3rd years early bird Clinical Teaching Fellows Dr G. Aidoo-Micah
Learning outcomes
• Describe an initial approach to all patients • Identify the relevant components in a respiratory examination • Know how to demonstrate a fluent and professional respiratory examination • Recognise abnormal signs, in the hands, face neck and chest. Respiratory Examination
• Things to think about before you start
• SOB/distress… • Exposure/dignity…
Things to do before you start…
1) Wash hands 2) Introduce yourself and ask patient’s name 3) Permission/Pain - explain exam and gain consent 4) Expose patient 5) Re-position to 45⁰
“WIPER” Inspection – “end-of-the-bedogram”
• 1. Patient: - What can you see/hear/smell? - General appearance - Chest deformities and operative scars. - Respiratory rate, regularity and depth. - Asymmetry of chest expansion. - Use of accessory muscles and positioning.
• 2. Around bed: - Oxygen, drugs chart, inhalers, nebs, peak flow meters, IV lines, chest drains (and contents), sputum pots (mmm).
Systematic 3. HANDS
• Inspect for: - Colour - ?peripheral cyanosis - Tremor - Tar staining - Clubbing - Asterixis - Thenar wasting
• Feel for: - Capillary refill - ?how many seconds - Radial pulse – rate, rhythm, character (sneakily check RR) - Temperature - Ask for BP
Take the hands of the person next to you…
Respiratory causes of clubbing 4. Face/neck a) Face: b) Eyes: -Plethora -Partial ptosis -Moon face -Miosis -Anhidrosis -Conjunctival pallor
c) Mouth: d) Neck: -Central cyanosis – underside of -JVP tongue -Trachea -Pursed lip breathing -LN’s -Tar staining of teeth -Tracheostomy scar
5. Chest – anterior then posterior (IPPA)
• Inspection (for any system) – DWARFS • Deformity, Wasting, Asymmetry, Redness,
Fasciculations, Scars. • Palpation - Apex beat - Chest expansion - Tactile vocal fremitus
Chest percussion
• Percussion - Start at apex of one lung, compare each side. Clavicles. - Resonant = normal - Dull = consolidation, collapse, pleural thickening - Stony dull = pleural effusion - Hyper-resonant = pneumothrax
• Tips Don’t forget over clavicles and axillae! Practise, practise, practise – on selves, doors, each other! Trim nails!!
• Auscultation • Ask patient to take slow, deep breaths through mouth.
• Breath sounds: - Normal = vesicular - Diminished = obesity, effusion, pneumothorax, COPD • Added sounds = crackles wheeze (expiratory, high pitched – e.g. asthma), stridor (airway obstruction).
• (Vocal resonance: “ninety-nine”) • DON’T FORGET TO EXAMINE THE BACK (IPPA)
6. Completion
• (Legs): If time - Inspect for erythema and swelling - Palpate for tenderness and pitting oedema a) Unilateral red, swollen, tender calf – think DVT b) Bilateral pitting oedema - ? R-sided heart failure
• To patient: - Thank, cover, comfort. Wash hands!!
• To examiner: To complete my examination I would like to… - Take a full history - Ask for O2 sats (obs chart), sputum sample, PEFR, CXR. - Relevant bloods and ABG - Summarise findings and differential diagnosis.
Watch the experts in action…
http://geekymedics.com/respiratory-examination-2/ Respiratory exam mark sheet
Task Adequate? Comments Y N Introduce self, task and exposure Consent Ask about pain Inspection End of the bed – makes obvious they look! Notes nebs, inhalers, oxygen, sputum pots Inspect Hands for … tar staining, clubbing, cyanosis, muscle wasting Check for tremor (salbutamol or CO2 retention) Check radial pulse – comment on rate rhythm and character Face – plethora, moon face Eyes – inspect for pallor, signs of Horners Mouth – inspect for central cyanosis under tongue Neck – raised JVP, use of SCM? Check trachea is central. LNs. Chest – use of accessory muscles, shape deformities, scars, drains, bandages Count RR Look for pursed lip breathing Palpation *Check trachea central if not done already. Apex beat if trachea is deviated Expansion – anterior and posterior Vocal fremitus (unless doing vocal resonance)- 1 will do! Percussion Anterior, posterior and axillae Auscultation Anterior, posterior and axillae Vocal resonance anterior, posterior and axillae
To conclude – ask for 02 sats/obs and CXR/PEFR if appropriate Thank the patient and cover them up Practise, practise, practise
• On patients • Colleagues • Unsuspecting friends and family • Teddy bears • Doors • Practice makes perfect! Any questions?
• Thank you! • Have a go… • Good luck!
Special thanks to Dr Emma Figures (CTF 2015)