objectives - elsevier

TAKING A HISTORY

In respiratory medicine your skills in history takingwill be tested by both:

• Acute presentations – diagnosis must be quickbut may be hindered by the patient’s condition

• Chronic presentations – documenting the keyfeatures in an illness that may span many years.

Each situation has its specific challenges and ineach a good history should tell you the diagnosis.

Initial observationsBefore you begin take a few minutes to introduceyourself and to put the patient at ease.

Simple observation at the bedside can often givea good clue to the likely diagnosis:

• Inhalers and oxygen bottles• Sputum pots• Walking sticks or frames.

How does the patient appear during the interview?Agitated, or distressed? Is there a visible tremor? Isthe patient too breathless to speak in full sentences?Is the voice rough or hoarse? Simple observationsnow will save time later.

Structure of the historyPresenting complaint (PC)The presenting complaint is a concise statement ofthe symptoms felt by the patient. Use the patient’sown words – this is not a diagnosis. For example, forshortness of breath the patient might use ‘out ofpuff’ or ‘can’t get any air in’.

187

Objectives

By the end of this chapter you should be able to:

• Describe why the social history is so important in respiratory medicine• Describe how features of a patient’s past medical history might be relevant• Explain why the initial observation of the patient is important• Describe the visible effects of long-term steroid use• List the causes of tachypnoea• List the different patterns of breathing and their significance• Describe the common causes of clubbing and how to look for clubbing• Describe the significance of unilateral muscle wasting of the hand• Describe the relevance of tracheal position in tension pneumothorax• Name the common scars seen on the thorax and the possible operations that the

patient may have undergone• List the surface markings of the lungs for percussion• Describe the relationship between added sounds and disease• Describe how lung disease alters examination findings.

History and examination 10

This section outlines a generic approach to history taking. In practice, you should tailor your history to the possible diagnoses. In a female patient with a suspected deep veinthrombosis (DVT) you will need to ask aboutpregnancy, oral contraceptive pill, recent travel orsurgery and family history of DVT or PE.Obviously, you will need a different set ofquestions to establish a diagnosis of asthma.

Ch10-M3419.qxd 5/16/07 2:31 PM 87

History and examination

History of presenting complaint (HPC)Build up a picture of the presenting complaint, in-vestigating each symptom as described in Chapter 9.You should establish the following details:

• Onset: acute or gradual• Pattern: intermittent or continuous• Frequency: daily, weekly or monthly• Duration: minutes or hours• Progression: better or worse than in the past• Severity: mild, moderate or severe• Character: e.g. is the pain sharp, dull or aching?• Precipitating and relieving factors: e.g. are any

medications used?• Associated symptoms: e.g. cough, wheeze,

haemoptysis, dyspnoea, chest pain, orthopnoea• Systemic symptoms: e.g. fever, malaise, anorexia,

weight loss.

Has the patient had the problem before? If so, whatwere the diagnosis, treatment and outcome?

Ask the patient how disabling the problem is andhow it affects daily life. In patients with chronicillness, you should establish their exercise toleranceand whether this has declined.

Past medical history (PMH)Present the PMH in chronological order, listing anyhospital admissions, surgical operations and majorillnesses.

Take a careful note of anything that might con-tribute to the presenting complaint; for example:

• Pneumonia – complications include pleuraleffusion, bronchiectasis

• ‘Wheezy bronchitis’ as a child – possibly asthma

• Severe measles or whooping cough inchildhood – may lead to bronchiectasis

• Previous pulmonary embolism (PE) or deepvein thrombosis (DVT)

• Pregnancy – risk of PE• Recent surgery – PE, hospital-acquired or

aspiration pneumonia• Eczema or hay fever – evidence of atopy.

Has the patient received BCG immunization orexperienced tuberculosis contact in the past? Has achest radiograph ever been taken: it may be usefulfor comparison.

Note any other factors that might have contributed,for example:

• Recent travel – DVT, legionella• Recent life events (e.g. moving house) – stress,

house dust.

Drug history (DH)When taking the drug history, list the patient’s cur-rent intake of both prescribed and over-the-counter(OTC) drugs, recording dosage, frequency and dura-tion of treatment. Ask the patient what each tablet isfor and when it is taken; this gives an indication ofpatients’ understanding of their problems andcompliance. Remember that some drugs (e.g. beta-blockers or NSAIDs) can make asthma worse. Theoral contraceptive pill is a risk factor for pulmonaryembolism. ACE inhibitors prescribed for hyperten-sion can cause cough.

Drug allergiesAsk about any allergies; if the patient mentions anallergy, ask what exactly happened, and how longago it happened.

Family history (FH)When noting a family history, it may be easier todraw a pedigree chart. Do any members of thefamily suffer from a respiratory disorder? A familyhistory of premature emphysema or liver cirrhosismay indicate α1-antitrypsin deficiency. Is there afamily history of pulmonary embolism or deep veinthrombosis. Ask about atopy, asthma, eczema andhay fever. Does anybody in the family smoke?

