Respiratory physical examination

Respiratory physical examinationCreated OnMay 27, 2020Last Updated OnMay 27, 2020byadmin You are here: Main Clinical Examination Respiratory physical examination < All Topics Table of Contents General Examination: Introduction: Wash your hand***** Introduce yourself, confirm the patient’s name, age, gender Explain the examination and gain consent Ask for any localized pain Exposure and position (top off, lie flat/supine at 45degree) Eg. Good morning, my name is Dr X. Can I just check your name and date of birth please? Nice to meet you Mr A, I’m going to do a simple respiratory examination. This involves looking from the end of the bed, feeling different parts of the chest, and then listening with the stethoscope at the end. Would that be okay? Do you have any pain anywhere? Do you have any questions about this examination? If no, we will start now. General observation: At the end of the bed General appearance (well/unwell/distress/in pain/dyspneic/unconscious) Speak in sentences/phrases/words Audible wheeze/stridor Accessory muscle use, pursed lips Nutritional status/cachexic Supplemental oxygen via ___ at ____ L/min Look inside sputum pot if available (colour, purulence,blood) Nebulized medication? On drip/catheter..etc ** Refer to common sign and symptoms ** Vital signs: Temperature of __ (febrile/afebrile) Pulse rate of __ (rate,rhythm,volume) Respiratory rate of __ Blood pressure __ (normotensive?) SpO2 __ % Eyes: Conjunctival pallor (SOB secondary to anemia) Ptosis,miosis (Horner syndrome secondary to Pancoast tumor) Horner’s syndrome triad: ptosis, miosis, anhidrosis Eyelid eczema Face: Cushingnoid (moon face, plethora, acne, hirsutism) *long term steroid ** ask for patient’s IC to compare any major change** Pink puffer ( emphysema ) Blue bloater ( chronic bronchitis ) Facial Eczema Neck: JVP ( cor pulmonale, SVC obstruction ) Lymph nodes Examination of lymph nodes of neck Examination sequence: Submental – submandibular – pre auricle – post auricle – jugular digastric chain – occipital Ask for any pain in the neck Look for enlargement. Palpate, note the size, consistency and fixity of any palpable nodes. Hogkin lymphoma (rubbery, painless) GIT ca (troisier sign/Virchow node: enlargement at left supraclavicular node) Neck flexural eczema Mouth: Central cyanosis (lips, underside of tongue) Ask patient to open his mouth then push the tongue against the roof to observe underside of the tongue. Angular stomatitis (iron defy) Oral candidiasis (steroid,immunocompromised) Hand: Look for BCG scar ***** Temperature (cold & sweaty – anxiety, warm & sweaty – resp failure) Peripheral cyanosis (PVD, Raynaud’s, CCF) Tar staining First web space wasting (Pancoast tumor) Wrist: Tremor Flapping tremor/asterixis (resp failure- CO2 retention, hepatic/renal failure. Examination Ask patient to hold out his arm with hands extended at the wrist. Look for jerky and flapping tremor. Then ask patient to squeeze your index fingers maintain this for 30-60 sec. patient with flapping tremor cannot maintain grip. Fine tremor (excessive use salbutamol) Pulse Tachycardia (if unwell, distress, excess beta agonist) Bounding (hypercapnia) Wrist flexural eczema Nails: Finger clubbing (refer to common signs) Koilonychia/spoon nails (iron defy anemia) Systemic examination Inspection: Deformity of chest, accessory muscles breathing? Both sides move symmetrically? Trachea centrally placed? **Refer to common signs**   Scars **Check carefully side and back, measure the scar and describe the extension of scar, healing of scar. Thoracotomy scars (lobectomy, pneumonectomy) Left thoracotomy Lt BT shunt PDA ligation Coarctation repair Right thoracotomy Rt BT shunt Mitral valve repair ASD repair **kindly ask patient to lift his left arm to inspect for any obvious scar. Then repeat the right side. Chest tube scar Usually mid-axillary pleural effusion Infraclavicular scar (pacemaker) Sternotomy scar (midline scar) Most cardiac surgery or bypass CABG A-P diameter **Refer to common signs for more details How to measure? Ask patient to lie on a flat surface/flat board (situation where patient is lying on the bed) Put another board on the anterior chest wall Measure the distance between the board Repeat the same procedure on the lateral chest wall to obtain transverse diameter. Normal AP to transverse is 1:2 Superficial veins (SVC, malignancy) Gynaecomastia Benign enlargement of the male breast. It should be differentiated from lipomastia which is characterized by fat deposition without glandular proliferation Examination: Differentiation gynaecomastia from pseudogynaecomastia The patient lies flat on his back with his hand clasped beneath his head Using thumb and fore finger, examiner run slowly brings finger together from either side of the breast. True gynaecomastia, a rubbery firm mound of tissue that is concentric with nipple-areolar complex is felt. Pseudogynaecomastia, no such tissue detected Palpation: Trachea position Examination of trachea position Locate the patient’s trachea palpate with index between sternocleidomastoid muscles at suprasternal notch Compare the tracheal position to an imaginary vertical line through the suprasternal notch Any deviation