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Clinical Examinations > Respiratory Examination > Flashcards

Respiratory Examination Flashcards

1
Q

State the 7 stages/sections of your respiratory examination

A
  1. Introduction & preparation
  2. General inspection
  3. Hands & arms
  4. Head & neck
  5. Chest: inspection, palpation, percussion, auscultation
  6. Legs
  7. Completing the examination
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2
Q

Describe what you must do in the introduction/preparation stage of your respiratory examination

A
  • Introduce yourself: name, role
  • Explain & consent: explain examination, offer chaperone, obtain consent, check for any pain
  • Check patient details: name, DOB
  • Wash hands
  • Position patient appropriately (45o and exposed neck and chest)
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3
Q

Describe what you must do in the general inspection stage of your respiratory examination

A

Inspect patient from end of bed, look for:

  • Obvious discomfort/pain
  • Colour
  • Evidence of dysnpoea?
  • Audible whee
  • Breathing: breathing pattern, pursed lip breathing, accessory muscle use, splinting of diaphragm, expiratory phase duration
  • Coughing
  • Cyanosis
  • Pink puffer
  • Blue bloater
  • Surroundings: oxygen, nebulisers, inhaler, peak flow
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4
Q

Describe what you must do in the hands & arms section of your respiratory examination

A
  • Inspection of hands: clubbing, tar staining, peripheral cyanosis, tremor, hypercapnic flap
  • Inspection: radial pulse
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5
Q

Describe what you must do in the head & neck section of your respiratory examination

A
  • Inspection of neck: JVP
  • Inspection of head: conjunctival pallor, central cyanosis, oral candidiasis, horner’s syndrome
  • Palpation of lymph nodes:submental, submandibular, pre-auricular, post-auricular, occipital, anterior cervical, posterior cervical, supraclavicular
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6
Q

Desribe what you must do in the chest stage of you respiratory examination

A
  • Inspection: movement, asymmetry, scars, shape/deformities, accessory muscle use, splinting of diaphragm
  • Palpation: tracheal palpation, chest expansion, apex beat, surgical emphysema
  • Percussion: all areas
  • Auscultation: breath sounds, vocal resonance

****DO IN ZIG-ZAG PATTERN FOR BOTH FRONT & BACK.

  • Extra note for back inspection: deformity of spine, sacral oedema
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7
Q

Describe what you must do in the legs stage of your respiratory examination

A
  • Inspection: calf swelling, superficial collateral non-varicose veins -any of these may indicate DVT (may make you think about PE risk)
  • Palpation: checking for DVT therefore check for tenderness & pitting oedema
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8
Q

Describe what you must do in the completing the examination part of the respiratory examination

A

Say that you would:

  • Temperature
  • Peak flow
  • Examine sputum

You may also be required to:

  • Present your fndings
  • Suggest diagnoses (max marks for 3)
  • Suggest appropriate next steps
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9
Q

What is the appropriate position to have your patient in when starting your respiratory examination?

A
  • Led at 45o
  • Neck and chest exposed
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10
Q

What is Kussmaul breathing and what is it suggestive of?

A
  • Kussmaul breathing is deep, laboured breathing
  • Suggestive of metabolic acidosis (e.g. due to DKA, organ failure, sepsis, seizures, toxins, long term use alcohol, some cancers)
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11
Q

What type of breathing is this?

A

Kussmaul breathing

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12
Q

What is pursed lip breathing indicative of?

*Can you explain why patients with this condition do this?

A
  • Pursed lip breathing is indicative of COPD
  • Patients purse their lips to increase intrathoracic pressure to help keep airways open for longer during expiration. Emphysema destroys elastic walls of alveoli hence there is a loss of radial traction keeping bronchioles open
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13
Q

What is splinting of the diaphragm?

A
  • Splinting is when a person reduces movement because the movement causes pain. Hence, splinting of diaphragm is when a patient has reduced movement of diaphragm (because movement causes pain)
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14
Q

Describe the appearance of a pink puffer

A
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15
Q

Patients with what condition can be described as pink puffers or blue bloaters?

