Respiratory Examination - University of the Free State

Respiratory Examination - University of the Free State

Respiratory Examination Dr Scarpa Schoeman Dept Internal Medicine Slides of Dr JM Nel Department Critical Care Respiratory Examination 1. Positioning 6.

The chest of the patient 7. The heart 2. General Appearance 8. The abdomen 3. The hands 9. Other 4. The face 5. The trachea

Positioning of the patient Undress Sitting to waist

position Acutely ill Lying down General appearance 1. Dyspnoea

Signs of dyspnoea at rest RR: 16- 25/min 2. Cyanosis Central cyanosis: tongue 3. Cough character General appearance

4. Sputum Colour/volume/type Hemoptysis 5. Stridor Loudest on inspiration 6.

Hoarseness The hands 1. Clubbing P51-Table 4.9 The hands Clubbing does not give clubbing COPD/TB

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

The hands HPO Periosteal inflammation Clubbing marked Distal end of long bones,wrists,metacarpal,metatarsal bones, knees, ankles Swelling/Tenderness The hands 2. Staining

Cigarette smoking 3. Wasting and weakness Wasting small muscles Weakness abduction Infiltration of brachial plexus by lung CA The hands 5. 4.

Flapping Pulse rate tremor(Asterixis) Pulse rate Pulsus paradoxus Dorsiflex hands Systolic BP drop > 10mmHg CO2

retention (COPD) The face 1. Horners syndrome Constricted pupil Partial ptosis Loss of sweating Apical lung tumour Compression of sympathetic nerves

The face 2. Skin changes Connective tissue diseases The face 3. URTI Look inside mouth

4. Sinuses Look inside mouth 5. SVC obstruction Facial plethora or cyanosis The trachea Position

Tracheal COPD tug The chest Inspection Palpation Percussion Auscultation The chest: Inspection

1. Shape and symmetry of chest shape shaped chest BarrelHarrisons sulcus chest Pigeon

Kyphosis, scoliosis, kyphoscoliosis Funnel Lesionschest of chest wall Movement of chest wall The chest: Inspection Barrel- shaped chest

Increased AP diameter Severe asthma/COPD Normal elderly people The chest: Inspection Funnel Pigeon chest(pectus excavatum) carinatum) Developmental Outward bowingdefect

sternum/costal cartilages Depression lower end of sternum childhood resp Chronic Severe: decreased lunginfectons capacity Rickets The chest: Inspection Harrisons

sulcus Linear depression lower ribs just above costal margins Severe asthma in childhood Rickets The chest: Inspection Kyphosis, scoliosis, kyphoscoliosis

Severe: reduced lung capacity The chest: Inspection Lesions of chest wall Scars Previous surgery Previous ICD Radiotherapy Erythema

Subcutaneous emphysema Prominent veins SVC obstruction 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 The chest: Inspection Movement of chest wall

Asymmetry Paradoxical inward movement abdomen during inspiration Diaphragm paralysis The chest: Palpation 1. Chest expansion Thumbs move symmetrical 5cm on inspiration

Lower lobe From back Upper lobe From front The chest: Palpation Impalpable 2. Apex beat COPD: hyperinflation Displacement Towards side of lesion

Collapse lower lobe Localized fibrosis Away from lesion Pleural effusion Tension pneumothorax The chest: Palpation 4. 3. Vocal fremitus Ribs

Localized Palm of hand pain Trauma, metastases, prolonged coughing 99 Differences Increased: Consolidation Same as vocal resonance The chest: Percussion The chest: Percussion

1. Symmetrical Ant/Post/Lat Supraclavicular fossa over lung apex Clavicle with finger The chest: Percussion The chest: Percussion 2.

Interpretation Stony dull Resonant Fluidfilled area (pleural effusion) Normal Hyperresonant Dull Over structures Solid hollow

structure (liver) Bowel, pneumothorax Consolidation The chest: Percussion 4. 3. Liver dullness Cardiac dullness

Decreased Upper level COPD 5th / 6th rib MCL Asthma If lower: hyperinflation The chest: Auscultation 1. Breath sounds 2.

Vocal resonance The chest: Auscultation 1. Breath sounds General Quality of breath sounds Intensity of breath sounds Added sounds

The chest: Auscultation(Breath sounds) General Diaphragm of stethoscope Compare sides Axilla Bell of stethoscope above clavicles Lung apices The chest: Auscultation(Breath sounds) Quality

of breath sounds p125 Normal breath sounds (vesicular) Bronchial breath sounds Amphoric breath sounds 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 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 The chest: Auscultation(Breath sounds) Amphoric

breathing Exaggerated bronchial quality Very hollow (blowing over bottle) LARGE CAVITY The chest: Auscultation(Breath sounds) Intensity of breath sounds

Normal or reduced Reduced COPD Pleural effusion Pneumothorax Pneumonia Large neoplasm Pulmonary collapse The chest: Auscultation(Breath sounds) Added

sounds Continuous sounds (wheezes) Interrupted sounds (crackles) The chest: Auscultation(Breath sounds) Low pitchedsounds Continuous (wheezes) Larger bronchi

Musical COPD Inspiration +/- expiration Monophonic Airway narrowing Localized High pitched Bronhial obstruction (Lung CA) Smaller bronchi Stridor

Asthma Louder over trachea Inspiratory The chest: Auscultation(Breath sounds) Late/pan-inspiratory Interrupted sounds Disease in alveoli (crackles) Fine

Non-musical Pulmonary fibrosis Early Medium inspiratory LV failure Small airway disease COPD Coarse Medium coarseness Bronchiectasis

Retention of secretions 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 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 The chest: Signs The chest: Signs The chest: Signs

The chest: Signs The chest: Signs Hyperinflation Increased AP diameter Trageal tug Apex not palpable Hyperressonant percussion Liver displaced downwards No cardiac dullness Soft heart sounds

The Heart Measure JVP Increased in RV failure Listen to P2 Loud in pulmonary hypertension

The Abdomen Liver examination Displaced downward in hyperinflation Enlarged in metastases (Lung CA) Other Pembertons sign

Lift arms over head one minute SVC obstruction Facial plethora Cyanosis Inspiratory stridor Non-pulsatile elevation of JVP Other Feet Oedema Cor pulmonale

DVT PE

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