Presentation on theme: "Respiratory System Physical Examination"— Presentation transcript:
1Respiratory System Physical Examination Ishraq ElshamliRespiratory UnitTripoli Medical Center
2Preparation for Examination Privacy : warm, well-lighted, quiet room.Wash your handsIntroduce yourself to the patient.Seek permission for the examination and be polite to the patient.“Stop me at any time if it becomes uncomfortable or I cause you any discomfort
3IntroductionWhile seated or standing, the patient should be exposed to the waist OR uncovered intermittently.Teach the patient how to breathe deeply and quietly, slowly inhaling and exhaling through an open mouth
5Physical Examination Initial impression Stand back, to the right hand side of the patient :General appearance :Thin, Pink puffer, cachexia.Obese, blue bloater, cushinoid featuresCyanosisFeatures of SVCO
6Physical Examination (Initial Impression) SOB?Using accessory muscles of respirationPursed lipsProlonged expiratory phase ?COPDCount Respiratory rateNormal adult, breaths/min regular and unlabored.Tachypnea is an adult RR> 24 breaths/min.Bradypnea is an adult RR< 10 breaths/min.
7Physical Examination (Initial Impression) Audible cough : is it dry/ productive. Is there a sputum pot? If so, look in it.WheezeStridorHoarseness
8Note the intercostals retractions (especially at the base of the neck,) and the position of the hands (a position known as 'tripodding.')
19Examination of the hands Tremor (fine ? Β2 agonist)Flapping tremor (CO2 retention) .Other conditions: e.g. Yellow Nails/ RA hands/ Scleroderma/ Wasting of the intrinsic muscles of the hands (cachexia/ pancoast tumour)Pulse
26Pulse Pulse: palpate rate, rhythm, character. Tachycardia: e.g. AF associated with pulmonary disease.Tachycardia associated with beta 2 agonists (nebulised salbutamol)
27Face and Neck Central cyanosis Neck veins Lymphadenopathy Crepitus Neck musclesIndrawingPursed lips
28FaceHorner’s Syndrome (MEAP! Myosis, enophthalmos, anhydrosis, ptosis).Central Cyanosis (4g of Hb has to be deoxygenated).Acneform eruptions associated with immunosuppressive therapy.Cushingoid appearance with long-term steroid use .
33Pursed lip breathing Improves ventilation. Releases trapped air. Keeps the airways open longer and decreases the work of breathingProlongs exhalation to slow the breathing rateRelieves shortness ofbreath
34The Neck Position of the trachea Lymph node enlargement (tuberculosis, lymphoma, malignancy, sarcoidosis)Scars (phrenic nerve crush for old TB)Tracheostomy scarprevious ventilation in COPD etc. Central line scarsScar from LN biopsyJVP - ? right sided heart failure (cor pulmonale as a result of chronic lung disease)
54Chest expansionPlace your palms on the patient’s chest with your thumbs parallel to each other near the midlineOR lightly pinch the skin between your thumbsAsk the patient to take a deep breath , observe for bilateral expansion
58Tactile Vocal fremitus Place the ulnar side of your hand on the patient’s chest .Instruct the patient to say “44” each time they feel your hand on their back.Comment on the tvf increased or decreased
62Percussion techniquePlace left hand on chest wall, palm downwards with fingers separated2nd phalanx over area of intercostal spaceRight middle finger strikes the 2nd phalanx producing hammer effectEntire movement comes from wrist
68Percussion Do not forget the apices of the lungs Compare both sides Impaired(dull)resonance obtained –Lung tissue is airless e.g. consolidation, collapse,fibrosisHyper resonant = pneumothorax/ COPDStony Dull = Pleural effusion
72Auscultation technique Diaphragm of stethoscope covers a larger surface than the bellBreath deeply with Mouth openSystematic approach over several areas, comparing both sideslisten to one complete respirationRepeat asking patient to say “9,9,9” for vocal resonanceWhispering pectoriloquy
73Auscultation The auscultatory assessment includes breath sounds audible or not .Character of breath sounds.Abnormal sounds or added sounds.Examination of the sounds produced by the spoken voice.Use a zigzag approach, comparing the finding atEach point with the corresponding point on theOpposite hemithorax.