A

COPD

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16
Q

Describe the appearance of a blue bloater

A
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17
Q

Explain why, scientifically, someone with chronic bronchitis may present as a blue bloater)

A

Chronic bronchitis can cause someone to be a ‘blue bloater’

  • Blue: cyanosis
  • Bloated: right sided heart failure (cor pulmonale) due to pulmonary vasculature remodelling. May also be due to hypoxic pulmonary vasoconstriction? Right sided heart failure causes peripheral oedema.
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18
Q

Explain, scientifically, why someone with emphysema may present as a pink puffer

A
  • Pink: CO2 retention & increased work of muscles?
  • Pufing: due to pursed lip breathing
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19
Q

State and describe 3 complications which may be experienced by blue bloaters

A
  • Secondary polycythaemia vera (due to hypoxia)
  • Pulmonary hypertension (due to vascular remodelling and hypoxic pulmonary vasoconstriction)
  • Cor pulmonale (from pulmonary hypertension)
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20
Q

State and describe 2 complications which may be experienced by ‘blue bloaters’

A
  • Pneumothorax (due to rupture of large bullae)
    *
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21
Q

Describe how you would test to see if your patient has a hypercapnic flap

A
  • Elevate arms with elbows straight
  • Cock wrist back (full wrist extension)
  • Ask patient to close eyes
  • Observe for at least 10 seconds
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22
Q

What is flapping tremor- also known as asterixis- indicative of?

A

CO2 retention (e.g. in metabolic encephalopathy)

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23
Q

State one possible cause of a fine tremor

A

B2 agonist

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24
Q

What should the JVP be below (in cm)?

A

JVP should be below 4cm

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25
Q

What is surgical emphysema?

A

Air/gas in subcutaneous tissue which can cause:

  • Pain/discomfort
  • Swelling (skin coloured)
  • Crepitus (crackling sound- like a crisp packet- under skin)
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26
Q

How do you test for vocal resonance?

A
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27
Q

Describe how you test for tacile vocal fremitus

A
  • Ask patient to say 99 each time hands placed on chest
  • Place medial side of each and on either side of chest and perform in at least 3 areas
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28
Q

If, when testing vocal resonance, you hear the word ‘99’ better on one side, what could this indicate?

A
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29
Q

If calf swelling is unilateral, where abouts on the leg should you measure?

A
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30
Q

What is the cricosternal distance?

What is the normal distance?

What does a reduced cricosternal distance indicate?

A
  • Distance from lower border of cricoid cartilage to the sternal notch
  • >2cm (should be about 3-4 fingers)
  • Hyperexpanded chest (can be seen in COPD or asthma)
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31
Q

Give a brief summary of a structure you could use to present your examinatino findings

A
  1. I performed ____ on a _____ year old ___ who presented with ____
  2. They appear ___(general inspection findings) ____
  3. On inspection of hands…
  4. In head and neck….
  5. In chest….
  6. Observations were….
  7. My differentials are…
  8. In summary, I believe the cause is….
  9. To complete my examination I would….
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32
Q

What does this image show?

A

Clubbing

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33
Q

How do you check for clubbing? (4)

HINT: think ABCD

A
  • Loss of Schamroth’s window (due to loss of angle between nail & nailbed)
  • Boggy nailbed
  • Increased longitudinal curvature
  • Drumstick appearance of fingertips
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34
Q

Clubbing is a non-specific sign of systemic disease; true or false?

A

True

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35
Q

State some respiratory conditions in which clubbing is seen

A
  • Inflammation: cystic fibrosis, bronchiectasis
  • Malignancy: all except small cell
  • Infection: empyema, abscess
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36
Q

State some other non-respiratory causes of clubbing

A
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37
Q

What does this image show?

A

Tar staining

38
Q

What does this image show?

A

Peripheral cyanosis

39
Q

Describe Raynauds phenomenom

A

Vasospams of arteries often triggered by cold. Colour change goes:

  • Pale/white
  • Blue (cyanosis)
  • Red (hyeraemia mediated by anaearobic metabolites causing vasodilation)

*Fingers will feel cool and numb

40
Q

State some causes of peripheral cyanosis

A
  • Peripheral: peripheral arterial disease, Raynauds, venous obstruction
  • Cardiac: shock, heart failure, hypotension
  • Respiratory: any that leads to decreased saturations
  • Haemoglobinopathy:
41
Q

What does this image show?

A

Horner’s syndrome (partial ptosis, miosis & ahidrosis)

42
Q

What respiratory pathology does Horner’s syndrome indicate?

A

Pancoast tumour (apcial pulmonary neoplasm that compresses surroudning structures)

43
Q

Other than Horner’s syndrome, state some other symptoms/consequences of a pancoast tumour

A
  • Pain, paraesthesia, weakness (compression of brachial plexus)
  • Hoarseness of voice, bovine cough (compression of recurrent laryngeal nerve)
  • Venous oedema or arterial ischaemia (compression of subclavian vessels
44
Q

What does conjuncival pallor indicate?

