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Respiratory System Physical Examination

Respiratory System Physical Examination

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Respiratory System Physical Examination

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  1. Respiratory SystemPhysical Examination Ishraq Elshamli Respiratory Unit Tripoli Medical Center

  2. 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

  3. 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

  4. Physical Examination

  5. 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

  6. 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.

  7. Physical Examination (Initial Impression) • Audible cough : is it dry/ productive. Is there a sputum pot? If so, look in it. • Wheeze • Stridor • Hoarseness

  8. Note the intercostals retractions (especially at the base of the neck,) and the position of the hands (a position known as 'tripodding.')

  9. Tri-Pod Position : In patients with emphysema

  10. Pink Puffer

  11. Blue Bloater

  12. Around the bed • Inhalers. • Oxygen. • CPAP machine (Obstructive sleep apnoea). • Sputum Pots.

  13. Oximeter

  14. Venturi mask : Provides controlled Oxygen therapy 24%, 28%, 35%, 60%

  15. Ventolin Inhaler (mdi) Metered dose inhaler Foradil (Formetrol) Powder inhaler

  16. Pulmicort and Oxisturbohaler Seretidediskhaler Metered dose inhalers(mdi) e.g. Becloforte (Beclomethasone), Ventolin (Salbutamol) Combivent(Salbutamol+ipratropium bromide)

  17. 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).

  18. 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

  19. Finger clubbing

  20. Flapping tremor

  21. Pulse • Pulse: palpate rate, rhythm, character. • Tachycardia: e.g. AF associated with pulmonary disease. • Tachycardia associated with beta 2 agonists (nebulisedsalbutamol)

  22. Face and Neck • Central cyanosis • Neck veins • Lymphadenopathy • Crepitus • Neck muscles • Indrawing • Pursed lips

  23. 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 .

  24. Acneform eruptions

  25. 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

  26. The Neck • Position of the trachea • Lymph node enlargement (tuberculosis, lymphoma, malignancy, sarcoidosis) • Scars (phrenic nerve crush for old TB) • Tracheostomy scar􀃆previous ventilation in COPD etc. Central line scars • Scar from LN biopsy • JVP - ? right sided heart failure (corpulmonale as a result of chronic lung disease)

  27. Tracheostomy Scar Thyroidectomy Scar

  28. Chest Traditional Sequence • Inspection. • Palpation. • Percussion. • Auscultation.

  29. Remember • Always describe the chest in terms ofanterior and posterior. • Describe the lungs as zones not lobes i.e. Upper/ middle/ lower zones

  30. Anterior View Posterior View

  31. Left Lateral View Right Lateral View

  32. 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.

  33. Inspection • Movements . • Equal symmetry or reduced on one side? • Respiratory effort, intercostalindrawing or use of accessory muscle .

  34. Kyphosis: Causes the patient to bend forward. X-Ray shows curvature of the spine.

  35. Pectusexcavatum: Congenital posterior displacement of lower sternum. The x-ray shows a concave appearance of the lower sternum.

  36. Barrel chest : In chronic lung hyperinflation (e.g.Asthma, COAD) Due to increased AP diameter of the chest.

  37. Scoliosis Is an increased lateral curvature of the spine . (i.e. Like the shape of the Letter “S”).

  38. Intercostal retraction