Social history (SH)Social history is hugely important in the respiratorysystem; many respiratory diseases can be caused, orworsened, by social factors such as housing, occu-pation, hobbies or pets.

Home and social situationAsk who lives with the patient at home and whetherthe person is fit and well. Do they have any addi-tional help around the home?

Ask about accommodation:

• Type: house, flat (which floor?) or bed-sit• Heating: coal fire, gas fire or central heating• Conditions: damp or dry• Number of people living in the accommodation• Area of town: gives an indication of

socioeconomic class• Pets: dogs, cats or birds.

188

Ch10-M3419.qxd 5/16/07 2:31 PM Page 188

EXAMINATION

OverviewAs with any examination, it is important that you:

• Introduce yourself if you have not already doneso

• Wash your hands before you begin and whenyou finish the examination

• Explain to the patient what you propose to doand ask if this is acceptable.

The structure of the examination is inspection,palpation, percussion and auscultation. For a respir-atory examination, patients should be fully exposedto the waist, comfortable, and sitting at 45°, withtheir hands by their sides.

In clinical examinations, purposefully walk to theend of the bed to observe the patient; this empha-sizes that you are observing the patient and alsogives you thinking time. Give a running com-mentary of what you are doing; this needs practiceas you will be nervous.

Ask about the patient’s financial situation: is thepatient entitled to any state benefits (e.g. socialsupport)? Enquire about diet and exercise.

Smoking and alcoholA detailed smoking history is essential. You shouldrecord:

• Age started• Age stopped (if applicable)• Whether cigarettes, cigars or pipe• Average smoked per day.

It may help to convert this information into ‘packyears’ (where 1 pack year is 20 cigarettes smokedeach day for a year).

Ask if the patient drinks alcohol. If yes, convertthe weekly intake into units if possible. One glass ofwine or one-half pint of beer is equivalent to 1 unit.Remember that some forms of pneumonia (Staphy-lococcus aureus and Klebsiella) occur in alcoholics.

OccupationPresent the patient’s jobs in chronological orderstarting from the time the patient left school. Somerespiratory conditions have a long latent periodbetween time of exposure and presentation.

Enquire about occupational related disorders(e.g. asbestos exposure and mesothelioma). Thelength of each job and the job description need tobe recorded. Figure 10.1 lists some lung diseasesassociated with specific occupations. Hobbies mayalso be relevant.

189

Examination 10

Asking about pets is important in a respiratory history. For example, cat dander may precipitate an asthma attack orallergic rhinitis and pet birds are a rare cause ofpneumonia.

The smoking history gives clues to correct diagnosis. Most patients with COPD have a 20 or more pack year history. Apatient with a diagnosis of COPD and a 10 packyear history may be a misdiagnosed asthmatic.

Once you have finished, check that you have not missed anything and then summarize the key points to add clarity and ease presentation.

Fig. 10.1 Occupational causes of lung disease

Disease Area of work

asbestosis Vehicle body workers, ship building, demolition

malignant as abovemesothelioma

byssinosis textile workers

stannosis tin mining

farmer’s lung farming (exposure to mauldy hay)

coal worker’s coal miningpneumoconiosis

silicosis mining, quarrying, foundry work etc.

occupational asthma see Fig. 7.15

beryllosis electronic industries

Ch10-M3419.qxd 5/16/07 2:31 PM Page 189


General inspectionThe initial observation is vital. If you have notalready done so as part of the history, stand at theend of the bed and look at the locker for sputumpots, inhalers and charts. Note any drip stands thatare present, venous cannulae, or bandages.

Stand back and note the patient’s generalappearance. Is the patient:

• Obviously unwell or distressed?• Alert or confused?• Thin or overweight?

There are some signs (e.g. use of accessorymuscles of inspiration or pallor) that you maynotice immediately. Does the patient have a coughand, if so, does it sound productive? Is there anyabnormality (e.g. hoarseness) in the voice?

Then run through a systematic general inspection.You should look generally at muscle bulk, notingany cachexia (Fig. 10.2) and then inspect the skin indetail (Fig. 10.3). You may want to inspect the thoraxat this point too; these aspects are discussed below.

It is essential that you look closely at how thepatient is breathing. In addition to respiratory rate

(Fig. 10.4), which is easier to test with the pulse, youshould note:

• Signs of dyspnoea (e.g. use of accessory musclesof inspiration such as the sternomastoids,patient ‘fixing’ upper body by leaning forward,mouth breathing, nasal flaring)

190

Fig. 10.2 Tests, signs and diagnostic inferences found in cachexia.

Fig. 10.3 Inspection of skin

Test performed Signs observed Diagnostic inference

observe the general state of steroidal skin: prolonged use ofthe skin shiny corticosteroids:

excessive bruising chronic obstructivethin pulmonary disease

asthmafibrosing alveolitissystemic disease(e.g. Crohn’s disease)

generalized dryness ichthyosis vulgarisand scaling of skin acquired ichthyosis

hypothyroidismsarcoidosis

thin skin ageingCushing’s syndrometopical or systemic

steroid use

observe the colour of the skin pale skin palloranaemialeukaemiashock

light brown café-au-lait spotscoloured spots neurofibromatosison skin tuberous sclerosis

Fig. 10.3 Tests, signs and diagnosticinferences found when inspecting theskin.