A

Anaemia

45
Q
A
46
Q

What does this image show?

A

Left shows central cyanosis

47
Q

Central cyanosis is usually the manifestation of severe respiratory, cardiac or neurological/MSK pathology; state some examples of causes of central cyanosis from each of the above categories

A

Respiratory

  • Acute:
    • Tension pneumothorax
    • Life-threatening asthma
  • Chronic:
    • End stage COPD

Cardiac

  • Congenital heart defects which mix oxygenated and dexoygenated blood

Neurological MSK:

  • Sedation
  • Neuromusular junction conduction impairing agents
  • Guillain-Barre syndrome
48
Q

Remind yourself of difference, in terms of pathology, between peripheral and central cyanosis

A
  • Peripheral: decreased blood flow
  • Central: decreased oxygen saturations
49
Q

What does this image show?

A

Oral candidiasis

50
Q

How can you differentiate between oral candidiasis and other causes such as oral hairy leukoplakia and oral lichen planus?

A
  • In oral candidiasis the white lesions can be scrapped off leaving a raw area
51
Q

When is oral candidiasis often seen in respiratory patients?

A

With inhaled corticosteroid use. Gargling with salt water after use can help to prevent candidiasis

52
Q

What causes:

a. ) Oral hairy leukoplakia
b. ) Oral lichen planus

A
  • Oral hairy leukoplakia= EBV infection
  • Oral lichen planus= chronic inflammatory condition that affects mucous membranes in mouth
    *
53
Q

What does this image show?

A

Oral lichen planus

54
Q

What does this iamge show?

A

Oral hairy leukoplakia

55
Q

State two ways in which you can confirm whether the pulsation you are seeing is the JVP

A
  • Palpate and ensure pulse is biphasic
  • Hepatojugular reflux
56
Q

State 5 possible causes of raised JVP

A
  • Right ventricular failure
  • Tricuspid disease
  • Fluid overload
  • PE
  • Obstruction to blood flow e.g. SVC obstruction (RARE)
57
Q

State 3 possible causes of cervical lymphadenopathy

A
  • Infection: glandular fever
  • Inflammation: Sjogren’s syndrome
  • Malignancy: tonsil, tongue etc…
58
Q

State some causes of tracheal deviation

A
  • Pulling: lung collapse, pneumonectomy
  • Pushing: tension pneumothorax, thyroid mass
59
Q

What does this image show?

A
  • Barrel chest (AP to transverse diameter ratio is closer to 1:1 wherease is should be 1:2)
60
Q

What does this image show?

What has happened to sternum?

When is it usually noticed?

A
  • Pectus excavatum (“funnel chest”)
  • Occurs when sternum is sunk into chest wall
  • May be noticed at birth
61
Q

What does this image show?

What has happened to sternum?

When does it usually present?

A
  • Pectus carinatum (“pigeon chest”)
  • Occurs when sternum grows outwards
  • Usually noticed during growth spurt of puberty
62
Q

What does the CXR show?

A

Surgical emphysema

63
Q

What causes surgical emphysema?

How does it feel to touch?

A
  • Gas in subcutaneous tissue
  • On palpation crepitus (crackling) is felt
64
Q

State some causes of surgical emphysema

A
  • Trauma
  • Surgery
  • Drainage
  • Fistula with gas containing organ
65
Q

What is the apex beat?

A

Point of maximal impulse during ventricular contraction

66
Q

Where is the apex beat usually found?

A

Left 5th ICS, mid-clavicular line

67
Q

State the 7 thoracic incisions you need to know

A
  1. Median sternotomy
  2. Infraclavicular
  3. Left inframammary
  4. Left anterolateral thoracotomy
  5. Right anterolateral thoracotomy
  6. Clamshell thoracotomy
  7. Posterolateral thoracotomy
68
Q

Describe where a median sternotomy incision is

State some surgeries which may use a median sternotomy

A
  • Number 1 on image (middle of sternum)
  • Access anterior mediastinal structures e.g. CABG, open aortic or mitral valve replacement
69
Q

Describe where an infraclavicular thoracic incision is

What surgeries may use this incision?

A
  • Number 2 on image (under clavicle)
  • Insert pacemaker
70
Q

Describe where an inframammary scar is

What surgeries may use this incision?

