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Respiratory Examination Slides of Dr JM Nel Department Critical Care Dr Scarpa Schoeman – Dept Internal Medicine

Respiratory Examination

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Respiratory Examination. Dr Scarpa Schoeman – Dept Internal Medicine. Slides of Dr JM Nel Department Critical Care. 1. Positioning of the patient 2. General Appearance 3. The hands 4. The face 5. The trachea. 6. The chest 7. The heart 8. The abdomen 9. Other. - PowerPoint PPT Presentation

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Page 1: Respiratory Examination

Respiratory Examination

Slides of Dr JM NelDepartment Critical Care

Dr Scarpa Schoeman – Dept Internal Medicine

Page 2: Respiratory Examination

Respiratory Examination 1. Positioning of the patient

2. General Appearance

3. The hands

4. The face

5. The trachea

6. The chest

7. The heart

8. The abdomen

9. Other

Page 3: Respiratory Examination

Positioning of the patient Undress to waist

Sitting position

Acutely ill– Lying down

Page 4: Respiratory Examination

General appearance 1. Dyspnoea

– Signs of dyspnoea at rest– RR: 16- 25/min

2. Cyanosis– Central cyanosis: tongue

3. Cough character

Page 5: Respiratory Examination

General appearance 4. Sputum

– Colour/volume/type– Hemoptysis

5. Stridor– Loudest on inspiration

6. Hoarseness

Page 6: Respiratory Examination

The hands 1. Clubbing

– P51-Table 4.9

Page 7: Respiratory Examination

The hands Clubbing

– Cardiovascular Congenital cyanotic heart disease Infective endocarditis

– Respiratory (80% the cause) Lung carcinoma Chronic pulmonary suppuration Idiopathic lung fibrosis Cystic fibrosis Asbestosis Pleural mesothelioma

– Gastrointestinal Cirrhosis Inflammatory bowel disease Coeliac disease

COPD/TB does not give clubbing

Page 8: Respiratory Examination

The handsHPO

Periosteal inflammation Clubbing marked Distal end of long

bones,wrists,metacarpal,metatarsal bones, knees, ankles

Swelling/Tenderness

Page 9: Respiratory Examination

The hands 2. Staining

– Cigarette smoking

3. Wasting and weakness

– Wasting small muscles– Weakness abduction– Infiltration of brachial plexus by lung CA

Page 10: Respiratory Examination

The hands 4. Pulse rate

– Pulse rate– Pulsus paradoxus

Systolic BP drop > 10mmHg

5. Flapping tremor(Asterixis)

– Dorsiflex hands– CO2 retention (COPD)

Page 11: Respiratory Examination

The face 1. Horner’s syndrome

– Constricted pupil– Partial ptosis– Loss of sweating

– Apical lung tumour– Compression of sympathetic nerves

Page 12: Respiratory Examination

The face 2. Skin changes

– Connective tissue diseases

Page 13: Respiratory Examination

The face 3. URTI

– Look inside mouth

4. Sinuses– Look inside mouth

5. SVC obstruction– Facial plethora or cyanosis

Page 14: Respiratory Examination

The trachea Position

Tracheal tug– COPD

Page 15: Respiratory Examination

The chest Inspection

Palpation

Percussion

Auscultation

Page 16: Respiratory Examination

The chest: Inspection 1. Shape and symmetry of chest shape

– Barrel- shaped chest

– Pigeon chest

– Funnel chest

– Harrison’s sulcus

– Kyphosis, scoliosis, kyphoscoliosis

– Lesions of chest wall

– Movement of chest wall

Page 17: Respiratory Examination

The chest: Inspection Barrel- shaped chest

– Increased AP diameter– Severe asthma/COPD– Normal elderly people

Page 18: Respiratory Examination

The chest: Inspection Pigeon chest(pectus carinatum)

– Outward bowing sternum/costal cartilages

– Chronic childhood resp infectons– Rickets

Funnel chest(pectus excavatum)– Developmental defect– Depression lower end of sternum– Severe: decreased lung capacity

Page 19: Respiratory Examination

The chest: Inspection Harrison’s sulcus

– Linear depression lower ribs just above costal margins

– Severe asthma in childhood– Rickets

Page 20: Respiratory Examination

The chest: Inspection Kyphosis, scoliosis, kyphoscoliosis

– Severe: reduced lung capacity

Page 21: Respiratory Examination

The chest: Inspection Lesions of chest wall

– Scars Previous surgery Previous ICD

– Radiotherapy Erythema

– Subcutaneous emphysema– Prominent veins

SVC obstruction

Page 22: Respiratory Examination

The chest: Inspection Movement of chest wall

– Expansion Upper lobes

– From behind– Look down at clavicles

Lower lobes– From behind– Unilateral

Localized fibrosis, consolidation, collapse, pleural effusion

– Bilateral COPD, diffuse pulmonary fibrosis

Page 23: Respiratory Examination

The chest: InspectionMovement of chest wall

–Asymmetry–Paradoxical inward movement

abdomen during inspiration Diaphragm paralysis

Page 24: Respiratory Examination

The chest: Palpation 1. Chest expansion

– Thumbs move symmetrical 5cm on inspiration

– Lower lobe From back

– Upper lobe From front

Page 25: Respiratory Examination

The chest: Palpation 2. Apex beat

– Displacement

Towards side of lesion– Collapse lower lobe– Localized fibrosis

Away from lesion– Pleural effusion– Tension pneumothorax

– Impalpable COPD: hyperinflation

Page 26: Respiratory Examination

The chest: Palpation 3. Vocal fremitus

– Palm of hand– “99”– Differences– Increased: Consolidation– Same as vocal resonance

