Slides of Dr JM Nel Department Critical Care Dr Scarpa Schoeman Dept Internal Medicine Respiratory Examination 1 Positioning of the patient 2 General Appearance 3 The hands ID: 572839
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Slide1
Respiratory Examination
Slides of Dr JM NelDepartment Critical Care
Dr Scarpa Schoeman – Dept Internal MedicineSlide2
Respiratory Examination
1. Positioning of the patient2. General Appearance
3. The hands4. The face
5. The trachea
6. The chest
7. The heart
8. The abdomen
9. OtherSlide3
Positioning of the patient
Undress to waistSitting positionAcutely illLying downSlide4
General appearance
1. DyspnoeaSigns of dyspnoea at restRR: 16- 25/min
2. Cyanosis
Central cyanosis: tongue3.
Cough characterSlide5
General appearance
4. SputumColour/volume/typeHemoptysis
5. Stridor
Loudest on inspiration6.
HoarsenessSlide6
The hands
1. ClubbingP51-Table 4.9 Slide7
The hands
ClubbingCardiovascularCongenital cyanotic heart diseaseInfective
endocarditis
Respiratory (80% the cause)
Lung carcinomaChronic pulmonary suppuration
Idiopathic lung fibrosisCystic fibrosis
Asbestosis
Pleural
mesothelioma
Gastrointestinal
Cirrhosis
Inflammatory bowel disease
Coeliac
disease
COPD/TB does not give clubbingSlide8
The hands
HPOPeriosteal inflammationClubbing marked
Distal end of long bones,wrists,metacarpal,metatarsal bones, knees, ankles
Swelling/TendernessSlide9
The hands
2. StainingCigarette smoking3.
Wasting and
weakness
Wasting small musclesWeakness abduction
Infiltration of brachial plexus by lung CA Slide10
The hands
4. Pulse ratePulse ratePulsus
paradoxusSystolic BP drop > 10mmHg
5.
Flapping
tremor(Asterixis)
Dorsiflex hands
CO2 retention (COPD)Slide11
The face
1. Horner’s syndromeConstricted pupilPartial ptosisLoss of sweating
Apical lung tumour
Compression of sympathetic nervesSlide12
The face
2. Skin changesConnective tissue diseasesSlide13
The face
3. URTILook inside mouth4. Sinuses
Look inside mouth5.
SVC obstructionFacial plethora or cyanosisSlide14
The trachea
PositionTracheal tugCOPDSlide15
The chest
InspectionPalpationPercussion
AuscultationSlide16
The chest: Inspection
1. Shape and symmetry of chest
shape
Barrel- shaped chestPigeon chest
Funnel chest
Harrison’s sulcus
Kyphosis, scoliosis, kyphoscoliosis
Lesions of chest wall
Movement of chest wallSlide17
The chest: Inspection
Barrel- shaped chestIncreased AP diameterSevere asthma/COPDNormal elderly peopleSlide18
The chest: Inspection
Pigeon chest(pectus carinatum)Outward bowing sternum/costal cartilagesChronic childhood resp infectonsRickets
Funnel chest(pectus excavatum)Developmental defect
Depression lower end of sternumSevere: decreased lung capacitySlide19
The chest: Inspection
Harrison’s sulcusLinear depression lower ribs just above costal marginsSevere asthma in childhoodRicketsSlide20
The chest: Inspection
Kyphosis, scoliosis, kyphoscoliosisSevere: reduced lung capacitySlide21
The chest: Inspection
Lesions of chest wallScarsPrevious surgeryPrevious ICDRadiotherapy
ErythemaSubcutaneous emphysemaProminent veins
SVC obstructionSlide22
The chest: Inspection
Movement of chest wallExpansionUpper lobesFrom behind
Look down at clavicles
Lower lobesFrom behind
UnilateralLocalized fibrosis, consolidation, collapse, pleural effusion
BilateralCOPD, diffuse pulmonary fibrosisSlide23
The chest: Inspection
Movement of chest wallAsymmetryParadoxical inward movement abdomen during inspirationDiaphragm paralysisSlide24
The chest: Palpation
1. Chest expansionThumbs move symmetrical 5cm on inspirationLower lobeFrom back
Upper lobeFrom frontSlide25
The chest: Palpation
2. Apex beatDisplacement Towards side of lesionCollapse lower lobe
Localized fibrosisAway from lesion
Pleural effusionTension pneumothorax
ImpalpableCOPD: hyperinflationSlide26
The chest: Palpation
3. Vocal fremitusPalm of hand“99”DifferencesIncreased: Consolidation
Same as vocal resonance
4.