A
  • Number 3 on image (under breast)
  • Breast augmentation or mitral valvotomy
71
Q

Describe where a left anterolateral thoracotomy incision is

What surgeries may use this incision?

A
  • Number 4 on image (mid axillary line to lateral sternal border)
  • May suggest emergency surgery to:
    • Cardiac massage in resuscitation
    • Repair coarctation of descending aorta
    • Repair anterior penetrating thoracic injury
72
Q

Describe where a right anterolateral thoracotomy incision is

What surgeries may use this incision?

A
  • Number 5 on image (right mid axillary line to lateral sternal edge)
  • To access:
    • Aortic valve
    • Ascending thoracic aorta
    • Anterior penetrating thoracic injury
73
Q

Describe where a clamshell thoracotomy incision is

What surgeries might use this incision?

A
  • Number 6 on image (combination of left and right anterolateral thoracotomy)
  • Suggests emergency surgery e.g. cardiac massage in resuscitation or repair of anterior penetrating thoracic injury
74
Q

Describe where a posterolateral thoracotomy incision is

What surgeries might use this incision?

A
  • Number 7 on image (mid spinal line to anterior axilla line)
  • Used to access:
    • Lungs: lobectomy, pneumonectomy or transplant
    • Oesophagus: oesophagectomy (requires rooftop incision aswell)
75
Q

Describe vesicular breath sounds

A
  • Normal breathing
  • Soft, non-musical
  • Inspiratory is longer than expiratory
  • No gap between
76
Q

State 2 broad causes of diminished breath sounds

For each of these broad causes give some specific example conditions

A

Decreased sound generation

  • Hypoventilation
  • Bronchospasm
  • Bronchial obstruction

Decreased transmission

  • Pneumothorax
  • Pleural effusion
77
Q

Describe bronchial breathing

A
  • Mimics normal trachea sound
  • Soft, non-musical
  • Inspiration and expiration
  • Gap inbetween
78
Q

State some reasons you may hear bronchial breath sounds (3)

A
  • Consolidation (e.g. pneumonia)
  • Fibrosis
  • Just above a pleural effusion
79
Q

Describe stridor

A
  • Musical
  • High pitched
  • Can be heard at end of bed or over upper airway
80
Q

A stridor suggests a large airway obstruction; state what each of the following specifically suggests:

  • Inspiratory stridor
  • Expiratory stridor
  • Biphasic stridor
A
  • Inspiratory stridor: extra-thoracic obstruction
  • Expiratory stridor: intra-thoracic obstruction
  • Biphasic stridor (both insp & exp): fixed lesion usually at level of vocal cords e.g. croup, bilateral vocal cord paralysis
81
Q

Describe a wheeze

A
  • Musical, high pitched
  • Usually on expiration (but may be heard on inspiration)
82
Q

If a wheeze is…

  • Localised and monophonic
  • Widespread and polyphonic

… what does it suggest?

A
  • Localised & monophonic: foreign body or tumour
  • Widespread & polyphonic: bronchospasm due to airway or COPD
83
Q

State two other words for crackles

A
  • Crepitations
  • Rales
84
Q

Compare fine and coarse crackles

A

Fine crackles

  • Sounds like velcro being torn
  • Short/explosive
  • Heard mid to end inspiration
  • Unaffected by coughing
  • May be gravity dependent (dependent on cause)

Coarse crackles

  • Short, explosvie
  • Low pitched
  • Heard throughout expiration (and occasionally inspiration)
  • May change or disappear on coughing
85
Q

State 2 possible causes of fine crackles

A
  • Pulmonary oedema
  • Interstitial lung diseases
86
Q

State 2 possible causes of coarse crackles

A

Coarse crackles represent intermittent airway opening and may relate to secretions:

  • Bronchiectasis
  • Pneumonia
87
Q

What does a pleural friction rub sound like?

When is it heard?

A
  • Like crunching snow under your foot
  • Biphasic
88
Q

A pleural friction rub indicates pleural inflammation; state some possible causes of pleural inflammation

A
  • Infection
  • Pulmonary infarction due to PE
  • Malignancy
89
Q

For each of these conditions (pneumothorax, consolidation, effusion, collapse) state what you would find for each of the following on examination:

  • Expansion
  • Percussion
  • Resonance/fremitus
  • Auscultation
A
90
Q
A

Clinical Examinations (16 decks)

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