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Respiratory Examination

Respiratory Examination. Dr Scarpa Schoeman – Dept Internal Medicine. Slides of Dr JM Nel Department Critical Care. 1. Positioning of the patient 2. General Appearance 3. The hands 4. The face 5. The trachea. 6. The chest 7. The heart 8. The abdomen 9. Other.

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Respiratory Examination

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  1. Respiratory Examination Dr Scarpa Schoeman – Dept Internal Medicine Slides of Dr JM Nel Department Critical Care

  2. 1. Positioning of the patient 2. General Appearance 3. The hands 4. The face 5. The trachea 6. The chest 7. The heart 8. The abdomen 9. Other Respiratory Examination

  3. Positioning of the patient • Undress to waist • Sitting position • Acutely ill • Lying down

  4. General appearance • 1.Dyspnoea • Signs of dyspnoea at rest • RR: 16- 25/min • 2.Cyanosis • Central cyanosis: tongue • 3.Cough character

  5. General appearance • 4.Sputum • Colour/volume/type • Hemoptysis • 5.Stridor • Loudest on inspiration • 6.Hoarseness

  6. The hands • 1. Clubbing • P51-Table 4.9

  7. Clubbing Cardiovascular Congenital cyanotic heart disease Infective endocarditis Respiratory (80% the cause) Lung carcinoma Chronic pulmonary suppuration Idiopathic lung fibrosis Cystic fibrosis Asbestosis Pleural mesothelioma Gastrointestinal Cirrhosis Inflammatory bowel disease Coeliac disease COPD/TB does not give clubbing The hands

  8. The hands HPO • Periosteal inflammation • Clubbing marked • Distal end of long bones,wrists,metacarpal,metatarsal bones, knees, ankles • Swelling/Tenderness

  9. The hands • 2. Staining • Cigarette smoking • 3. Wasting and weakness • Wasting small muscles • Weakness abduction • Infiltration of brachial plexus by lung CA

  10. 4. Pulse rate Pulse rate Pulsusparadoxus Systolic BP drop > 10mmHg 5. Flapping tremor(Asterixis) Dorsiflex hands CO2 retention (COPD) The hands

  11. The face • 1. Horner’s syndrome • Constricted pupil • Partial ptosis • Loss of sweating • Apical lung tumour • Compression of sympathetic nerves

  12. The face • 2. Skin changes • Connective tissue diseases

  13. The face • 3. URTI • Look inside mouth • 4. Sinuses • Look inside mouth • 5. SVC obstruction • Facial plethora or cyanosis

  14. The trachea • Position • Tracheal tug • COPD

  15. The chest • Inspection • Palpation • Percussion • Auscultation

  16. 1. Shape and symmetry of chest shape Barrel- shaped chest Pigeon chest Funnel chest Harrison’s sulcus Kyphosis, scoliosis, kyphoscoliosis Lesions of chest wall Movement of chest wall The chest: Inspection

  17. The chest: Inspection • Barrel- shaped chest • Increased AP diameter • Severe asthma/COPD • Normal elderly people

  18. Pigeon chest(pectus carinatum) Outward bowing sternum/costal cartilages Chronic childhood resp infectons Rickets Funnel chest(pectus excavatum) Developmental defect Depression lower end of sternum Severe: decreased lung capacity The chest: Inspection

  19. The chest: Inspection • Harrison’s sulcus • Linear depression lower ribs just above costal margins • Severe asthma in childhood • Rickets

  20. The chest: Inspection • Kyphosis, scoliosis, kyphoscoliosis • Severe: reduced lung capacity

  21. The chest: Inspection • Lesions of chest wall • Scars • Previous surgery • Previous ICD • Radiotherapy • Erythema • Subcutaneous emphysema • Prominent veins • SVC obstruction

  22. The chest: Inspection • Movement of chest wall • Expansion • Upper lobes • From behind • Look down at clavicles • Lower lobes • From behind • Unilateral • Localized fibrosis, consolidation, collapse, pleural effusion • Bilateral • COPD, diffuse pulmonary fibrosis

  23. The chest: Inspection • Movement of chest wall • Asymmetry • Paradoxical inward movement abdomen during inspiration • Diaphragm paralysis