AU: Fig.captionsfound to

mismatchwith theFig. title.

Pleaseadvise

which touse.

AUcafou

miswiFig

wh

Fig. 10.2 Cachexia


observe muscle generalized malignant diseasebulk and general muscle wasting bronchial condition of the and lack of carcinomaskin nutrition; pallor; chronic disease

dry and wrinkled renal diseaseskin hepatic disease

cardiac failure tuberculosis

other anorexia nervoso malnutrition emotional disturbance



Pleaseadvise

which touse.

Acafo

miswFig

wh

Acafo

miswFig

wh

Ch10-M3419.qxd 5/16/07 2:31 PM Page 190

• Unusual patterns of breathing (Fig. 10.5)• Any noises you can hear unaided (e.g. wheeze

or stridor).

Hands and limbsExamination of the handsThe hands can reveal key signs of respiratory dis-ease. Take both the patient’s hands and note theirtemperature. Abnormally warm and cyanosed handsare a sign of CO2 retention. Check the fingers fornicotine staining. One important sign of respiratorydisease is finger clubbing (Figs 10.6 and 10.7). Thisis a painless, bulbous enlargement of the distal

191

Examination 10

Fig. 10.4 Abnormal ventilation rate


discretely count the respiratory 12–20 breaths normalrate while feeling the patient’s pulse per minute

>12 breaths per anxietyminute (tachypnoea) pain

infectionpneumothoraxpulmonary embolism

<12 breaths per hypothyroidismminute (bradypnoea) increased intracranial

pressure

Fig. 10.4 Tests, signs and diagnosticinferences found when checking thebreathing rate.



Pleaseadvise

which touse.

Fig.tionsnd toatch

h thetitle.easedvisech touse.

Fig. 10.5 Abnormal patterns of breathing

Signs observed Diagnostic inference

hyperventilation with deep diabetic ketoacidosissighing respirations aspirin overdose(Kussmaul’s respiration) acute massive

pulmonary embolism

increased rate and volume terminal diseaseof respiration followed by increased intracranialperiods of apnoea pressure(Cheyne–Stokes respiration)

prolongation of expiration airflow limitation

pursed lip breathing air trapping

Fig. 10.5 Unusual patterns of breathing.



Pleaseadvise

which touse.



Pleaseadvise

which touse.

Fig. 10.6 Clubbing

Test performed Sign observed Diagnostic inference

view the nail from the increase in the soft pulmonary causes:side at eye level; rock the tissue of the nail-bed tumour (bronchial nail from side to side on and fingertip, with carcinoma, mesothelioma)the mail-bed; look at the increased sponginess of chronic pulmonary sepsisnail-bed and nail angle. the nail-bed (empyema, lung abscess,

bronchiectasis, cystic fibrosis)place nails back to back; loss of angle between fibrosing alveolitisa diamond-shaped area nail and nail-bed asbestosisis evident between them hypertrophic pulmonaryif clubbing does not exist. transverse curvature of osteoarthropathy

nail increasescardiac causes:

in final stages, whole congenitaltip of the finger bacterial endocarditisbecomes clubbed

other causes:clubbing may also idiopathic causesaffect the toes cirrhosis

inflammatory bowel diseasebones are normal

Fig. 10.6 Tests, signs and diagnosticinferences found in clubbing.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 191


fingers; it is accompanied by softening of the nailbed and loss of nail bed angle. Also assess for:

• Muscle wasting (Fig. 10.8)• Rheumatoid hands (Fig. 10.9)• Hypertrophic pulmonary osteoarthropathy

(HPOA) (Fig. 10.10)• Hand tremor (Fig. 10.11).

Examination of the pulseA normal resting pulse in an adult is between60–100 b.p.m. Bradycardia is defined as a pulse rateof less than 60 b.p.m. and tachycardia of greater than100. Palpate the radial pulse, wait for a moment andthen count for 15 seconds. You can then multiply byfour to give a rate per minute. Is the pulse regularand if not how is it irregular? (Fig. 10.12).

In addition to testing pulse volume and charac-ter, which are better assessed from the carotid pulse,you should also check for the presence of pulsusparadoxus. In normal individuals the pulse decreasesslightly in volume on inspiration and systolic bloodpressure falls by 3–5 mmHg. In severe obstructivediseases (e.g. severe asthma) the contractile force ofrespiratory muscles is so great that there is a marked

192

Fig. 10.7 One method of inspecting for clubbing. Normal fingers:note diamond-shaped area.

