Transcript Examination of the respiratory system

Examination of the respiratory
system
LEYLA SWAFE, FY1, NNUH
Directives
 Examine the respiratory system
 Examine patient´s chest
Overview
 Introduction
 Inspection
 Palpation
 Percussion
 Auscultation
 Concluding remarks
 OSCE video
Introduction
 Wash hands
 Introduce, explain, consent, expose
 Position: 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:
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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!
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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:
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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
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Finger clubbing
Nicotine staining
Peripheral cyanosis
Warmth
 Wrist
 Flapping tremor / Fine tremor
 Respiratory rate
 Pulse
Inspection: signs
 Face
 Cushingoid
 Eyes
Conjunctival pallor
 Horners
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Mouth
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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
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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
 Trachea
 Apex beat
 Chest expansion
Chest wall deformities
Pectus excavatum: Congenital
posterior displacement of lower
aspect of sternum.
Scoliosis: Condition where the spine is
curved to either the left or right.
Kyphosis: Causes the
patient to be bent forward.
Barrel chest: Associated with
emphysema and lung hyperinflation.
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 the
normally air filled lung parenchyma
becomes engorged with fluid or tissue,
most commonly in the setting of
pneumonia. If a large enough segment
of parenchyma is involved, it can alter
the transmission of air and sound. In
the presence of consolidation, fremitus
becomes more pronounced.
Pleural fluid: Fluid, known as a pleural
effusion, can collect in the potential
space that exists between the lung and
the chest wall, displacing the lung
upwards. Fremitus over an effusion will
be 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 down
 Compare side to side including axillae
 Map out abnormalities
Auscultation
Auscultation
Auscultation
Use diaphragm
 Vesicular breathing (normal)/Bronchial breathing
(pathological)
 Decreased or absent breath sounds
 Added sounds
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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_cya
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 http://www.med.ucla.edu/wilkes/lungintro.htm
 http://www.google.co.uk/imgres?imgurl=http://www.emsjunkie.com/wpcontent/uploads/2012/11/Lung-SoundsAnterior.jpg&imgrefurl=http://www.emsjunkie.com/patient-assessment/patientassessment-lungsounds/&usg=__4t6XnB9CMmwFxdXfeBVg32pPHwc=&h=398&w=314&sz=60&hl=en&
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General examination
 Back
 Sacral oedema
 Ankles
 Peripheral oedema
Causes of physical signs found on respiratory
examination
Concluding remarks
 To Complete My Examination...
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Observation chart (BP, temp, sats)
Abdominal Examination for hepatomegaly
Sacral or peripheral oedema
Investigations you may like to perform might include:
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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/cl
inical-exam/respiratory