4. Ribs– Localized pain

Trauma, metastases, prolonged coughing

Page 27: Respiratory Examination

The chest: Percussion

Page 28: Respiratory Examination

The chest: Percussion 1. Symmetrical

– Ant/Post/Lat– Supraclavicular fossa over lung apex– Clavicle with finger

Page 29: Respiratory Examination

The chest: Percussion

Page 30: Respiratory Examination

The chest: Percussion 2. Interpretation

– Resonant Normal

– Dull Solid structure (liver) Consolidation

– Stony dull Fluid- filled area (pleural effusion)

– Hyperresonant Over hollow structures

– Bowel, pneumothorax

Page 31: Respiratory Examination

The chest: Percussion 3. Liver dullness

– Upper level 5th / 6th rib MCL If lower: hyperinflation

4. Cardiac dullness

– Decreased COPD Asthma

Page 32: Respiratory Examination

The chest: Auscultation 1. Breath sounds

2. Vocal resonance

Page 33: Respiratory Examination

The chest: Auscultation 1. Breath sounds

– General

– Quality of breath sounds

– Intensity of breath sounds

– Added sounds

Page 34: Respiratory Examination

The chest: Auscultation(Breath sounds)

General

– Diaphragm of stethoscope– Compare sides– Axilla– Bell of stethoscope above clavicles

Lung apices

Page 35: Respiratory Examination

The chest: Auscultation(Breath sounds)

Quality of breath sounds p125– Normal breath sounds (vesicular)

– Bronchial breath sounds

– Amphoric breath sounds

Page 36: Respiratory Examination

The chest: Auscultation(Breath sounds)

Normal breath sounds (vesicular)

– Most of chest– Breath through mouth– Inspiration

Longer and louder than expiration– No gap between inspiration and

expiration

Page 37: Respiratory Examination

The chest: Auscultation(Breath sounds)

Bronchial breathing– Hollow, blowing sound– Audible in expiration– Gap between inspiration and expiration– Expiration

Higher intensity than inspiratory– Normal posteriorly over upper chest

– CONSOLIDATION

Page 38: Respiratory Examination

The chest: Auscultation(Breath sounds)

Amphoric breathing– Exaggerated bronchial quality– Very hollow (blowing over bottle)

– LARGE CAVITY

Page 39: Respiratory Examination

The chest: Auscultation(Breath sounds)

Intensity of breath sounds– Normal or reduced

– Reduced COPD Pleural effusion Pneumothorax Pneumonia Large neoplasm Pulmonary collapse

Page 40: Respiratory Examination

The chest: Auscultation(Breath sounds)

Added sounds– Continuous sounds (wheezes)

– Interrupted sounds (crackles)

Page 41: Respiratory Examination

The chest: Auscultation(Breath sounds)

Continuous sounds (wheezes)– Musical– Inspiration +/- expiration– Airway narrowing– High pitched

Smaller bronchi Asthma

– Low pitched Larger bronchi COPD

– Monophonic Localized Bronhial obstruction (Lung CA)

– Stridor Louder over trachea Inspiratory

Page 42: Respiratory Examination

The chest: Auscultation(Breath sounds)

Interrupted sounds (crackles)

– Non-musical– Early inspiratory

Small airway disease COPD Medium coarseness

– Late/pan-inspiratory Disease in alveoli Fine

– Pulmonary fibrosis Medium

– LV failure

Coarse– Bronchiectasis– Retention of secretions

Page 43: Respiratory Examination

The chest: Auscultation(Breath sounds)

Pleural friction rub Thickened pleural surfaces rub together Grating sound Causes

– Pleurisy Secondary to pulmonary infarction

– Pneumonia– Malignant involvement of pleura– Spontaneous pneumothorax

Page 44: Respiratory Examination

The chest: Auscultation 2. Vocal resonance

– Auscultation while patient speaks– Ability of lung to transmit sounds– Normal– Consolidation

Can hear “99” Aegophony

– Bee becomes bay Whispering pectoriloquy

– Can hear when whispers

Page 45: Respiratory Examination

The chest: Signs

Page 46: Respiratory Examination

The chest: Signs

Page 47: Respiratory Examination

The chest: Signs

Page 48: Respiratory Examination

The chest: Signs

Page 49: Respiratory Examination

The chest: Signs Hyperinflation

– Increased AP diameter– Trageal tug– Apex not palpable– Hyperressonant percussion– Liver displaced downwards– No cardiac dullness– Soft heart sounds

Page 50: Respiratory Examination

The Heart Measure JVP

– Increased in RV failure

Listen to P2– Loud in pulmonary hypertension

Page 51: Respiratory Examination

The Abdomen Liver examination

– Displaced downward in hyperinflation– Enlarged in metastases (Lung CA)

Page 52: Respiratory Examination

Other Pemberton’s sign

– Lift arms over head one minute– SVC obstruction

Facial plethora Cyanosis Inspiratory stridor Non-pulsatile elevation of JVP

Page 53: Respiratory Examination

Other Feet

– Oedema Cor pulmonale

– DVT PE

Page 54: Respiratory Examination