Fig. 10.8 Muscle wasting


look at the dorsal muscle wasting: localized:aspect of the hand note the distribution unilateralfor any reduction in and if it is unilateral –Pancoast’s tumourmuscle bulk or bilateral bilateral

–disuse atrophy; rheumatoid arthritisalways compareboth hands together generalized:

diabetesthyrotoxicosisanorexia nervosa

Fig. 10.9 Rheumatoid hands


look at the hands for ulnar deviation of fingers rheumatoid disease, whichsigns of rheumatoid swan-neck or boutonniere may affect the lung:disease deformity pulmonary nodules

Z-deformity of thumb pleural effusionsubluxation of

proximal phalanxwasting of small muscles

Fig. 10.8 Tests, signs and diagnosticinferences found in muscle wasting.

Fig. 10.9 Tests, signs and diagnosticinferences found in rheumatoid hands.



Pleaseadvise

which touse.



Pleaseadvise

which touse.

Acafo

miswFig

wh

Acafo

miswFig

wh

Know the causes of clubbing before any clinical examination. Note that chronic bronchitis does not cause clubbing.

Acafo

miswFig

w

Ch10-M3419.qxd 5/16/07 2:31 PM Page 192

fall in systolic pressure on inspiration. A fall ofgreater than 10 mmHg is pathological. Figure 10.13shows how to test for this sign.

193

Examination 10

Fig. 10.10 Hypertrophic pulmonary osteoarthropathy


apply pressure to tenderness on palpation of hypertrophic pulmonarythe wrist the wrist, the pain is over osteoarthropathy, a

the shafts of the long nonmetastatic complication ofbones adjacent to the joint malignancy – subperiosteal new-

bone formation in the long bones arthralgia and joint swelling of the lower limbs and forearms;

clubbing is also present – 90% of cases are associated with bronchogenic carcinoma, especially squamous cell carcinoma

other causes:rheumatoid arthritissystemic sclerosis

Fig. 10.11 Hand tremor


ask patient to hold very fine finger tremor on • stimulation of b-receptorsfingers outstretched and outstretched fingers; by bronchodilator drugsspread in front; place a finger tremor is made especially nebulized drugs.piece of paper on the more obvious by • thyrotoxicosisdorsal aspect of the placing a piece of paperhands; observe hands at on top of the handseye level from the side

ask patient to hold arm flapping tremor (asterixis) CO2 retentionoutstretched in front; against your hands, which hepatic failurefully extend the wrists; is coarse and irregular encephalopathyapply pressure to hands; in nature; maximum metabolic diseasesleave patient like this activity at wrist and subdural haematomafor 30 seconds metacarpophalangeal joints

Fig. 10.10 Tests, signs and diagnosticinferences found in hypertrophicpulmonary osteoarthropathy.

Fig. 10.11 Tests, signs and diagnosticinferences found in hand tremor.



Pleaseadvise

which touse.



Pleaseadvise

which touse.

You will gain marks if your examination looks fluent and professional. It is easy to move smoothly from introducing yourself andshaking the patient’s hand to examination of thehands to testing the radial pulse. Then you candiscreetly test for respiratory rate without patientsrealizing and altering their breathing.

Fig. 10.12 Abnormal radial pulse

Sign observed Diagnostic inference

rate <100 beats per minute normal

rate >100 beats per minute pain(tachycardia) shock

infectionthyrotoxicosissarcoidosispulmonary embolismdrugs e.g. salbutamoliatrogenic causes

full, exaggerated CO2 retentionarterial pulsation thyrotoxicosis(bounding pulse) fever

anaemiahyperkinetic states

Fig. 10.12 Tests, signs and diagnostic inferences found when testingthe radial pulse.



Pleaseadvise

which touse.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 193


194

Fig. 10.13 Pulsus paradoxus


measure blood pressure pulse volume severe asthmausing a sphygmomanometer: decreases withcuff pressure is reduced inspiration, the other causes:and systolic sound is heard; reverse or normal cardiac tamponadethis initially occurs only massive pulmonary embolismin expiration; with further large fall inreduction of cuff pressure systolic blood fall is exaggerated when venousyou can hear systole pressure during return to the right heart isin inspiration as well; the inspiration impairedpressure difference between the initial systolic sound in expiration and whenit is present throughoutthe breathing cycle iswhat is measured

Fig. 10.14 Enlarged axillary lymph nodes


Method 1: face the enlarged lymph node localized spread of viral or patient; place the (axillary lymphadenopathy) bacterial infectionpatient’s right arm tuberculosison your right arm; humanpatient’s arm must immunodeficiency virus be relaxed; palpate (HIV) infectionaxilla with left hand; actinomycosisplace the patient’s cytomegalovirus (CMV) left arm on your left infection measlesarm; palpate left axilla

Method 2: ask the axial lymphadenopathypatient to place hands is often present in breastbehind head; palpate carcinomaaxilla by placing your fingers high up in axilla; press tips of fingers against chest wall; move fingers down over ribs

Fig. 10.13 Tests, signs and diagnosticinferences found in pulsus paradoxus.



Pleaseadvise

which touse.

Fig. 10.14 Tests, signs and diagnosticinferences found when examining theaxillary lymph nodes.



Pleaseadvise

which touse.

Acafo

miswFig

wh

Acafo

miswFig

wh

Head and neckExamination of the faceFirst, observe the face generally. You may notice:

• Signs of superior vena cava obstruction (Fig. 10.15)

• Cushingoid features (Fig. 10.15).

