LEYLA SWAFE, FY1, NNUH

Examination of the respiratory system

Directives

Examine the respiratory systemExamine patient´s chest

Overview

IntroductionInspectionPalpationPercussionAuscultationConcluding remarks

OSCE video

Introduction

Wash handsIntroduce, explain, consent, exposePosition: supine at 45

Inspection: signs

General inspection Appearance: ill/distressed/pain/short of breath Accessory muscles, pursed lip, wheeze, stridor Nutritional statius: cachexia Oxygen, fluids and medications Sputum pot

Inspection/Observation:

A great deal of information can be gathered from simply watching a patient breathe. Pay particular attention to: General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic, labored? Are the

breaths regular and deep? Use of accessory muscles of breathing (e.g. scalenes,

sternocleidomastoids). Their use signifies some element of respiratory difficulty.

Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad!

Video – respiratory distress

Beside

Always look for a sputum pot! Yellow/green sputum –infection Massive amounts of sputum – most likely bronchiectasis Look for signs of blood –infection/malignancy

Inhalers

Flapping tremor

http://www.youtube.com/watch?v=Rbv-zaVszlk

Cyanosis:

A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. As with clubbing, it is not at all sensitive for either of these conditions.

Clubbing

Clubbing: Bulbous appearance of the distal phalanges of all fingers

along Concurrent loss of the normal angle between the nail base

and adjacent skin. Most commonly associated with conditions that cause

chronic hypoxemia (e.g. severe emphysema), also associated with a number of other conditions.

However, in general it is neither common nor particularly sensitive for hypoxia, as most hypoxic patients do not have clubbing.

Nicotine staining

Pulse

At the wrist you should take the patient’s pulse. A bounding pulse may indicate carbon dioxide retention. After you have taken the pulse it is advisable to keep your hands in

the same position and subtly count the patient’s respiration rate. This helps to keep it as natural as possible.

Inspection: signs

Hands Nails

Finger clubbing Nicotine staining Peripheral cyanosis Warmth

Wrist Flapping tremor / Fine tremor Respiratory rate Pulse

Inspection: signs

Face Cushingoid Eyes

Conjunctival pallor Horners

Mouth Central cyanosis

Inspection: signs

Neck Tracheal position Cricosternal distance Tracheal tug on inspiration

Nodes Palpation of lymph nodes

Lymphadenopathy

Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow’s Node) as an enlarged node (Troisier’s Sign) may suggest metastatic lung cancer.

Chest wall deformities

Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient's ability to breathe normally. A few common variants include:

Palpation

Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be identified on exam.

Inspection: signs

Chest A-P diameter Scars Chest drain sites Deformity of chest/spine

Palpation

TracheaApex beatChest expansion

Chest wall deformities

Pectus excavatum: Congenital posterior displacement of lower aspect of sternum.

Barrel chest: Associated with emphysema and lung hyperinflation.

Kyphosis: Causes the patient to be bent forward.

Scoliosis: Condition where the spine is curved to either the left or right.

Tactile Fremitus:

Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall.

Pathologic conditions will alter fremitus. In particular:

Lung consolidation: Consolidation occurs when thenormally air filled lung parenchymabecomes engorged with fluid or tissue,most commonly in the setting ofpneumonia. If a large enough segment of parenchyma is involved, it can alterthe transmission of air and sound. Inthe presence of consolidation, fremitusbecomes more pronounced.

Pleural fluid: Fluid, known as a pleuraleffusion, can collect in the potentialspace that exists between the lung andthe chest wall, displacing the lungupwards. Fremitus over an effusion willbe decreased.

Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung. In this model, an infiltrate is depicted by the blue coloration that has invaded the sponge itself (sponge on left). An effusion is depicted by the blue fluid upon which the lung is floating (sponge on right).

Percussion

Start in supraclavicular fossa then work downCompare side to side including axillaeMap out abnormalities

Auscultation

Auscultation

Auscultation

Use diaphragmVesicular breathing (normal)/Bronchial

breathing (pathological)Decreased or absent breath soundsAdded sounds

Crepitations (cough) Wheezes Pleural rub Vocal resonance

Vocal resonance ”say 99

Auscultation

http://www.google.co.uk/imgres?imgurl=http://meded.ucsd.edu/clinicalmed/upper_cyanosis2.jpg&imgrefurl=http://meded.ucsd.edu/clinicalmed/upper.htm&usg=__vqgXEIDs3sow-yiUQEJfAhTrVEM=&h=960&w=1280&sz=167&hl=en&start=1&zoom=1&tbnid=n0NQ6CAJ2HI20M:&tbnh=113&tbnw=150&ei=fOAIUYCUFsil0AW-xoDADw&prev=/search%3Fq%3Dperipheral%2Bcyanosis%26hl%3Den%26safe%3Dstrict%26gbv%3D2%26tbm%3Disch&itbs=1

http://www.med.ucla.edu/wilkes/lungintro.htm http://www.google.co.uk/imgres?imgurl=http://www.emsjunkie.com/wp-

content/uploads/2012/11/Lung-Sounds-Anterior.jpg&imgrefurl=http://www.emsjunkie.com/patient-assessment/patient-assessment-lung-sounds/&usg=__4t6XnB9CMmwFxdXfeBVg32pPHwc=&h=398&w=314&sz=60&hl=en&start=77&zoom=1&tbnid=EB1hN1Q6xG7gfM:&tbnh=124&tbnw=98&ei=zecIUZaEAqTJ0AXEwoHoBA&prev=/search%3Fq%3Dlung%2Bauscultation%26start%3D60%26um%3D1%26hl%3Den%26safe%3Dstrict%26sa%3DN%26gbv%3D2%26tbm%3Disch&um=1&itbs=1

General examination

Back Sacral oedema

Ankles Peripheral oedema

Causes of physical signs found on respiratory examination

Concluding remarks

To Complete My Examination... Observation chart (BP, temp, sats) Abdominal Examination for hepatomegaly Sacral or peripheral oedema

Investigations you may like to perform might include: Chest x-ray Sputum microscopy, culture and sensitivity Pulse Oximetry Arterial blood gas analysis Spirometry Peak expiratory flow rate

OSCE video

http://www2.le.ac.uk/departments/msce/existing/clinical-exam/respiratory