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Tiphaine Gilbert DCR TUTORIAL 7 - RESPIRATORY EXAM HISTORY – What in the history points to the need for a Respiratory 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 Causes Blue Cyanosis, Wilson’s disease, ochronosis. Red Polycythaemia, carbon monoxide poisoning. Pink carbon dioxide retention Yellow Yellow nails syndrome Clubbing Lung cancer, chronic pulmonary suppuration, infective endocarditis, cyanotic heart disease, congenital, HIV, chronic IBD. Splinter Haemorrhages Infective endocarditis, vasculitis Spoon shape nail Iron deficiency, fungal infection, Raynaud’s disease Pale nail bed Anaemia Onycholysis Thyrotoxicosis, psoriasis White band Fever, cachexia, malnutrition, trauma, acute illness, hypoalbuminaemia, chemotherapy, renal failure, arsenic poisoning. Nail fold erythema and telangiecyasia SLE Half and half (white/pink) Chronic renal failure, cirrhosis

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Page 1: Respiratory Exam

Tiphaine Gilbert

DCR TUTORIAL 7 - RESPIRATORY EXAM

HISTORY – What in the history points to the need for a Respiratory 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 CausesBlue Cyanosis, Wilson’s disease, ochronosis.Red Polycythaemia, carbon monoxide poisoning.Pink carbon dioxide retentionYellow Yellow nails syndromeClubbing Lung cancer, chronic pulmonary suppuration,

infective endocarditis, cyanotic heart disease, congenital, HIV, chronic IBD.

Splinter Haemorrhages Infective endocarditis, vasculitisSpoon shape nail Iron deficiency, fungal infection, Raynaud’s

diseasePale nail bed AnaemiaOnycholysis Thyrotoxicosis, psoriasisWhite band Fever, cachexia, malnutrition, trauma, acute

illness, hypoalbuminaemia, chemotherapy, renal failure, arsenic poisoning.

Nail fold erythema and telangiecyasia SLEHalf and half (white/pink) Chronic renal failure, cirrhosis

Face CausesBluish color (can be pale or grey) due to lack of oxygen=cynosisFlaring nose Difficulty getting air inSweaty but cold face.

Mouth Causes“pursed lips” breathing COPD, Pulmonary larval migrans,

Bronchiolitis, Pneumonia, Alveolitis , Laryngomalacia, Broncholithiasis.

Bluish color around and inside Cynosis

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Tiphaine Gilbert

Trunk causesKyphosisScoliosisProtruding and indented sternum Marfan syndromeOutward projection of sternum Pigeon chest

EyesPalor anaemiaRed, inflammation Conjunctivitis

Limbs CausesNon-pitting Edema lymphedema, lipoedema and myxedema.Pitting edema 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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Tiphaine Gilbert

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:

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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 Description causesWheeze Continous sounds of hign

frequency on inspiration and expiration.Whistling, sibilant, musical

asthma

Stridor Continous sounds of hign frequency on inspiration mostly.Whistling, sibilant, musical

Epiglottis, foreign body

Rhonchi Continuous sound of low frequency, more pronounced in expiration.Snoring

Bronchitis

Inspiratory gasp Continous sounds of hign frequency on inspiration.Whoop

Whooping cough

Rales, crackles or crepitations

Discontinuous sounds or high or low frequency on inspiration

Pneumonia, congestive heart failure

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Tiphaine Gilbert

Crackling, clicking, rattlingHamman’s sign (Mediastinal crunch)

Discontinuous heartbeat sounds.Crunching, rasping

Pneumomediastinum, pneumopericardium.

Listen to that:

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).

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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 CONDITIONSCan 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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Tiphaine Gilbert

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.

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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 edemaLook for edema (pitting and non-pitting) on lower leg

Trachea: collapse lungtumor

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Tiphaine Gilbert