Tiphaine Gilbert DCR TUTORIAL 7 - RESPIRATORY EXAM HISTORY What in the history points to the need for a Respiratory

y exam ? Frequent cough, Cough with sputum, Asthma, Smoker, Chest pain on breathing/Exx, Shortness of breath, Difficulty breathing, Hxx respiratory disorder. OBSERVATION Starts with your first sight/touch of the patient, how do they move breathe, stand, talk etc. Formal observation starts with the extremities and works inward. What are you looking for in hands, feet, limbs, face, eyes, mouth, trunk etc. Can you describe any abnormalities in chest shape? What is the difference between Wheeze and Stridor. Name some respiratory causes of nail clubbing. What lymph nodes might alert you to possible lung cancer? What might pursed lips breathing indicate. Nails Hand and Feet Blue Red Pink Yellow Clubbing Splinter Haemorrhages Spoon shape nail Pale nail bed Onycholysis White band Nail fold erythema and telangiecyasia Half and half (white/pink) Face Bluish color (can be pale or grey) Flaring nose Sweaty but cold face. Mouth pursed lips breathing Causes Cyanosis, Wilsons disease, ochronosis. Polycythaemia, carbon monoxide poisoning. carbon dioxide retention Yellow nails syndrome Lung cancer, chronic pulmonary suppuration, infective endocarditis, cyanotic heart disease, congenital, HIV, chronic IBD. Infective endocarditis, vasculitis Iron deficiency, fungal infection, Raynauds disease Anaemia Thyrotoxicosis, psoriasis Fever, cachexia, malnutrition, trauma, acute illness, hypoalbuminaemia, chemotherapy, renal failure, arsenic poisoning. SLE Chronic renal failure, cirrhosis Causes due to lack of oxygen=cynosis Difficulty getting air in

Causes COPD, Pulmonary larval migrans, Bronchiolitis, Pneumonia, Alveolitis , Laryngomalacia, Broncholithiasis. Cynosis

Bluish color around and inside

Tiphaine Gilbert Trunk Kyphosis Scoliosis Protruding and indented sternum Outward projection of sternum Eyes Palor Red, inflammation Limbs Non-pitting Edema Pitting edema causes

Marfan syndrome Pigeon chest

anaemia Conjunctivitis

Causes lymphedema, lipoedema and myxedema. Pregnancy, heart failure, varicose veins, thrombophlebitis, insect bites, and dermatitis. Also look at: Use of accessory mm, respiration rate, pulse, nicotine staining Lymph nodes: metastatic cancer, immune system response. CYANOSIS What is the difference between Peripheral and Central Cyanosis.

Central cyanosis

Due to a circulatory or ventilatory problem that leads to poor blood oxygenation in the lungs. It develops when arterial saturation of blood with oxygen is 85%. Cyanosis may not be detected until saturation is 75% in dark-skinned individuals. Acute cyanosis can be a result of asphyxiation or choking, and is one of the surest signs that respiration is being blocked.

Peripheral cyanosis

Blue tint in fingers or extremities, due to inadequate circulation. The blood reaching the extremities is not oxygen rich and when viewed through the skin a combination of factors can lead to the appearance of a blue color. All factors contributing to central cyanosis can also cause peripheral symptoms to appear, however peripheral cyanosis can be observed without there being heart or lung failures. Small blood vessels may be restricted and can be treated by increasing the normal oxygenation level of the blood.

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SURFACE ANATOMY - Can you show the upper and lower extents of the lungs and of the pleura? Can you locate the lobes of each lung and the position of the fissures which separate them.

PALPATION How do you palpate for Tracheal Deviation? What might it indicate? How would you assess the mechanical movement of the rib cage. Palpation:

Tiphaine Gilbert Indication of: Trachea is index of upper mediastinal position. The pleural pressures on either side determine the position of the mediastinum. The mediastinum will shift towards the side with relatively higher negative pressure compared to the opposite side. Tracheal deviation can occur under the following conditions: Deviated towards diseased side Atelectasis, Agenesis of lung, Pneumonectomy, Pleural fibrosis

Deviated away from diseased side

Pneumothorax, Pleural effusion, Large mass Mediastinal masse Tracheal masses Kyphoscoliosis

Mechanical movement of the rib cage: Observation: Rib cage movement on normal breathing and on forced respiration. Palpation: Level of expansion: Practitioner hands flats on side of sternum (upper ribs) and hands around low ribs. AUSCULTATION Do you know what the normal breath sounds are? What added sounds might you notice? What might these indicate? What might it mean if you could not hear any breath sounds in a particular area? What is Pleural Rub and what might it indicate? Sound Wheeze Description Continous sounds of hign frequency on inspiration and expiration. Whistling, sibilant, musical Continous sounds of hign frequency on inspiration mostly. Whistling, sibilant, musical Continuous sound of low frequency, more pronounced in expiration. Snoring Continous sounds of hign frequency on inspiration. Whoop Discontinuous sounds or high or low frequency on inspiration causes asthma

Stridor

Epiglottis, foreign body

Rhonchi

Bronchitis

Inspiratory gasp Rales, crackles or crepitations

Whooping cough Pneumonia, congestive heart failure

Tiphaine Gilbert Crackling, clicking, rattling Discontinuous heartbeat sounds. Crunching, rasping

Hammans sign (Mediastinal crunch) Listen to that:

Pneumomediastinum, pneumopericardium.

