Respiratoryٍ System Examination Med 434 Content: ➔ Starting of examination ➔ Important Signs ➔ Hands, Face, and Neck examination ➔ Chest and Back examination ➔ Examination end ➔ Summary of important abnormalities ➔ OSCE Notes Feel free to contact us on: Our resources are: Nicholas Talley & Team 432 [email protected] Start the examination with: WIP³E ● Wash hands: Wash your hands in front of the examiner or bring a sanitizer with you! ● Introduce yourself ● Permission: Explain what are you going to do and take his permission. ● Position: Sitting at 90° ● Privacy: ensure patient’s privacy. ● Exposure: the patient should be exposed from the waist up. General appearance: ABC²DE Observe the patient from the end of the bed ● Appearance: Patient is (young, middle aged or old) and looks well. ● Body built: He looks (normal, thin or obese) ● Connections: Around the bed I can't see any medications, O2 mask, or chest tube(seen at the lateral sides of chest wall), metered dose inhalers, and the presence of a sputum mug. ● Color: Check if he looks pale, jaundiced, cyanosed. ● Distress: The patient looks comfortable and he doesn't appear short of breath and he doesn't obviously use accessory muscles or any heard wheezes. ● ELSE: Check if he is conscious Important Signs ● Dyspnea: Assess the rate, depth, and regularity of the patient's breathing. Count the respiratory rate. Range(16–25 breaths per minute). ● Signs of COPD: Using the accessory muscles of respiration, or if there’s pursed-lips breathing (close their lips during expiration > to generate positive back pressure > prevent the airway collapse). Patients with severe COPD may feel more comfortable leaning forwards with their arms on their knees (because this position compresses the abdomen > pushes the diaphragm upwards > improve breathing). They may also have in-drawing of the intercostal and supraclavicular spaces during inspiration. ● Character of the cough: ”Coughing is a protective response to irritation” ★ A muffled, wheezy, ineffective cough caused by OPD (obstructive pulmonary disease). ★ A very loose productive cough caused by excessive bronchial secretions due to chronic bronchitis, pneumonia or bronchiectasis. Simply it could be caused by post-nasal drip as in cold ★ A dry, irritating cough may occur with chest infection, asthma or carcinoma of the bronchus and sometimes with left ventricular failure or interstitial lung disease (ILD). It is also typical of the cough produced by ACE inhibitor drugs. Also, it could be caused by air pollutants ★ A barking or croupy cough may suggest a problem with the upper airway—the pharynx and larynx, or pertussis infection. ● Sputum: Comment on colour, volume and type (purulent, mucoid or mucopurulent), foul smell(abscess - bronchiectasis), diurnal variation (increased in morning : bronchiectasis) and the presence or absence of blood. ● Stridor: A rasping or croaking noise loudest on inspiration, due to an obstruction of the larynx or trachea foreign body, a tumor, infection, or inflammation. ● Hoarseness- Audible breathing ● Cyanosis: Central cyanosis by inspecting the tongue & mucous membranes. “The absence of obvious cyanosis does not exclude hypoxia” BREATH SOUNDS- STRIDOR , Respiratory Examination , wheezy cough , Other types of cough Hands ● Palm: Muscle wasting(1) , palmar erythema marginatum, r Symmetrical warm, palm sweating, and flapping tremor(Ask the patient to dorsiflex the wrists with the arms outstretched and to spread out the fingers. A flapping tremor with a 2- to 3-second cycle may occur with severe CO2 retention in severe COPD, renal and liver failure) ● Nailes : look for :clubbing (lung CA, fibrosis, bronchiectasis) . Note that clubbing does not occur as a result of COPD, cyanosis, nicotine staining(2), splinter hemorrhages, ● Puls: Take the patient’s radial pulse and determine the Rate, Rhythm, Volume and the Character of the pulse.Tachycardia and pulsus paradoxus are important signs of severe asthma. ● Capillary Refill Normal capillary refill time is usually less than 2 seconds. Face Eyes: pallor, Horner’s syndrome(ptosis, miosis, anhidrosis) can be due to an apical lung carcinoma compressing the sympathetic nerves in the neck. Nose: Nasal septum deviation, nasal polyps or discharge. Mouth: Central cyanosis, congested tonsils and pharynx, oral hygiene, a broken tooth (may predispose to lung abscess) Neck ● Trachea: deviates to the same side in case of lung Fibrosis, Pneumonectomy, and collapse, deviates to the other side in case of pneumothorax and pleural effusion. Slight displacement of trachea to the right is common in normal people. ● Lower limb: Inspect the patient’s legs for swelling or cyanosis. (caused by cor pulmonale), and look for evidence of deep venous thrombosis. ● Sacral edema ● Jugular venous pressure: (assess the pulse bilaterally). ● Regional lymph nodes : The axillary and cervical and supraclavicular nodes must be examined; they may be enlarged in lung malignancies and some infections. 