Respiratory Physical Exam

Question 1

Adult physical exam: What are the four things you assess and in what order?

Answer 1

observe pattern of breathing, inspect (extrapulmonary signs of pulm, disease), palpate, percussion, auscultate

Question 2

A normal respiratory rate in an adult?

Answer 2

12-20

Question 3

Why is it important for you as the FNP to inspect for extrapulmonary signs of pulmonary disease?

Answer 3

directs your exam, gives you more details about what is going on with the patient

Question 4

What areas of the patient are you going to palpate during a respiratory exam?

Answer 4

Trachea (is it deviated?) posterior chest wall (fremitus during spoken words?), anterior chest wall (cardiac impulse)

Question 5

What are you assessing for during the percussion portion of the adult resp exam?

Answer 5

identify any dull areas or consolidation

Question 6

In an adult, the primary muscle of respiration is?

Answer 6

Diaphragm, with chest/abdominal wall expands simultaneously

Question 7

Normal breathing: is 12-20rr, symmetrical chest expansion, and what sounds should you hear over periphery of the chest wall?

Answer 7

vesicular (gentle, rustling heard throughout inspiration – fades in expiration)

Question 8

Concerning the rate of an adult patient, if their respiratory rate goes up - what is this called and what do you expect to happen to
their tidal volume?

Answer 8

tachypnea; decreased Tidal Volume

Question 9

What is the physiological cause of cyanosis in patients?

Answer 9

increased amounts of UNSATURATED HgB in capillary blood

Question 10

A patient presents to the clinic with anemia. The patient appears very short of breath. What are two indicators of hypoxemia that would not be accurate/present in this patient? To determine the extent of hypoxemia in this patient, what labs or studies would you
order?

Answer 10

Answer: pulse ox and cyanosis; order hgb/hct (see their blood levels and extent of anemia); ABG (to assess degree of hypoxemia);

(Patients who have anemia do not develop cyanosis until the oxygen saturation (also called SaO2) falls below normal hemoglobin levels. Patients with
lower hemoglobin or anemia say with hemoglobin of 6 g/dL, the saturation has to drop as low as 60% before cyanosis becomes clinically apparent)

Question 11

A patient presents to your clinic with hx of polycythemia. The patient appears cyanotic but there is no apparent respiratory distress noted (sitting comfortably, respirations even and unlabored, AAOX4). What do you suspect is going on?

Answer 11

This is a normal finding in this patient. (Polycythemia vera is a slow-growing blood cancer in which your bone marrow makes too many red blood cells – increased hemoglobin concentration; therefore, minimal dips in O2 will appear cyanotic in these patients)

Question 12

When a patient displays an increased work of breathing, you would expect them to be using accessory muscles. However, a patient at
rest who is using accessory muscles - what is this a sign of?

Answer 12

Sign of significant pulmonary impairment

Question 13

If a patient’s chest expands but the abdomen collapse on inspiration - what could be the physiological cause?

Answer 13

weakness of diaphragm (neuromuscular diseases)

Question 14

A patient presents with unilateral volume loss on the right side when inspecting their CXR film. What could be the cause?

Answer 14

pleural effusion, atelectasis, empyema

Question 15

You are assessing a patient and note hyperresonance on percussion. What do you suspect could be the cause?

Answer 15

Hyperresonant sounds may be heard when percussing lungs hyperinflated with air (COPD, acute asthma attack). An area of hyperresonance on one side of the chest may indicate a pneumothorax.

Question 16

In a patient with tracheal deviation - what do you suspect the cause is?

Answer 16

Tension pneumo – REFER!

Question 17

If you hear bronchial lung sounds over the periphery of lung - is this normal or abnormal?

Answer 17

abnormal; suspect consolidation

Question 18

Globally diminished lung sounds are predictive of what?

Answer 18

significant airflow obstruction

Question 19

A patient presents with a high-pitched musical respiration. What does this signify? What could be the cause?

Answer 19

wheezing; bronchospasms (acute asthma attack), mucosal edema (allergic reaction), excessive secretions (from narrowed airway);
POWERFUL INDICATOR OF OBSTRUCTIVE LUNG DISEASE

Question 20

A patient presents with lower-pitched snorous respirations. What do you suspect? What intervention could you perform immediately to test your theory?

Answer 20

Rhonchi; often caused by secretions in large airways; seen in patients with pneumonia, chronic bronchitis, CF, and COPD. ask the patient to cough – should clear

Question 21

You are assessing a patient and note dullness on percussion. What do you suspect could be the cause?

Answer 21

lung consolidation, pleural effusion

Question 22

Patient presents with lower-pitched popping sounds heard on auscultation. This sound is longer in duration. What do you suspect?
What is MOST often the cause?

Answer 22

Coarse crackles; most often caused by CHF or pneumonia

Question 23

Patient presents with brief, nonmusical sounds that have a crisp poppy quality heard during auscultation. What do you suspect?

Answer 23

Fine crackles

Question 24

What is NOT a reliable indicator of hypoxemia?

Answer 24

Cyanosis (get arterial PO2 or HgB saturation measured)

Question 25

BLE edema is an indirect measurement of what?