75Vesicular – Normal, Or Diminished localised or diffuse expirationinspirationVesicular – Normal, Or Diminishedlocalised or diffuseinspirationexpirationinspirationexpirationVesicular with prolonged expirationBronchial Breathing
76Vesicular breath sounds Vibrations of the vocal cords caused by turbulent flow through the larynxTransmitted along trachea, bronchi to chest wallRustling qualityInspiration continuous with expirationIntensity increases during inspiration & fades during first 1/3rd expiration
80RhonchiDue to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedemaMusical qualityHigh or low pitchedUsually expiratoryExpiration prolonged
81Crepitations Inspiratory noises, usually 2nd half Non-musical Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration
82Pleural Rub Creaking noise Movement of visceral pleura over parietal pleuraSurfaces roughened by exudate2 separate phases at end inspiration and early expiration
83Vocal sounds Vocal resonance Increased when voice sounds are louder and more distinct e.g. consolidationReduced when transmission impeded e.g. effusion, collapse
84Information from auscultation Type and amplitude of breath soundsType of added sounds and their locationQuality and amplitude of conducted sounds
85Whisper pectoriloquyWith your stethoscope the over area of possible pathology, have the patient whisper the phrase ‘one-two-three’. Listen to hear if the sound is distorted.Confirm that a similar change is absent over the identicallocation on the contralateral chest.
86EgophonyWith your stethoscope over the area of possible pathology, have the patient vocalize the vowel ‘EEEE’.Listen for the sound to be distorted into the sound ‘AHHH’.Confirm that a similar change is absent over the identical location on the contralateral chest.
87I would like to complete my examination by Reviewing the temperature and blood pressure.Examine for features of cor pulmonale. (Inspect the JVP / look for peripheral oedema / other signs of right heart failure).Check the patient’s peak flow and forced expiratory time.
88Forced expiratory time Instruct the patient to:take in as deep breath in as deep as you can and then hold it. Then, breathe out as forcefully and as quickly as possible.Orblow as hard as you can until all the air has emptied from your lungs.
89If you can’t empty your lungs in 6 seconds, this suggests a degree of obstruction i.e. COPD.
90Finishing off the examination At this stage say to the patient“Thank-you, you may sit back now”And to cover them up with the blanket
91Interpretation of findings Breath sounds locally reduced or absent over pleural effusion, thickened pleura, collapsed areaBreath sounds diffusely reduced in emphysema, asthmaRhonchi heard in asthma, COPDCrepitations may be widespread in COPD, LVFCrepitations localised in area of consolidationPleural rub in pleurisy
97A candidate was asked to examine the respiratory system EXAMPLE:A candidate was asked to examine the respiratory system
98Examiner observations: A reasonable method.She did commence examination of the chest from the posterior aspect.The findings:The patient was breathless at rest.Was using oxygen via nasal prongs.There were no peripheral signs .The chest was normal apart from bilateral basal crepitations.
99What is your Diagnosis: Fibrosing alveolitis.What are other causes of bilateral basal crepitations :Heart failure.Brocnhiectasis.Atypical pneumoniaJVPsputum pots or inhalers
100Patient re-examined: General Examination: The patient was propped up in bed suggesting dyspnoea.The face was flushedflaring of the alae nasiO/E No clubbing but the peripheries were warm with high volume pulse not collapsingneck we noted a raised JVP almost to the ear lobe with no predominant waveform .Causes of DyspneaA pink pufferThe patient had respiratory distresscor pulmonale or heart failure
101On examination of the chest: Barrel shaped .There was little movement of the chest wall with respiration being predominantly abdominal.Respiratory rate was 26 per minute.The apex beat was difficult to palpateRespiratory movements were equal on the two sided vocal fremitus unremarkable
102Percussion not showed increased resonance with diminished cardiac and liver dullness Breath sounds were vesicularThere were a few crepitations at both bases but they were mostly mid-inspiratory and cleared with coughingHeart sounds were soft