1Caused by Compression and infiltration of a lower trunk of the T1 nerve root results in wasting of the small muscles of the hand and weakness of finger . abduction .2The density of staining does not indicate the number of cigarettes smoked, but depends rather on the way the cigarette is held in the hand Chest Inspection: ● Shape of chest and spine : ○ Barrel-shaped : severe asthma or emphysema. ○ Severe kyphoscoliosis :may be idiopathic, secondary to poliomyelitis or associated with Marfan’s syndrome. ○ A pigeon chest (pectus carinatum): seen in rickets or as a manifestation of chronic childhood respiratory illness . ○ A funnel chest (pectus excavatum)due to a pneumothorax or emphysema ○ Harrison’s sulcus : (a horizontal groove along the lower border of the thorax corresponding to the costal insertion of the diaphragm) seen in severe asthma in childhood, or rickets. ● Movement of the chest wall : ★ Look for asymmetry of chest wall movement anteriorly and posteriorly best achieved by inspection from behind the patient ○ Bilateral reduction of chest wall movement : indicates a diffuse abnormality (COPD or interstitial lung disease. ○ Unilateral reduction: due to localised lung fibrosis, consolidation, collapse, pleural effusion or pneumothorax. may be present when patients have pleuritic chest pain or injuries such as rib fractures ○ paradoxical inward motion of the abdomen during inspiration when the patient is supine >indicating diaphragmatic paralysis. ● Scars : ○ From previous thoracic operations (pneumonectomy or lobectomy) ○ Radiotherapy : may cause erythema and thickening of the skin over the irradiated area. ● Prominent veins : may be seen in patients with superior vena caval obstruction. ★ It is important to determine the direction of blood flow PALPATION: ”Ask the patient if he has any pain before starting” ● Chest expansion:As the patient takes a big breath in, your thumbs should move symmetrically apart at least 5 centimetres, Reduced expansion on one side indicates a lesion on that side.Cervical lymph nodes : may be enlarged in lung malignancies and infections. ● Chest Expansion : ○ If COPD is suspected, Hoover’s sign may be sought ● Apex beat : ○ Movement of the apex beat away from the side of the lung lesion can be caused by pleural effusion or tension pneumothorax. ○ often impalpable in a chest that is hyperexpanded secondary to COPD. ● Vocal (tactile) fremitus : Palpate the front and back of the chest with the palm of the hand while the patient repeats ‘ninety-nine’ in two comparable positions ○ It is only abnormal if different on one side from the other. ● Ribs : ● Localised pain suggests a rib fracture,bone disease or because of severe and prolonged coughing. ● Tenderness over the costochondral junctions suggests the diagnosis of costochondritis as the cause of chest pain. Chest Percussion: Percuss the chest: Normally it is resonant and Symmetrical in both sides. Remember: ★ Percussion of symmetrical areas of the anterior, posterior and axillary regions is necessary. ★ Percussion in the supraclavicular fossa over the apex of the lung. ★ Direct percussion of the clavicle. ★ For percussion posteriorly, the scapulae should be moved out of the way. By asking the patient to move the elbows forwards across the front of the chest; this rotates the scapula anteriorly. ★ Percussion sounds affected by the thickness of the chest wall, as well as by underlying structures. ● Percussion over a fluid-filled area, such as a pleural effusion, produces an extremely dull (stony dull) ● Liver dullness The upper level is determined by percussing down the anterior chest in the midclavicular line. Normally, the upper level of liver dullness is the sixth intercostal space in the right midclavicular line. If the chest is resonant below this level, it is a sign of hyperinflation, usually due to emphysema or asthma. ● Cardiac dullness The area of cardiac dullness usually present on the left side of the chest may be decreased in emphysema or asthma. Auscultation: Breath sounds ★ Normal breath sounds are heard with the stethoscope over nearly all parts of the chest. ★ Remember to listen high up into the axillae. ★ Use the bell of the stethoscope and apply it above the clavicles. ★ Listen for the quality , intensity of the breath sounds, and the presence of additional (adventitious) sounds. ★ Always compare both sides. 1. Ask the patient to take deep breaths through the mouth. 2. Follow the same areas of percussion: 3. Normally it is vesicular breathing, which is symmetrical in both sides, with no added sounds, crackles