Answer 25

``` pulmonary HTN (Why? Because if the fluid is not being pumped by the heart correctly you know it is backing up. Backing up in the heart goes from left side to lungs to right side. if the fluid continues collecting in legs and the right side of the heart is failing - you’re going to expect increased pressures in the lungs = pulmonary HTN) ```

Question 26

What are some causes of digital clubbing that you may encounter as an FNP in an outpatient setting?

Answer 26

lung abscess, empyema, bronchiectasis, CF, cirrhosis, Graves’ disease

Question 27

You are making rounds in the hospital and are visiting the neuro ICU. A patient you are assessing is noted to have a rhythmic breathing pattern with regular periods of apnea. What is this called? And what do you suspect the cause is?

Answer 27

Cheyne-Stokes respirations; suspect increased ICP, cardiac failure, renal failure, overdose on narcotics

Question 28

Patient presents to your clinic with a history of DM uncontrolled. Their breathing is deep and rapid. What is this called and what does this signify?

Answer 28

Kussmaul respirations; suspect DKA

Question 29

What lung sounds are considered normal when heard over suprasternal notch (large, visible dip in between the neck and the two collarbones)?

Answer 29

tracheal or bronchial (louder – higher pitched, hollow quality, louder on expiration)

Question 30

``` As an FNP, you wish to measure a patients' airflow rates and gas exchange. What test would you order? A: spirometry B: ABG C: Cardiac stress test D: PFTs ```

Answer 30

Answer: D: PFTs

Question 31

What indication would warrant the FNP to order PFTs? (what are you assessing for) A: assess the presence of obstructive/restrictive pulmonary dysfunction B: see how much air a person can inhale/exhale C: assess the type and extent of lung dysfunction D: none of the above

Answer 31

Answer: C assess the type and extent of lung dysfunction (assess type and extent of lung dysfunction, causes of dyspnea/cough, early detection of lung dysfunction, follow-up response to therapy)

Question 32

``` What patient would NOT be appropriate to order PFTs on? A: chronic bronchitis B: acute asthma exacerbation C: patient awaiting surgery D: new onset of SOB on exertion ```

Answer 32

Answer: B acute asthma exacerbation (PFTs are contraindicated in acute severe asthma, resp. distress, angina aggravated by testing, pneumothorax, ongoing hemoptysis, active TB)

Question 33

How do you measure your patients PFTs to establish if they are normal or not? A: measured against predicted values B: compare to the patients' previous values C: perform a PFT and check a blood gas afterward D: measure the patients O2 saturation while performing PFTs

Answer 33

Answer: A – measured against predicted values derived from large studies of healthy subject (vary with age, gender, height, weight, ethnicity)

Question 34

You are evaluating a patient in clinic for a follow-up appointment. You order spirometry testing on this patient. The co-morbid condition you would expect this patient to have would be? A: AV malformation B: Pneumonia C: COPD D: Foreign Body obstruction

Answer 34

Answer: C - COPD (spirometry is measuring lung volumes to assess the presence or severity of obstructive/restrictive pulmonary dysfunction; expressed in FEV and FVC)

Question 35

FEV (forced expiratory volume): how much air is the person exhaling during a forced breath FEV1: the amount of air exhaled during 1st breath FVC: the total amount of air exhales during the entire test So, in a patient with obstructive dysfunction, what would you expect the FEV1 / FVC ratio to be?

Answer 35

Answer: Both decreased (reduced airflow rates seen in asthma, COPD, bronchiectasis, bronchiolitis, upper airway obstruction, CF) Explanation: Obstruction can occur when inflammation and swelling cause the airways to become narrowed or blocked, making it difficult to expel air from the lungs. This results in an abnormally high volume of air being left in the lungs (increased residual volume). Increased residual volume, in turn, leads to both the trapping of air and hyperinflation of the lungs—changes that contribute to a worsening of respiratory symptoms.

Question 36

The results obtained on your patient show low FEV1/FVC ratio. You've determined the cause is obstructive. What should you do to assess if this is reversible?

Answer 36

Answer: If obstruction is evident (low FEV1/FVC) – repeat spirometry 10-20 mins after inhaled bronchodilator to help assess if dx is reversible

Question 37

After administering a bronchodilator to this patient, you repeat spirometry testing 15 minutes later. The results are low FEV1/FVC ratio. What do you suspect the cause of this is?

Answer 37

Answer: COPD (obstructive disorder that would NOT improve with bronchodilator; asthma would improve – although spirometry is used in hospital to prevent pneumonia – but in the case of using it as a diagnostic tool, it is being used to see if your lung issue is obstructive or restrictive; repeating the test after bronchodilator, allows you to further pinpoint WHAT type of obstructive disease they have) Explanation: Restrictive conditions are defined by inhalation that fills the lungs far less than would be expected in a healthy person. These patients have a difficult time filling the lungs completely in the first place, and can be due to intrinsic factors (e.g. stiff lungs); extrinsic factors, such as when pressure from an enlarged abdomen limits the expansion of the lungs; or neurological factors, such as muscular dystrophy, where damage to the nervous system interferes with movements necessary to draw air into the lungs.

Question 38

So, in a patient with restrictive lung dysfunction, what results would be reflected after obtaining a spirometry test?

Answer 38

Answer: reduced FVC