Respiratory SystemPhysical Examination Ishraq Elshamli Respiratory Unit Tripoli Medical Center
Preparation for Examination • Privacy : warm, well-lighted, quiet room. • Wash your hands • Introduce 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
Introduction • While 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
Physical ExaminationInitial impression Stand back, to the right hand side of the patient : • General appearance : • Thin, Pink puffer, cachexia. • Obese, blue bloater, cushinoid features • Cyanosis • Features of SVCO
Physical Examination (Initial Impression) • SOB? • Using accessory muscles of respiration • Pursed lips • Prolonged expiratory phase ?COPD • Count Respiratory rate • Normal adult, 12 - 20 breaths/min regular and unlabored. • Tachypneais an adult RR> 24 breaths/min. • Bradypnea is an adult RR< 10 breaths/min.
Physical Examination (Initial Impression) • Audible cough : is it dry/ productive. Is there a sputum pot? If so, look in it. • Wheeze • Stridor • Hoarseness
Note the intercostals retractions (especially at the base of the neck,) and the position of the hands (a position known as 'tripodding.')
Around the bed • Inhalers. • Oxygen. • CPAP machine (Obstructive sleep apnoea). • Sputum Pots.
Venturi mask : Provides controlled Oxygen therapy 24%, 28%, 35%, 60%
Ventolin Inhaler (mdi) Metered dose inhaler Foradil (Formetrol) Powder inhaler
Pulmicort and Oxisturbohaler Seretidediskhaler Metered dose inhalers(mdi) e.g. Becloforte (Beclomethasone), Ventolin (Salbutamol) Combivent(Salbutamol+ipratropium bromide)
Hands and Pulse • Perfusion • Nicotine staining • Peripheral cyanosis • Bruising/ thin skin: steroid therapy • Clubbing - lung cancer, bronchiectasis, CF, lung abscess/empyema), pulmonary fibrosis, mesothelioma, (HPOA).
Examination 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/ pancoasttumour) • Pulse
Pulse • Pulse: palpate rate, rhythm, character. • Tachycardia: e.g. AF associated with pulmonary disease. • Tachycardia associated with beta 2 agonists (nebulisedsalbutamol)
Face and Neck • Central cyanosis • Neck veins • Lymphadenopathy • Crepitus • Neck muscles • Indrawing • Pursed lips
Face • Horner’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 .
Pursed lip breathing Relieves shortness of breath • Improves ventilation. • Releases trapped air. • Keeps the airways open longer and decreases the work of breathing • Prolongs exhalation to slow the breathing rate
The 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 scars • Scar from LN biopsy • JVP - ? right sided heart failure (corpulmonale as a result of chronic lung disease)
Tracheostomy Scar Thyroidectomy Scar
Chest Traditional Sequence • Inspection. • Palpation. • Percussion. • Auscultation.
Remember • Always describe the chest in terms ofanterior and posterior. • Describe the lungs as zones not lobes i.e. Upper/ middle/ lower zones
Anterior View Posterior View
Left Lateral View Right Lateral View
Inspection Inspection is performed to: • Scars : pneumonectomy ,lobectomy • Chest drains , thoracocentesis. • Radiation tattoo’s (previous radiotherapy). • Shape or Chest wall deformity – pectusexcavatum / carinatum(pigeon chested), Barrel chest (Hyper-inflated), Kyphosis, Scoliosis. • Resp rate, depth& Mode of breathing.
Inspection • Movements . • Equal symmetry or reduced on one side? • Respiratory effort, intercostalindrawing or use of accessory muscle .
Kyphosis: Causes the patient to bend forward. X-Ray shows curvature of the spine.
Pectusexcavatum: Congenital posterior displacement of lower sternum. The x-ray shows a concave appearance of the lower sternum.
Barrel chest : In chronic lung hyperinflation (e.g.Asthma, COAD) Due to increased AP diameter of the chest.
Scoliosis Is an increased lateral curvature of the spine . (i.e. Like the shape of the Letter “S”).