RibsLocalized pain
Trauma, metastases, prolonged coughingSlide27
The chest: PercussionSlide28
The chest: Percussion
1. SymmetricalAnt/Post/LatSupraclavicular fossa over lung apexClavicle with fingerSlide29
The chest: PercussionSlide30
The chest: Percussion
2. InterpretationResonantNormal
DullSolid structure (liver) Consolidation
Stony dull
Fluid- filled area (pleural effusion)
HyperresonantOver hollow structures
Bowel, pneumothoraxSlide31
The chest: Percussion
3. Liver dullnessUpper level5
th / 6th rib MCL
If lower: hyperinflation
4.
Cardiac
dullness
Decreased
COPD
AsthmaSlide32
The chest: Auscultation
1. Breath sounds2. Vocal resonanceSlide33
The chest: Auscultation
1. Breath soundsGeneralQuality of breath sounds
Intensity of breath sounds
Added soundsSlide34
The chest: Auscultation(Breath sounds)
GeneralDiaphragm of stethoscopeCompare sidesAxilla
Bell of stethoscope above claviclesLung apicesSlide35
The chest: Auscultation(Breath sounds)
Quality of breath sounds p125Normal breath sounds (vesicular)Bronchial breath sounds
Amphoric breath soundsSlide36
The chest: Auscultation(Breath sounds)
Normal breath sounds (vesicular)Most of chestBreath through mouthInspiration
Longer and louder than expirationNo gap between inspiration and expirationSlide37
The chest: Auscultation(Breath sounds)
Bronchial breathingHollow, blowing soundAudible in expirationGap between inspiration and expiration
ExpirationHigher intensity than inspiratory
Normal posteriorly over upper chest
CONSOLIDATIONSlide38
The chest: Auscultation(Breath sounds)
Amphoric breathingExaggerated bronchial qualityVery hollow (blowing over bottle)LARGE CAVITYSlide39
The chest: Auscultation(Breath sounds)
Intensity of breath soundsNormal or reducedReduced
COPDPleural effusion
PneumothoraxPneumoniaLarge neoplasm
Pulmonary collapseSlide40
The chest: Auscultation(Breath sounds)
Added soundsContinuous sounds (wheezes)Interrupted sounds (crackles)Slide41
The chest: Auscultation(Breath sounds)
Continuous sounds (wheezes)MusicalInspiration +/- expirationAirway narrowingHigh pitched
Smaller bronchiAsthma
Low pitchedLarger bronchi
COPDMonophonic
Localized Bronhial obstruction (Lung CA)
Stridor
Louder over trachea
InspiratorySlide42
The chest: Auscultation(Breath sounds)
Interrupted sounds (crackles)Non-musicalEarly inspiratory
Small airway diseaseCOPDMedium coarseness
Late/pan-inspiratory
Disease in alveoli
FinePulmonary fibrosis
Medium
LV failure
Coarse
Bronchiectasis
Retention of secretionsSlide43
The chest: Auscultation(Breath sounds)
Pleural friction rubThickened pleural surfaces rub togetherGrating soundCauses
PleurisySecondary to pulmonary infarction
PneumoniaMalignant involvement of pleura
Spontaneous pneumothorax
Slide44
The chest: Auscultation
2. Vocal resonanceAuscultation while patient speaksAbility of lung to transmit soundsNormal
ConsolidationCan hear “99”
AegophonyBee becomes bay
Whispering pectoriloquyCan hear when whispersSlide45
The chest: SignsSlide46
The chest: SignsSlide47
The chest: SignsSlide48
The chest: SignsSlide49
The chest: Signs
HyperinflationIncreased AP diameterTrageal tugApex not palpable
Hyperressonant percussionLiver displaced downwards
No cardiac dullnessSoft heart soundsSlide50
The Heart
Measure JVPIncreased in RV failure
Listen to P2Loud in pulmonary hypertensionSlide51
The Abdomen
Liver examinationDisplaced downward in hyperinflationEnlarged in metastases (Lung CA)Slide52
Other
Pemberton’s signLift arms over head one minuteSVC obstructionFacial plethoraCyanosis
Inspiratory stridorNon-pulsatile elevation of JVPSlide53
Other
FeetOedemaCor pulmonaleDVTPESlide54