Look at the mouth for signs of:

Examination of the limbsExamine the axillary lymph nodes as shown inFigure 10.14. Check the patient’s ankles for oedemaby applying pressure with fingers and thumb for afew seconds. If there is subcutaneous fluid you maysee pitting persisting. Bilateral pitting oedema isseen in many conditions including congestivecardiac failure, liver failure and, important to yourrespiratory enquiry, cor pulmonale.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 194

195

Examination 10

Fig. 10.15 Observation of the face


observe the oedema superior venapatient’s face cyanosis cava obstruction:

puffy eyes bronchial carcinomafixed, engorged neck veins lymphoma

mediastinal goitrefibrosis

features associated with long-termCushing’s syndrome: administration of steroids

moon face ACTH secretion by plethora small-cellacne bronchialhirsute carcinomaoral candidiasis

Fig. 10.16 Central cyanosis


good natural blue discoloration to skin and level of deoxygenated light is needed mucous membrane haemoglobin >5 g/dLask the patient central cyanosis cannot be diseases caused by markedto stick tongue accurately identified in black ventilation–perfusion out and Asian patients mismatch will cause look at the central cyanosis:mucous severe pulmonary membranes of fibrosis chronic the lips and bronchitis right–lefttongue heart shunts

pneumoniarespiratory failurebronchiectasischronic obstructivepulmonary disease

Fig. 10.15 Tests, signs and diagnosticinferences found when observing theface.

Fig. 10.16 Tests, signs and diagnosticinferences found in central cyanosis.



Pleaseadvise

which touse.



Pleaseadvise

which touse.

• Candida infection – white coating on tongueoften seen after steroids or antibiotics

• Central cyanosis (Fig. 10.16).

Then examine the eyes (Figs 10.17 and 10.18)and test for anaemia (Fig. 10.19).

Remember that an anaemic patient may be danger-ously desaturated without appearing cyanosed.

Examination of the neckExamine tracheal position and measure the crico-sternal distance (Figs 10.20 and 10.21). Then makesure the patient is at 45° and test the jugular venouspulse (Figs 10.22 and 10.23). Finally, test for cervicallymphadenopathy from behind (Figs 10.24 and10.25).

Develop a set system of palpating the lymph nodes of the neck (as mentioned above). Sit the patient up and examine frombehind with both hands.

Before a clinical examination, learn the lymph nodes of the neck and into which set of nodes different structures drain.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 195


196

Fig. 10.17 Tests, signs and diagnostic inferences found whenexamining the eyes.

normal right ptosis

Fig. 10.18 Typical appearance of a patient with ptosis.

Fig. 10.19 Anaemia


ask patient to pale mucous membrane indication of anaemia; look up, then however, anaemia can evert lower lid only be conclusivelyof eye diagnosed by measuringnote the colour haemoglobin levelsof mucous membrane

Scoliosis and kyphosis can lead to respiratory failure caused by compressional effects.

Fig. 10.19 Tests, signs and diagnosticinferences found in anaemia.



Pleaseadvise

which touse.



Pleaseadvise

which touse.

Acafo

miswFig

whFig. 10.17 Examination of the eyes


Look at the Dropping of Third nerve palsyeyes, noting upper eyelids (with dilated pupil).the position so that upper Horner’s syndromeof the eyelid part of iris and (with small reactiveand pupil size; pupil are pupil); involvementalways compare covered (ptosis) of the sympatheticwith the other chain on theside. posterior chest

wall by an apical bronchial carcinoma; T1 wasting and sensoryloss also occur.

If an Idiopathic (usually abnormality is in young females).present, check Myasthenia gravisthat the pupils (with bilateral are reactive to ptosis)light Dystrophia.

Mitochondrial disease (rare)

small pupil Old age.Horner’s syndrome.Argyll Robertson’s pupil: miotic and responsive to accommodation effort, but not to light.Disease in pons.Cerebrovascular accident.Drugs (e.g. opiates).

The thoraxObservation of the thoraxAs already noted, it is often easier to inspect thethorax as part of your general inspection. In addi-tion to observing chest wall movement, you shouldnote any lesions, thoracic scars (Fig. 10.26) or radio-therapy tattoos (small green or blue dots used asguidance for radiotherapy). Then observe the shapeof the thorax from the front, side and back and lookat the curvature of the spine. Chest deformities maybe asymptomatic or they may restrict the ventilatorycapacity of the lungs. Common chest abnormalitiesand their clinical significance are shown in Figures 10.27 and 10.28.

Before a clinical examination, learn the lymphnodes of the neck and into which set of nodes dif-ferent structures drain.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 196

• Hyperresonant• Dull• Stony dull.

Map out any abnormality you find but do not con-fuse the cardiac borders or liver edge with lung path-ology; they will sound dull normally. The note alsosounds muffled in a very muscular or obese patient.

AuscultationNormal breath sounds are described as vesicular andhave a rustling quality heard in inspiration and thefirst part of expiration. Listen to the patient’s chest:

• Using the bell of the stethoscope• In a logical order comparing the two sides (as

for percussion)• With the patient taking fairly quick breaths

through an open mouth.

