Respiratory Examination PDF

Respiratory Examination Prepare patient • Introduction • Position semi-recumbent at 45º with whole chest exposed General Inspection General signs: • Cachexia, cyanosis, sputum pot contents, rate & depth of breathing, stridor/wheeze, use of accessory muscles. Ask to cough & note character (dry, bar...

Respiratory Examination Prepare patient • Introduction • Position semi-recumbent at 45º with whole chest exposed General Inspection General signs: • Cachexia, cyanosis, sputum pot contents, rate & depth of breathing, stridor/wheeze, use of accessory muscles. Ask to cough & note character (dry, barking, productive, bovine). Hands & Wrist Peripheral cyanosis Clubbing (many causes including): • • • Cyanotic congenital heart disease Infective endocarditis Atrial myxoma • • Lung Ca Chronic lung suppuration o Lung abscess or empyema o Bronchiectasis or CF Idiopathic pulmonary fibrosis Pleural mesothelioma Asbestosis • • • • • • • • • • IBD Cirrhosis Coeliac disease SB lymphoma Thyrotoxicosis (acropachy) Idiopathic/familial Rarely: o Pregnancy o 2º Hyperparathyroidism Tar staining of fingers Wrist tenderness (HPOA- Hypertrophic pulmonary osteoarthopathy) Wasting & weakness (test strength of spreading digits) of small muscles (?lung Ca affecting brachial plexus) Wrist flap (Extend both for 30s – ?CO2 narcosis) Radial Pulse • Rate & rhythm. ?Tachycardia ?Pulsus paradoxus Face Eyes: Horner’s – ipsilateral ptosis, small pupil, enophthalmos, ↓facial sweating (apical lung Ca) Sinuses: Tenderness Nose: Patency Mouth: Cyanosis Voice: Hoarseness (recurrent laryngeal nerve palsy) Neck Trachea - ?midline Posterior Chest Inspect • • • Scars – thoracotomy? Shape of chest o Barrel chest: ↑AP diameter compared to lateral diameter – asthma, COPD o Pectus carinatum (pigeon chest): localised outward bowing of sternum/costal cartilages – rickets, chronic childhood respiratory disease o Pecus excavatum (funnel chest): localised depression of distal sternal – development defect o Harrison’s sulcus: linear depression of lower ribs just above costal margin – asthma, rickets Spine deformity Palpate • • • Cervical LN Chest expansion o Upper lobes – watch clavicles from behind & above to see if R=L o Lower lobes – encircle chest & check ↑thumb separation (>5cm) on breathing Tactile vocal fremitus (“99”) Percuss • Back & axillae: stony dull for effusion, hyperresonant for hyperexpansion, PTX Auscultate • • • Breath sounds o Vesicular (normal over lung) o Bronchial (normal over trachea) Adventitious sounds o Stridor o Wheezes – exp>insp usually. Imply airway narrowing. Fixed wheeze - ?lung Ca o Crackles (high freq = crepitations, low freq = rales)
Early inspiratory crackles – COPD
Late/pan-inspiratory crackles • Fine – pulmonary fibrosis • Medium - LVF • Coarse - Bronchiectasis, retention of secretions Vocal resonance o Muffled over normal lung, aegophony or whispering pectoriloquy over consolidation Anterior chest Inspect • • • Radiotherapy marks Subcutaneous emphysema Upper chest expansion Percuss • • • • • Supraclavicular regions, clavicles, ant chest Liver upper edge (usually 5icsmcl) Auscultate As shown. Note a pleural rub (pleurisy, PE, pneumonia) or displaced apex beat Assess for Right Heart Failure Inspect JVP – if elevated then: • • • • Check for Pemberton’s sign for SVC obstruction (arms over head >1min → facial plethora) Auscultate the heart Palpate/Percuss the liver Examine the legs for oedema Other Temperature Recent chest x-ray PEFR/Spirometry