Respiratory Examination
Respiratory Examination
Respiratory Examination
Try to be safe.
Wash
Use
Introduce yourself
Know you patient
Coat ID card
Shake hands
Tell patient what you intend to do and gain consent. Start to give a running commentary of what you are doing
Cultural issues
Position
Anterior exam: supine Posterior: sitting upright
Eye of an Eagle
On the patient
Drips Oxygen masks Nebulizer CPAP
General inspection
General inspection
From foot of the bed
Is it asymmetrical?
RESPIRATORY RATE
Assess when the patient is at rest and calm Try to not let the patient realize you are counting the respiration Check respiratory rate with your peripheral vision watching for each breath.
RESPIRATION
How to measure
observe rise and fall of chest
Patterns Of Respiration
Bradypnea: rate under 12: coma, medications, deep sleep Tachypnea: rate over 20: anxiety, heart or lung disease, pain Cheyne-Stokes: drugs, CNS damage Kussmaul: rapid, deep, labored: metabolic acidosis
Clubbing Peripheral cyanosis Nicotine stain on fingers Resting tremor Thin, paper like skin Muscle wasting Flapping tremor
Digital Clubbing
Pulmonary
Cardiovascular GI
Bronchiectasis Idiopathic lung fibrosis Chronic lung infection Cystic fibrosis Lung abscess Lung cancer
Cyanotic congenital heart disease Infective endocarditis Cirrhosis of liver Inflammatory bowel disease
Digital Clubbing
Cyanosis
A bluish or purplish tinge to the skin and mucous membranes Presence of 5 g/dL of deoxygenated hemoglobin in the capillaries Peripheral
Fingernails and tips
Central
Mouth
Anemia
Surface Anatomy
The lungs extend from 4cm above the first rib to the 6 th rib
Chest Inspection
Palpation
Superficial palpation
Placing the palms of the hands symmetrically on either side of the chest wall with the thumbs pointing towards the midline Ask the patient Could you please take a deep breath in? and feel whether the fingers move apart symmetrically The thumbs should separate by 5cm
Chest wall vibrations from speech (patient says "ninety-nine or ) Compare both sides
Decreased fremitus
Increased fremitus
In pneumonia (consolidation)
Tactile Fremitus
Tactile Fremitus
Percussion
Dont forget clavicles and apices Move across in a systematic fashion Note the resonance of percussion note Decreased to dull Normal Hyperresonant to tympanic Note the level of note change
Percussion
Percussion
Hyper-resonant
Dull
Normal
Tactile Fremitus
Auscultation
AUSCULTATION
Technique
Diaphragm Vs. Bell !!! Move from side to side
Breath Sounds
Vesicular
Heard over most of the lung (periphery) Sound of air moving in small airways and alveoli Continuous from inspiration to expiration Inspiration > Expiration Low pitched and soft
Breath Sounds
Bronchial
Higher pitched Expiration > Inspiration Gap between inspiration and expiration Heard normal over the trachea Abnormal elsewhere
Consolidation
AUSCULTATION FEATURES
AUSCULTATION FEATURES
Vocal resonance
Transmission of patient's voice The auditory equivalent of tactile fremitus
Whispered pectoriloquy
A whisper is clear to the stethoscope
Egophony
Patient says EEE and stethoscope hears AAA Similar to increased tactile fremitus
AUSCULTATION ABNORMALITIES
Crackles
Inspiratory sound Water in the alveoli (heart failure) Pus in the alveoli (pneumonia) Scarring (pulmonary fibrosis)
AUSCULTATION ABNORMALITIES
Wheezes
High pitched Continuous whistles Usually in expiration Sign of asthma or COPD
AUSCULTATION ABNORMALITIES
Rhonchi
Low pitched, snore-like Heard in inspiration and expiration Originate in larger airways Secretions in the airways
Friction rub
Dry, leathery sound Heard in inspiration and expiration It is a sign of inflammation of the pleura
Reading list
http://www.conntutorials.com/video.html