

Answer 11

Location: Manubrium if heard at all
Sound: relatively high pitched, quieter, shorter inspiration, longer and louder expiration. If heard elsewhere patient may have consolidation.

Question 12

Bronchovesicular breath sounds

Answer 12

Location: 1st and 2nd interspaces anteriorly, and between the scapulae
Sound: Medium pitched, equal inspiration and expiration

Question 13

Vesicular breath sounds

Answer 13

Location: most of the lungs, normal finding.
Sound: soft, relatively low pitched sounds, long inspiration, short expiration

Question 14

Adventitious breath sounds

Answer 14

Crackles/rales, wheezes, ronchi, stridor, pleural friction rubs

Question 15

Vocal fremitus

Answer 15

Technique: ‘99’ while listening to lungs
Interpretation: generally done in area where abnormality was found upon inspection, palpation or percussion), sounds are normally muffled and indistinct

Question 16

Egophony

Answer 16

‘Voice of the goat’
Say ‘EEEE’
Abnormal finding if it sounds like ‘AAA’ upon auscultation; indicates emphysema

Question 17

Whispered Pectoriloquy

Answer 17

‘Voice of the chest’

Whisper words have increased intensity & pitch and indicates pneumonia, fibrosis

Question 18

Tactile fremitus

Answer 18

Technique: palpable vibration of the chest wall resulting from speech. (ulnar surface of hand)
Interpretation:
Decreased/absent: excess air in the lungs, emphysema, pleural effusion, massive pulmonary edema, or bronchial obstruction
Increased: lung consolidation, heavy/ non obstructive bronchial secretions, compressed lung or tumor

Question 19

Bronchophony

Answer 19

‘Bronchial sounds’

spoken words are louder than normal; indicates consolidation

Question 20

Diaphragmatic excursion

Answer 20

Movement of thoracic diaphragm that occurs with inhalation and exhalation (distance: 3 - 5 cm; higher on the right b/c liver)
Descent may be limited by several types of processes such as pulmonary emphysema, abdominal ascites or tumor, or superficial pain

Question 21

A/P diameter

Answer 21

Normally less than the lateral diameter, increases with age

Question 22

Additional organ systems to thoroughly evaluate resp. complaint

Answer 22

Face, hands, feet, chest Neuro, abdomen

Question 23

Barrel chest

Answer 23

lateral greater than AP, results from compromised respiration such as asthma, emphysema, cystic fibrosis

Question 24

Flail chest

Answer 24

paradoxical chest movement, a section of the chest is disconnected from the bony structure, as may occur with multiple rib fractures, also indicates underlying lung injury (pulmonary contusion)

Question 25

Scoliosis

Answer 25

spine deviated laterally, best seen from behind when patient is bent over

Question 26

Kyphosis

Answer 26

spine deviated posteriorly

Question 27

Gibbus

Answer 27

sharp angular deformity, associated with a collapsed vertebrae from osteoporosis

Question 28

Lordosis

Answer 28

inward curvature of the lower spine

Question 29

Pectus carinatum/ excavatum

Answer 29

carinatum- prominent sternal protrusion, pigeon chest (most ly cosmentic) excavatum- funnel chest, indentation of the lower sternum above the xiphoid process (results on more issues with internal organs)

Question 30

cough

Answer 30

deep inspiration, air and secretions are exhaled, voluntary or reflexive Note: dry/moist, frequency, regularity, pitch and loudness, quality

Question 31

Sputum production

Answer 31

generally associated with a cough, when it involves more than small amount and with any degree of consistency always suggests disease, can be chronic or acute Note: color, consistency, blood, amount, time of day

Question 32

Hemoptysis

Answer 32

coughing up blood

Question 33

Dyspnea

Answer 33

difficult, labored breathing with shores of breath. Commonly observed with pulmonary/cardiac compromise Note: what makes it better/ worse and severity

Question 34

Pulsus paradoxous

Answer 34

characterized by an exaggerated decrease (greater than 10mmHg) in the amplitude of pulsation during inspiration and increased amplitude during expiration. Seen with premature cardiac contraction, tracheobronchial obstruction, bronchial asthma, emphysema, pericardial effusion, constrictive pericarditis

Question 35

Shortness of breath

Answer 35

Can be subjective, sign of respiratory distress Note: onset, pattern, position of comfort, relation to activity, harder to inhale or exhale, severity, associated symptoms

Question 36

Tachypnea/bradypnea/eupnea

Answer 36

Tachy: rapid breathing (greater than 20) Brady: slow breathing (less than 12) Eu: normal (12 - 20)

Question 37

Pleural rub

Answer 37

indicates inflammation, increased friction of the pleural lining of the lung

Question 38

Cyanosis

Answer 38

results from hypoxia, associated with a pulmonary or cardiovascular condition, can be seen centrally (mottling of lips, thorax) and acrocyanosis (extremities, hands, feet)

Question 39

Chest pain

Answer 39

does not generally originate in the heart when there is a constant ashiness that lasts all day, does not radiate, is made worse by palpation, fleeting, needle-like jab that lasts only a few seconds, it is situated in the shoulders or between the shoulder blades in the back. Note: onset, duration, associated symptoms, efforts to treat, drug use

Question 40

Stridor

Answer 40

a wheeze that is entirely or predominantly inspiratory, indicates partial obstruction of the trachea or larynx and warrants immediate attention (commonly seen w/foreign body aspiration, croup)

Question 41

Orthopnea

Answer 41

Shortness of breath that begins or increases when the patient lies down, ask for how many pillows they sleep with at night

Question 42

Paroxysmal nocturnal dyspnea

Answer 42

Sudden onset of SOB after a period of sleep, sitting upright is helpful

Question 43

Fine crackles

Answer 43

Discontinuous; high pitched, discrete, crackling sounds heard during the end of inspiration, cleared by a cough

Question 44

Course crackles

Answer 44

Discontinuous; Loud, bubbly noise heard during inspiration, not cleared by a cough

Question 45

Rales

Answer 45

Discontinuous; Caused by the disruptive passage of air through the small airways in the respiratory tree, same as crackles

Question 46

Wheezes

Answer 46

Continuous; high pitched, musical, suggests narrowed smaller airways such as in asthma, COPD, bronchitis

Question 47

Ronchi:

Answer 47

Continuous; low pitched, snoring, honking sounds perhaps caused by the rattling of secretions in the large airways, transient airway plugging (bronchitis, cystic fibrosis, bronchiectasis)

Question 48

Diaphragmatic excursion process

Answer 48

- Have pt take a deep breath and hold it - Percuss along the scapular line until you locate the lower border (point marked by a change in note from resonance to dullness) - Mark that point with a pen at the scapular line - Let pt take a breath and repeat on the other side - Ask pt to take several breaths, to exhale as much as possible, and then to hold breath - Percuss up from the parked point and make a mark at the change from dullness to resonance - Have patient breathe and repeat on other side - Measure and record the distance in cm between the marks on each side