PalpationYou should palpate any lumps or depressions younoticed on inspection and test for the symmetry and extent of chest expansion (Fig. 10.29). Testingchest expansion from the posterior is illustrated inFigure 10.30.

Test for the position of the apex beat by movingyour hand inwards from the lateral chest until youfeel the pulsation. The apex beat should be in thefifth intercostal space at the midclavicular line. Theclinical significance of deviations is shown in Figure 10.31.

Test for tactile vocal fremitus as shown in Figure 10.32.

PercussionThe percussion note tells us the consistency of thematter underlying the chest wall, i.e. if it is air, fluidor solid. The correct method of percussion is shownin Figure 10.33 and described in Figure 10.34, whichalso describes the diagnostic inferences from per-cussion. Percuss in a logical order, comparing oneside with the other and remember to include theaxilla (Fig. 10.35). A normal percussion note isdescribed as resonant. In lung pathology the percus-sion note may be:

197

Examination 10

Fig. 10.20 Tracheal position and crico-sternal distance


stand at the front of the deviation of the pulled to side of collapsepatient; pressing gently, trachea away from pushed away from massplace one finger on the the midline or fluidtrachea contralateral side to judge if the finger slides tension pneumothoraxto one side (tracheal deviation gives an indication of the position of the upper mediastinum; however, the only conclusive method of judging the position is chest radiography)

measure the distance (in three or four finger normalfinger breadths) between breathsthe sternal notch and reduced distance air flow limitationcricoid cartilage during a full inspiration

Fig. 10.20 Tests, signs and diagnosticinferences found when checking thetrachea.



Pleaseadvise

which touse.

When percussing, remember that the upper lobe predominates anteriorly and the lower lobe predominates posteriorly.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 197


198

sternomastoidmuscle

trachea

pneumothorax

effusionfluid

Fig. 10.21 Palpation to determine tracheal position.

Acafo

miswFig

wh

You should listen for:

• Diminished vesicular breaths (Fig. 10.36)• Bronchial breathing (Fig. 10.36)• Added sounds, such as wheezes or stridor

(Fig. 10.37), crackles (Fig. 10.38) or pleural rub(Fig. 10.39).

With auscultation always think BAR (B – Breathsounds; A – Added sounds; R – vocal Resonance).Added sounds that disappear when the patientcoughs are not significant.

Vocal resonanceThe tests for vocal resonance and whispering pec-toriloquy are shown in Figures 10.40 and 10.41.

SummaryOnce you have finished your examination, sum upthe positive findings in a clear and concise manner.Figure 10.42 is a summary of the signs found onexamination of the respiratory system as a whole.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 198

199

Examination 10

Fig. 10.22 Jugular venous pressure


patient must be at 45° looking straight ahead; good elevated jugular venous resting pressure in thorax is raised:light is needed; ask patient to rest head comfortably pressure • tension pneumothoraxagainst a pillow, neck slightly flexed; the patient’s • severe hyperinflation is asthmaneck must be relaxed, as it is impossible to assessjugular venous pressure if the sternomastoid musclesare tensed

a normal jugular pulse becomes visible just above the elevated nonpulsatile superior vena cava obstruction, clavicle between the two heads of sternocleidomastoid; jugular venous pressure usually caused by malignant jugular venous pressure is difficult to assess and needs enlargement of the right bronchusmuch practice; if the jugular pulse is not seen, try the elevated pulsatile jugular paratracheal lymph nodes corhepatojugular reflex: apply pressure to the liver, venous pressure pulmonaleincreasing venous return to the heart, and so increasing the jugular venous pressure

time against the contralateral pulse and measure thedepressed jugular venous shock

height of the pulse above the heart (giving a measurepressure dehydration

of pressure); the normal height of the pulse above thesevere infection

atrium is <4 cm

jugularvenousposition

sternalangle

mid rightatrium

45°

Fig. 10.23 Measurement of the height of the jugular venous pulse.

Fig. 10.22 Tests, signs and diagnostic inferences found when checking the jugular venous pulse.



Pleaseadvise

which touse.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 199


200

Fig. 10.24 Cervical lymphadenopathy


examine the cervical chain of cervical infectionlymph nodes from behind the lymphadenopathy carcinomapatient; it helps if the neck is tuberculosisslightly flexed; most patients note number of sarcoidosisextend neck to try and help you palpable nodes hard node: calcified

Know the nodes which you are describe as for any soft, matted node:feeling lump tuberculous

using both hands, start at the mandibular ramus, palpate the submandibular nodes then anterior chain nodes, supraclavicular nodes, and posterior chain nodes in a Z-fashion

occipital

mastoid

parotidlymphnodes

submandibular

sublingual

deep cervical

thyroidgland

sternomastoidmuscle

carotidartery

internaljugular vein

Fig. 10.25 Anatomy of the neck including lymph node distribution.



Pleaseadvise

which touse.

