Respiratory examination

[Mahmood Ahmad]

This is what I have been told to do in respiratory examination for PACES


Say "I would lie to examine your chest.
Do I have your permission to do this?"

The patient should be at a 45 degree angle with the chest uncovered

Count to ten and look from the end of the bed. Look at the face pursing of lips.Look for lupus pernio (Sarcoidosis),central cyanosis ( Cor pulmonale,fibrosing alveolitis, bronchiectasis) , signs of systemic sclerosis, neck (superior vena caval obstruction), ank spond (stooped, question mark posture, patient turns his whole body), and hands.

Neck
JVP, Tracheal tug ( number of fingers between cricothyroid and sternum), tracheal deviation

check axillary lymph nodes

check pulse

Chest (Front)

Check if accessory muscles are being used, indrawing of intercostal muscles or supraclavicular fossae, indrawing of lower ribs (emphysema) and localized indrawing of intercostal muscles (bronchial obstruction)

Check apex beat (may not be palpable in COPD)

Check for asymmetry
Expansion (i) supramammary (ii) inframammary 'deep breath in all the way out and in again'

Percuss over clavicles then three levels anterior chest wall and axillae
Ausculate supraclavicular with bell then all other areas with diaphraghm do not forget axillae

Do tactile vocal fremitus


Listen to breathing to see if expiration more prolonged than inspiration,



Feel cervical LN
Expansion at three levels
Percussion
Auscultation

Back of chest for tactile vocal fremitus with ulnar side of hand

I would like to

Measure the peak flow
Look at sputum pot
Look at temperature chart




Common conditions in PACES exam


Bronchiectasis

Patient may have productive cough,clubbing crepts and a sputum pot.

Other diffrentials for patients with clubbing and crepts are

1. Carcinoma of the lung ( may have heavy nicotine staining and palpable lymph nodes)
2. Fibrosing alveolitis ( lack of sputum production)
3. lung abscess

Causes of bronchectasis

1. post pneumonia and post TB
2. CF ( young and malnourished)
3. obstruction due to foreign body, carninoma, sarcoidosis, TB, lymph nodes
4. hypogammaglobenemia
5. Fibrosis ( after TB, pneumonia,Mycotic infections, and sarcoidosis)
6. ABPA
7. Yellow nail syndrome ( Excessively curly yellow nails and odema of extremities)
8. Kartegeners syndrome ( Situs inversus, infertility,dextrocardia, dysplasia of frontal sinuses, sinusitis, ciliary dysmotility and otitis media)
9. Marfan's syndrome




Complications
1. Amyloidosis ( check spleen)
2. Brain abscess
3. hemoptysis

Emphysema

Nicotine staining on fingers, lip pursing during prolonged expiration, the supra sternal notch to cricoid distance is reduced ( a sign of hyperinflation),tracheal tug, accessory muscles used at rest, indrawign of lower ribs on inspiration and hyperresonant precussion note
May not have palpable apex beat, quiet breath sounds

Definition Abnormal dilatation of the airway distal to the terminal respiratory bronchiole

Causes of Emphysema

Smoking

Alpha one antitrypsin deficency ( May have icterus and/or hepatomegaly) Panacinar

Coal dust (Centrilobular)

Chronic bronchitis Blue bloater

Nicotine staining, centrally cyanosed, hyperinflated chest, usage of accessory muscles of respiration, indrawing of intercostal muscles, tracheal tug, reduced supra sternal notch to cricoid distance,Expansion is equal but reduced to 2 cm, precussion note is resonant, on auscultation the expiratory phase is prolonged and he has widespread expiratory rhonchi and coarse inspiratory crackles.

Chronic bronchitis is productive cough for 3 months of the year in two consecutive years



Indications for LTOT are FEV1<1.5, PO2<7.3 and non smoking

Indications for lung transplant are <60, end stage lung disease, life expectancy 12-18 months, non smoker

Fibrosing Alveolitis

Clubbing, possible cyanosis, reduced expansion of the chest, fine inspiratory crackles in the bases. If they have pulmonary hypertension they will have increased JVP, loud P2 and RV heave.

Causes

Autoimmune

SLE
Systemic sclerosis
Polymyositis/Dermatomyositis
Ankylosing Spondylitis (Upper lobe)
Rheumatoid arthritis
Cryptogenic fibrosing alvelolitis
Extrinsic allergic alveolitis ( Upper lung)
Sarcoidosis

Drugs

Methotrexate, Amiodarone, Nitrofurantoin

Radiation

Occupational

Asbestosis
Silicosis

Tests

ESR,ANA, RF, CXR, ABG, PFT, HRCT

Treatment

Trial of steriods


Pleural Effusion


Stony dullness at base, diminished tactile vocal resonance and diminished tactile fremitus and diminished breath sounds, Can have bronchial breathing in area above effusion


Causes of pleural effusion

Exudate>30 g /l

Bronchial Carcinoma ( clubbing, radiation burns, lymph nodes), other Ca Eg breast, ,lymphoma

Pulmonary embolus and infract

Pneumonia/TB

Autoimmune Rheumatoid arthritis,SLE

Transudate <30 g/l


Cardiac failure

nephrotic syndrome

Cirrhosis

Meig's syndrome


Light's criteria

pleural:serum protein >0.5, pleural: serum LDH >0.6

Pleural LDH> 2/3 limit of serum LDH


Tests
CXR, U/S, Pleural tap ( glucose, protein, LDH, microbiology, albumin,AFB) and biopsy(specific for detecting TB and malignancy and better than pleural aspiration)

D/D dullness at base

Raised hemidiaphragm
basal collapse
Collapse/Consolidation
Pleural thickening(old TB, malignancy, empysema)

[guest18]

Thank you, Mahmood Ahmad, for your effort.

This is very comprehensive and informative. It would be great if you could post similar information about other systems as well. Thanks.

Could you tell us where you you learned all this?