Wheeze, Stridor and Rales: http://en.wikipedia.org/wiki/Respiratory_sounds Woopingcough:http://www.whoopingcough.net/sound%20of%20whooping%20cough %20with%20much%20whooping.htm Pleural rub: Squeaking or grating sounds of the pleural linings rubbing together and can be described as the sound made by treading on fresh snow. They occur where the pleural layers are inflamed and have lost their lubrication. Pleural rubs are common in pneumonia, pulmonary embolism, and pleurisy (pleuritis). Because these sounds occur whenever the patient's chest wall moves, they appear on inspiration and expiration. PERCUSSION How might you use percussion to find information on the health of a lung? What might cause a) Hyper-resonance, b) Dullness. It is used to diagnose pneumothorax, emphysema and other diseases. It can be used to assess the respiratory mobility of the thorax. Based on the auditory and tactile perception, the notes heard can be categorized as: Tympanic or tympanitic, drum-like sounds heard over air filled structures during the abdominal examination. Hyper-resonance (pneumothorax) Normal resonance/ Resonant Impaired resonance (mass, consolidation) Dullness (consolidation) Stony dull (test) FREMITUS How does tactile vocal fremitus help you assess a lung? Can you relate this to whispering pectoriloquy. Fremitus is a palpable vibration on the body. Tactile Fremitus, known by many other names including pectoral fremitus, tactile vocal fremitus, or just vocal fremitus, is a vibration felt on the patient's chest during low frequency vocalization. Commonly, the patient is asked to repeat a phrase while the examiner feels for vibrations by placing a hand over the patient's chest or back. Tactile fremitus is normally more intense in the right second intercostal space, as well as in the interscapular region, as these areas are closest to the bronchial bifurcation. Tactile fremitus is pathologically increased over areas of consolidation and decreased or absent over areas of pleural effusion or pneumothorax (where there is liquid or air instead of usual lung).

Tiphaine Gilbert The reason for increased fremitus in a consolidated lung is the fact that the sound waves are transmitted with less decay in a solid or fluid medium (the consolidation) than in a gaseous medium (aerated lung). Conversely, the reason for decreased fremitus in a pleural effusion or pneumothorax (or any pathology separating the lung tissue itself from the body wall) is that this increased space diminishes or prevents entirely sound transmission.

Pleural fremitus is a palpable vibration of the wall of the thorax caused by friction between the parietal and visceral pleura of the lungs. Rhonchal fremitus is a palpable vibration produced during breathing caused by partial airway obstruction. The obstruction can be due to mucus or other secretions in the airway, bronchial hyperreactivity, or tumors. Subjective fremitus is a vibration felt by the patient on humming with the mouth closed. Tussive fremitus is a vibration felt on the chest when the patient coughs. Whispered pectoriloquy refers to an increased loudness of whispering noted on the lung fields on a patient's back. Usually sounds of this volume would not be heard when whispered. It is a test performed for the presence of lung consolidation, which could be caused by cancer or pneumonia. INTERACTION BETWEEN RESPIRATORY AND CVS CONDITIONS Can you describe how heart problems can affect the lungs and vice-versa. Can you name a condition where such an effect has occurred?How might a vascular problem cause a serious respiratory problem?

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Respiratory examination routine: http://www.youtube.com/watch?v=a-4BUharWMA .Explain procedure to patient .Plinth at 45 degree .General observation: Discomfort, perfusion, breathing (acc mm), scars, abnormalities Hands: Perfusion (evaluating skin color, temperature, condition and capillary refill), nicotine stain, clubbing and other abnormal signs (see table). Pulse: normal 60-100/mins (higher in children and lower in elderly) Arm straight in from of patient with palm at 90* for CO2 retention. Face, mouth (inside and outside) . Raised Jugular Vein Pressure (JVP): Patient lying with plinth at 45* and head rotated to one side

Tracheal deviation Level of expansion: Practitioner hands flats on side of sternum (upper ribs) and hands around low ribs.

Tiphaine Gilbert Percussion (front and back) Tactile fremitus (resonance) (front and back) Stethoscope: Listen to breathing sound on each lung and each lobes (front and back) Listen for dullness. Lymph nodes examination (lymphanopathy)

Look for sacral edema Look for edema (pitting and non-pitting) on lower leg Trachea: collapse lung tumor

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