Fig. 10.24 Tests, signs and diagnosticinferences found in cervicallymphadenopathy.

Acafo

miswFig

wh

Acafo

miswFig

wh

Ch10-M3419.qxd 5/16/07 2:31 PM Page 200

201

Examination 10

Fig. 10.26 Thoracic scars


look at the thorax for any obvious scars present median sternotomy (most scars, remembering to look at the from previous open-heart surgery; front and back of the chest, axilla, operations cardiopulmonary bypass)and under the breasts

posteriolateral thoracotomy (ligation of posterior descending artery; lung and oesophageal resections)

lateral thoracotomy (pneumothorax)

left thoracotomy (closed mitral valvotomy)

Fig. 10.27 Assessing the chest wall and spice


Look at the sternum and its depressed in benign condition requiring relationship to the ribs pectus no treatment.

excavatum On chest radiograph, the (funnel chest) heart may be displaced and

appear enlarged

prominent in may be secondary to severe pectus carinatum childhood asthma(pigeon chest)

observe the patient from the anteroposterior hyperinflationside; ask patient to fold arms diameter of chest asthmaand take a deep inspiration > lateral diameter

(barrel chest)

ask the patient to stand; stand increased lateral structural abnormalitydirectly behind the patient and curvature of the development abnormalitylook at the curvature of the spine vertebral disc prolapsespine (scoliosis)

next, stand at the side of the increased forward osteoporosispatient and again look at the curvature of the ankylosing spondylitiscurvature of the spine spine

(kyphosis)

Fig. 10.26 Tests, signs and diagnosticinferences found in thoracic scars.



Pleaseadvise

which touse.

Fig. 10.27 Tests, signs and diagnosticinferences found in chest wallabnormalities.



Pleaseadvise

which touse.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 201


202

scoliosis kyphosis

Fig. 10.28 Features of scoliosis and kyphosis.

Fig. 10.29 Chest expansion


place the flat of both hands on symmetrical rise of normalthe pectoral region of the hands as chest chest; ask the patient to take a expandsdeep breath, and note any asymmetrical rise unilateral pathology on asymmetry the depressed side

put fingers of both hands as far – –around the chest as possible;bring thumbs together in themidline; keep thumbs offchest wall; ask patient to take adeep breath in; note distancebetween thumbs; examine bothfront and back

place a tape measure around >4 cm expansion normalthe internipple line and measure <4 cm expansion reduced expansionthe difference between inspiration and expiration



Pleaseadvise

which touse.

Fig. 10.29 Tests, signs and diagnosticinferences found in chest expansion.

Acafo

miswFig

wh

Ch10-M3419.qxd 5/16/07 2:31 PM Page 202

203

Examination 10

inspiration

expiration

Fig. 10.30 Examining chest expansion from the back. (After Burton,Hodgkin & Ward 1977, with permission of Lippincott-Raven.)

Fig. 10.31 Apex beat


pulsation in fifth intercostal normalspace midclavicular line

deviated pulsation; lower left deviation:mediastinum displacement cardiomegaly

pulmonary fibrosisscoliosispectus excavatumbronchiectasis

right deviation:pneumothoraxpleural effusiondextracardia

Fig. 10.32 Tactile vocal fremitus


place either the ulnar edge or increased solid areas of lung with openthe flat of your hand on the resonance airwayschest wall; ask the patient to consolidationrepeatedly say ‘99’ or ‘1, 2, 3’; pneumoniarepeat for front and back, tuberculosiscomparing opposite zones extensive fibrosis

the vibrations produced by the decreased feeble voicemanoeuvre are transmitted resonance pleural thickeningthrough the lung substance blocked bronchusand felt by the hand; alterations in disease are the same as for vocal resonance

Fig. 10.31 Signs and diagnostic inferences found in examination ofthe apex beat.

AU: Fig.captionsfound tomismatchwith theFig. title.Pleaseadvisewhich touse.

Fig. 10.32 Tests, signs and diagnosticinferences found in tactile vocal fremitus.



Pleaseadvise

which touse.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 203


204

chest wall

Fig. 10.33 Correct method of percussion (see Fig. 10.34 forexplanation).

Fig. 10.34 Percussion

Test performed Sign obserbed Diagnostic inference

place your nondominant hand on the chest wall, increased resonance (resonance increased air in lung:palm downwards, with fingers slightly separated; depends on the thickness of the chest • emphysemathe second phalanx of the middle finger should be wall and the amount of air in the • large bullaein an intercostal space directly over the area to be structures underlying it) • pneumothoraciespercussed; strike this finger with the terminal • asthmaphalanx of the middle finger of the other hand

to achieve a good percussion note, the striking finger dullness (solid lung tissue does not reflect consolidation:should be partially flexed and striked at right angles sound as readily as aerated lung); if a • fibrosisto the other finger; the striking movement must be dull area exists, map out its limits by • collapsea flick of the wrist percussing from the resonant to the dull • pleural thickening

area • tuberculosison percussion you will hear a percussion note and • extensive carcinomafeel vibrations

stony dullness fluid present:percuss from top to bottom including axilla; to check • pleural effusionfor disease in the lung apices, percuss directly onto the clavicles; do not percuss more heavily than you need and always compare both sides, front and back

dullness occurs as you percuss over the liver; note that the right diaphragm is higher than the left diaphragm

Fig. 10.34 Tests, signs and diagnostic inferences found when doing percussion of the thorax.



