respiratory exam
DESCRIPTION
UndergrTRANSCRIPT
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Respiratory examination
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History• Six principal symptoms
• Dyspnoea
• Wheeze
• Cough
• Sputum
• Haemoptysis
• Chest pain
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History• Acute or chronic• Preceding systemic disturbance• Past medical history• Drug history• Social history – smoking, pets• Family history• Occupational history – allergens/asbestos
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Physical examination
• Look around• Hands, pulse, BP• Face & Neck• Chest examination
– Inspect– Palpate– Percuss– Auscultate
• Other bits
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Look around• Initial impression
– Audible cough– Wheeze– Stridor– Hoarseness– Dyspnoea
• O2, Nebs, Inhalers• TPR & Sputum sample
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Hands, pulse, BP• Perfusion• Peripheral cyanosis• Tremor• Flap – type II respiratory failure• Tar staining• Finger clubbing• Pulse• BP
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Face• Central cyanosis• Pursed lips
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Neck• Neck veins• Lymphadenopathy• Neck muscles• Trachea• Crepitus• Indrawing
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The Chest• Inspection
• Palpation
• Percussion
• Auscultation
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Inspection• Shape• Scars• Lesions• Respiratory rate• Respiration depth• Abnormal movement
– inspiration– expiration– asymmetry
pectus carinatum excavatum
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Palpation• Chest expansion• Tactile vocal fremitus
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Percussion• Compare both sides• Map out abnormal area
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Percussion technique• Palm over chest wall• Middle finger strikes 2nd phalanx• Movement from wrist
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Percussion• Resonant - normal
• Dull – no air– consolidation– collapse– pleural thickening
• Stony dull – pleural effusion
• Hyperresonant - pneumothorax
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Auscultation• Air entry• Vocal sounds
– vesicular– bronchial
• Added sounds– wheeze– crackles/creps– rub
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Breath Sounds• Vesicular
– normal breath sounds with a “rustling quality”
• Diminished - localised or diffuse– reduced airflow
something between the chest wall and the lung
• Bronchial – consolidation– altered quality with distinct inspiratory and expiratory
phases
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Added sounds• Wheeze
– musical notes –expiratory: mucosal oedema or spasminspiratory: secretions or obstruction
• Crackles– non-musical –
inspiratory
• Pleural sounds– rubs and clicks
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Vocal sounds• Vocal resonance
• Increased– voice sounds are louder and more distinct
e.g. consolidation
• Reduced– transmission impeded
e.g. effusion, collapse
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Information...• Type and amplitude of breath sounds
• Type of added sounds and location
• Quality of vocal sounds
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Auscultation technique• Diaphragm of stethoscope
• Mouth open
• Breathing deeply
• Systematic approach – left and right– Anteriorly to 6th rib– Posteriorly to 8th rib
• Vocal resonance: say “one one one” or “ninety nine”
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Other bits• Peak flow
• Oedema
• Pulsatile liver
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Interpretation of findings• Breath sounds
– locally reduced or absent:pleural effusion, thickened pleura, collapsed area
– diffusely reduced: emphysema, asthma
• Wheeze: asthma, COPD• Crackles: Infection, LVF
– localised in area of consolidation
• Pleural rub: pleurisy, PTE
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Pleural effusion
Pleural effusion• Trachea deviated AWAY• reduced tactile vocal
fremitus• reduced chest expansion• stony dull• reduced air entry• no added sounds• reduced vocal resonance
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Consolidation
Consolidation• increased tactile vocal
fremitus• reduced expansion• dull percussion• bronchial breathing• coarse creps• increased vocal
resonance• whispering pectoriloquy
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Collapse
Collapse
• deviated trachea TOWARDS
• reduced tactile vocal fremitus
• dull percussion
• reduced air entry
• +/- creps
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Pneumothorax
Pneumothorax
• deviated trachea (tension) AWAY
• reduced tactile vocal fremitus
• hyper-resonance
• reduced air entry
• reduced vocal resonance
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