  24. The chest: Palpation • 1. Chest expansion • Thumbs move symmetrical 5cm on inspiration • Lower lobe • From back • Upper lobe • From front

  25. 2. Apex beat Displacement Towards side of lesion Collapse lower lobe Localized fibrosis Away from lesion Pleural effusion Tension pneumothorax Impalpable COPD: hyperinflation The chest: Palpation

  26. 3. Vocal fremitus Palm of hand “99” Differences Increased: Consolidation Same as vocal resonance 4. Ribs Localized pain Trauma, metastases, prolonged coughing The chest: Palpation

  27. The chest: Percussion

  28. The chest: Percussion • 1. Symmetrical • Ant/Post/Lat • Supraclavicular fossa over lung apex • Clavicle with finger

  29. The chest: Percussion

  30. 2. Interpretation Resonant Normal Dull Solid structure (liver) Consolidation Stony dull Fluid- filled area (pleural effusion) Hyperresonant Over hollow structures Bowel, pneumothorax The chest: Percussion

  31. 3. Liver dullness Upper level 5th / 6th rib MCL If lower: hyperinflation 4. Cardiac dullness Decreased COPD Asthma The chest: Percussion

  32. The chest: Auscultation • 1. Breath sounds • 2. Vocal resonance

  33. The chest: Auscultation • 1. Breath sounds • General • Quality of breath sounds • Intensity of breath sounds • Added sounds

  34. The chest: Auscultation(Breath sounds) • General • Diaphragm of stethoscope • Compare sides • Axilla • Bell of stethoscope above clavicles • Lung apices

  35. The chest: Auscultation(Breath sounds) • Quality of breath sounds p125 • Normal breath sounds (vesicular) • Bronchial breath sounds • Amphoric breath sounds

  36. The chest: Auscultation(Breath sounds) • Normal breath sounds (vesicular) • Most of chest • Breath through mouth • Inspiration • Longer and louder than expiration • No gap between inspiration and expiration

  37. The chest: Auscultation(Breath sounds) • Bronchial breathing • Hollow, blowing sound • Audible in expiration • Gap between inspiration and expiration • Expiration • Higher intensity than inspiratory • Normal posteriorly over upper chest • CONSOLIDATION

  38. The chest: Auscultation(Breath sounds) • Amphoric breathing • Exaggerated bronchial quality • Very hollow (blowing over bottle) • LARGE CAVITY

  39. The chest: Auscultation(Breath sounds) • Intensity of breath sounds • Normal or reduced • Reduced • COPD • Pleural effusion • Pneumothorax • Pneumonia • Large neoplasm • Pulmonary collapse

  40. The chest: Auscultation(Breath sounds) • Added sounds • Continuous sounds (wheezes) • Interrupted sounds (crackles)

  41. Continuous sounds (wheezes) Musical Inspiration +/- expiration Airway narrowing High pitched Smaller bronchi Asthma Low pitched Larger bronchi COPD Monophonic Localized Bronhial obstruction (Lung CA) Stridor Louder over trachea Inspiratory The chest: Auscultation(Breath sounds)

  42. Interrupted sounds (crackles) Non-musical Early inspiratory Small airway disease COPD Medium coarseness Late/pan-inspiratory Disease in alveoli Fine Pulmonary fibrosis Medium LV failure Coarse Bronchiectasis Retention of secretions The chest: Auscultation(Breath sounds)

  43. The chest: Auscultation(Breath sounds) • Pleural friction rub • Thickened pleural surfaces rub together • Grating sound • Causes • Pleurisy • Secondary to pulmonary infarction • Pneumonia • Malignant involvement of pleura • Spontaneous pneumothorax

  44. The chest: Auscultation • 2. Vocal resonance • Auscultation while patient speaks • Ability of lung to transmit sounds • Normal • Consolidation • Can hear “99” • Aegophony • Bee becomes bay • Whispering pectoriloquy • Can hear when whispers

  45. The chest: Signs

  46. The chest: Signs

  47. The chest: Signs

  48. The chest: Signs

  49. Hyperinflation Increased AP diameter Trageal tug Apex not palpable Hyperressonant percussion Liver displaced downwards No cardiac dullness Soft heart sounds The chest: Signs

  50. The Heart • Measure JVP • Increased in RV failure • Listen to P2 • Loud in pulmonary hypertension

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