Pleaseadvise

which touse.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 204

205

Examination 10

Fig. 10.35 Sites for percussion. (From Munro & Campbell 2000, withpermission of Churchill Livingstone.)

Fig. 10.36 Auscultation of the thorax


vesicular breath sounds breath sounds are produced in the larger airways where flow is turbulent; sounds are transmitted through smaller airways to the chest wall; vesicular breath sounds are normal

if vesicular breath sounds are reduced or absent:• airway obstruction• asthma• chronic obstructive

pulmonary disease• tumour

bronchial breath sounds normal, if heard at the tip of (described in relation to the scapula; otherwise caused timing; a gap exists by:between inspiration and • consolidationexpiration, which are of • pneumoniaequal duration; harsh • lung abscessclear breath sounds) if inaudible:

• severe emphysema• bullae• pneumothorax• pleural effusion

Fig. 10.37 Wheeze and stridor


prolonged none: the amount of wheeze musical sound is not a good indicator of the

degree of airway obstruction

polyphonic sound (many small airway obstruction:musical notes), mainly in narrowing caused by expiration combination of smooth

muscle contraction; inflammation within airways; increased bronchial secretions

monophonic sound large airway obstruction: a worrying finding, suggesting a single narrowing (e.g. tumour)

loud inspiratory sound large airway narrowing (larynx, trachea, main bronchi):• laryngotracheobronchitis• epiglotitis• laryngitis

Fig. 10.36 Tests, signs and diagnostic inferences found in auscultationof the thorax.

Fig. 10.37 Signs and diagnostic inferences found in stridor andwheeze.



Ch10-M3419.qxd 5/16/07 2:31 PM Page 205


206

Fig. 10.38 Crackles


listen to the patient nonmusical, short, crackles represent breathing uninterrupted sounds equalization of intraluminal

heard during inspiration pressure as collapsed small crackles may be airways open during mimicked by rolling inspirationhair on your temple early inspiratory crackles diffuse airflow limitation between two fingers; chronic obstructive timing during the pulmonary disease respiratory cycle is of pulmonary oedemahuge significance

late inspiratory crackles conditions that largely involve alveoli:• fibrosis• fibrosing alveolitis• bronchiectasis

Fig. 10.39 Pleural rub


listen to the patient leathery creaking sound caused by inflamed surfaces breathing associated with each of pleura rubbing together:

breath • pneumonia• pulmonary embolism

inspiratory and expiratory • emphysemasound that is not shifted • pleurisyby cough; reoccurs at the same time in each respiratory cycle

Fig. 10.40 Vocal resonance


auscultatory equivalent normal lung attenuates as for vocal fremitusto vocal fremitus; place high-frequency notes; the stethoscope on to normally, booming low- the chest and ask the pitched sounds are heardpatient to repeatedly say ‘99’ or ‘1, 2, 3’

Fig. 10.41 Whispering pectoriloquy


place the stethoscope on words are clear and seem whispered speech to the chest and ask the to be spoken right into cannot usually be heardpatient to repeatedly the listener’s ears over healthy lung; solidwhisper ‘99’ or ‘1, 2, 3’ (whispering pectoriloquy) lung tissue conducts

sound better than normally aerated lung,indicating consolidation, cavitation, tuberculosis, or pneumonia



Pleaseadvise

which touse.

Fig. 10.38 Tests, signs and diagnosticinferences found in crackles.



Pleaseadvise

which touse.

Fig. 10.39 Tests, signs and diagnosticinferences found in pleural rub.



Pleaseadvise

which touse.

Fig. 10.40 Tests, signs and diagnosticinferences found in vocal resonance.



Pleaseadvise

which touse.

Fig. 10.41 Tests, signs and diagnosticinferences found in whisperingpectoriloquy.

Ch10-M3419.qxd 5/16/07 2:31 PM 6

207

Examination 10

Signs found on examination of the respiratory system

Chest radiograph

Mediastinal shiftand trachea

Chest wall excursion

Percussion note

Breath sounds

Added sounds

Tactile vocal fremitus or vocal resonance

Consolidation

none

normal or decreasedon the affected side

dull

increased (bronchial)

crackles

increased

Pneumothorax

none (simple), away (tension)

normal or decreasedon the affected side

resonant

decreased

click (occasional)

decreased

Pleural effusion

none or away

decreasedon the affected side

stony dull

decreased

rub (occasional)

decreased

Lobar collapse

towards the affected side

decreased

dull

decreased

none

decreased

Pleural thickening

none

decreased

dull

decreased

none

decreased

FPO

Fig. 10.42 Summary table of signs found on examination of the respiratory system.

Ch10-M3419.qxd 5/16/07 2:31 PM Page 207

objectives - elsevier

Documents