from the midline is consider abnormal. Common causes of tracheal deviation Toward the side of lung lesion Upper lobe or lung collapse Upper lobe fibrosis Pneumonectomy Away from the side of the lung lesion Tension pneumothorax Massive pleural effusion Upper mediastinal mass Retrosternal goitre Lymphoma Lung cancer Chest expansion Normal>5cm Emphysema<1cm Location of assessment ** Above nipple Below nipple Lower back Examination sequence Stand behind the patient and assess expansion of the upper lobes by watching the clavicles during tidal breathing. Assess expansion of the lower lobes by placing your hands firmly on the chest wall. Extend your fingers around the sides of the patient’s chest Your thumbs should almost meet in the midline and hover just off the chest so they can move freely with respiration. Ask the patient to take a deep breath. Your thumbs should move symmetrically apart by at least 5 cm. Abnormalities Unilateral (reduce expansion indicates abnormality on that side) pleural effusion lung or lobar collapse pneumothorax unilateral fibrosis Bilateral severe COPD diffuse pulmonary fibrosis. Apex beat is the most lateral and inferior position where the cardiac impulse can be felt. Normal: 5th left intercostal space at, or medial to, the mid-clavicular line Examination of apex beat Place your right hand flat over the precordium to obtain a general impression of the cardiac impulse Locate the apex beat by lying your fingers on the chest parallel to the rib spaces. if you cannot feel it, ask the patient to roll on to his left side Assess the character of the apex beat and note its position Description Character Underlying problem Tapping Sudden but brief pulsation Mitral stenosis Thrusting Vigorous, non-sustained Mitral/Aortic regurgitation Heaving Vigorous and sustained Aortic stenosis Systemic hypertension LVH Non palpable Overweight Muscular asthma or emphysema Displaced inferiorly and laterally: left ventricular dilatation, e.g. after myocardial infarction, with aortic stenosis, severe hypertension and dilated cardiomyopathy or in chest deformity. Tactile fremitus palpable fremitus through patent bronchi and lung parenchyma to the chest wall where they can be felt as vibration. Increases Lung fibrosis Lung consolidation (pneumonia) Tumor Decreases (TF decreases when transmission of vibration from larynx to chest wall impeded.) Obstructed bronchus COPD Separation of the lungs from chest well Air: pneumothorax Fluid: pleural effusion, hemothorax Pleural thickening Tactile fremitus Place either palmar base of ulnar edge of one hand on the person’s back Ask patient to repeat “99” Start from lung apexes (2cm above the medial 3rd of clavicle) Then 2nd, 4th, 6thC.S, mid-clavicular line Symmetry is important **picture above as reference** Percussion: Examination sequence Place the palm of your left hand on the chest, with your fingers slightly separated Press the middle finger of your left hand firmly against the chest, aligned with the underlying ribs over the area to be percussed. Strike the centre of the middle phalanx of your left middle finger with the tip of your right middle finger, using a loose swinging movement of the wrist and not the forearm. Remove the percussing finger quickly so the note generated is not dampened. Percuss the lung apices by placing the palmar surface of your left middle finger across the anterior border of the trapezius muscle, overlapping the supraclavicular fossa and percussing downwards. Then 2nd, 4th, 6thC.S, mid-clavicular line 2nd, 4th, 6thC.S, mid-axillary line Ask the patient to fold the arms across the front of the chest, moving the scapulae laterally and percuss the upper posterior chest. Do not percuss near the midline, as solid structures of the thoracic spine and paravertebral musculature produce a dull note. Map out abnormal areas by percussing from resonant to dull.  Percuss each side alternately and compare the note. Normal: Normal lung produces a resonant note Abnormal findings Type Disease Resonant Normal lung Hyperresonant Pneumothorax Dull Pulmonary consolidation Pulmonary collapse Severe pulmonary fibrosis Stony dull Pleural effusion Hemothorax Eg.On percussion, there was stony dullness heard over the right lower region of the lungs. Auscultation: 1.Breath sound & added sound Breath sound Description Vesicular Normal findings over lung fields Quiet, low pitched, rustling No gap between inspiration phase and expiration phase Expiratory phase is shorter than inspiratory phase Breath sound Description Bronchial Abnormal findings if auscultate over lung fields Usually louder Similar to sound heard over trachea Gap between inspiration and expiration Expiration phase prolonged Indicates that part of lung is not expanding and collapsing normally. 2.Air entry Ask patient to take a deep breath, compare the intensity of sound of both lungs for symmetry. Mammary, axillary, suprascapular, interscapular, infrascapular. 3.Expiratory time Normal: shorter than inspiratory time Prolonged: asthma, COPD 4.Added sounds Crackles non-musical sounds and result from collapse of peripheral airways on expiration On inspiration, air rapidly enters these...

Continue reading

Please Login/Register to read full article.