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Respiratory Examination. Dr Scarpa Schoeman – Dept Internal Medicine. Slides of Dr JM Nel Department Critical Care. 1. Positioning of the patient 2. General Appearance 3. The hands 4. The face 5. The trachea. 6. The chest 7. The heart 8. The abdomen 9. Other.

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respiratory examination

Respiratory Examination

Dr Scarpa Schoeman – Dept Internal Medicine

Slides of Dr JM Nel

Department Critical Care

respiratory examination1
1. Positioning of the

patient

2. General Appearance

3. The hands

4. The face

5. The trachea

6. The chest

7. The heart

8. The abdomen

9. Other

Respiratory Examination
positioning of the patient
Positioning of the patient
  • Undress to waist
  • Sitting position
  • Acutely ill
    • Lying down
general appearance
General appearance
  • 1.Dyspnoea
    • Signs of dyspnoea at rest
    • RR: 16- 25/min
  • 2.Cyanosis
    • Central cyanosis: tongue
  • 3.Cough character
general appearance1
General appearance
  • 4.Sputum
    • Colour/volume/type
    • Hemoptysis
  • 5.Stridor
    • Loudest on inspiration
  • 6.Hoarseness
the hands
The hands
  • 1. Clubbing
    • P51-Table 4.9
the hands1
Clubbing

Cardiovascular

Congenital cyanotic heart disease

Infective endocarditis

Respiratory (80% the cause)

Lung carcinoma

Chronic pulmonary suppuration

Idiopathic lung fibrosis

Cystic fibrosis

Asbestosis

Pleural mesothelioma

Gastrointestinal

Cirrhosis

Inflammatory bowel disease

Coeliac disease

COPD/TB does not give clubbing

The hands
the hands2
The hands

HPO

  • Periosteal inflammation
  • Clubbing marked
  • Distal end of long bones,wrists,metacarpal,metatarsal bones, knees, ankles
  • Swelling/Tenderness
the hands3
The hands
  • 2. Staining
    • Cigarette smoking
  • 3. Wasting and

weakness

    • Wasting small muscles
    • Weakness abduction
    • Infiltration of brachial plexus by lung CA
the hands4
4. Pulse rate

Pulse rate

Pulsusparadoxus

Systolic BP drop > 10mmHg

5. Flapping

tremor(Asterixis)

Dorsiflex hands

CO2 retention (COPD)

The hands
the face
The face
  • 1. Horner’s syndrome
    • Constricted pupil
    • Partial ptosis
    • Loss of sweating
    • Apical lung tumour
    • Compression of sympathetic nerves
the face1
The face
  • 2. Skin changes
    • Connective tissue diseases
the face2
The face
  • 3. URTI
    • Look inside mouth
  • 4. Sinuses
    • Look inside mouth
  • 5. SVC obstruction
    • Facial plethora or cyanosis
the trachea
The trachea
  • Position
  • Tracheal tug
    • COPD
the chest
The chest
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
the chest inspection
1. Shape and

symmetry of chest

shape

Barrel- shaped chest

Pigeon chest

Funnel chest

Harrison’s sulcus

Kyphosis, scoliosis, kyphoscoliosis

Lesions of chest wall

Movement of chest wall

The chest: Inspection
the chest inspection1
The chest: Inspection
  • Barrel- shaped chest
    • Increased AP diameter
    • Severe asthma/COPD
    • Normal elderly people
the chest inspection2
Pigeon chest(pectus carinatum)

Outward bowing sternum/costal cartilages

Chronic childhood resp infectons

Rickets

Funnel chest(pectus excavatum)

Developmental defect

Depression lower end of sternum

Severe: decreased lung capacity

The chest: Inspection
the chest inspection3
The chest: Inspection
  • Harrison’s sulcus
    • Linear depression lower ribs just above costal margins
    • Severe asthma in childhood
    • Rickets
the chest inspection4
The chest: Inspection
  • Kyphosis, scoliosis, kyphoscoliosis
    • Severe: reduced lung capacity
the chest inspection5
The chest: Inspection
  • Lesions of chest wall
    • Scars
      • Previous surgery
      • Previous ICD
    • Radiotherapy
      • Erythema
    • Subcutaneous emphysema
    • Prominent veins
      • SVC obstruction
the chest inspection6
The chest: Inspection
  • Movement of chest wall
    • Expansion
      • Upper lobes
        • From behind
        • Look down at clavicles
      • Lower lobes
        • From behind
        • Unilateral
          • Localized fibrosis, consolidation, collapse, pleural effusion
        • Bilateral
          • COPD, diffuse pulmonary fibrosis
the chest inspection7
The chest: Inspection
  • Movement of chest wall
    • Asymmetry
    • Paradoxical inward movement abdomen during inspiration
      • Diaphragm paralysis
the chest palpation
The chest: Palpation
  • 1. Chest expansion
    • Thumbs move symmetrical 5cm on inspiration
    • Lower lobe
      • From back
    • Upper lobe
      • From front
the chest palpation1
2. Apex beat

Displacement

Towards side of lesion

Collapse lower lobe

Localized fibrosis

Away from lesion

Pleural effusion

Tension pneumothorax

Impalpable

COPD: hyperinflation

The chest: Palpation
the chest palpation2
3. Vocal fremitus

Palm of hand

“99”

Differences

Increased: Consolidation

Same as vocal resonance

4. Ribs

Localized pain

Trauma, metastases, prolonged coughing

The chest: Palpation
the chest percussion1
The chest: Percussion
  • 1. Symmetrical
    • Ant/Post/Lat
    • Supraclavicular fossa over lung apex
    • Clavicle with finger
the chest percussion3
2. Interpretation

Resonant

Normal

Dull

Solid structure (liver)

Consolidation

Stony dull

Fluid- filled area (pleural effusion)

Hyperresonant

Over hollow structures

Bowel, pneumothorax

The chest: Percussion
the chest percussion4
3. Liver dullness

Upper level

5th / 6th rib MCL

If lower: hyperinflation

4. Cardiac dullness

Decreased

COPD

Asthma

The chest: Percussion
the chest auscultation
The chest: Auscultation
  • 1. Breath sounds
  • 2. Vocal resonance
the chest auscultation1
The chest: Auscultation
  • 1. Breath sounds
    • General
    • Quality of breath sounds
    • Intensity of breath sounds
    • Added sounds
the chest auscultation breath sounds
The chest: Auscultation(Breath sounds)
  • General
    • Diaphragm of stethoscope
    • Compare sides
    • Axilla
    • Bell of stethoscope above clavicles
      • Lung apices
the chest auscultation breath sounds1
The chest: Auscultation(Breath sounds)
  • Quality of breath sounds p125
    • Normal breath sounds (vesicular)
    • Bronchial breath sounds
    • Amphoric breath sounds
the chest auscultation breath sounds2
The chest: Auscultation(Breath sounds)
  • Normal breath sounds (vesicular)
    • Most of chest
    • Breath through mouth
    • Inspiration
      • Longer and louder than expiration
    • No gap between inspiration and expiration
the chest auscultation breath sounds3
The chest: Auscultation(Breath sounds)
  • Bronchial breathing
    • Hollow, blowing sound
    • Audible in expiration
    • Gap between inspiration and expiration
    • Expiration
      • Higher intensity than inspiratory
    • Normal posteriorly over upper chest
    • CONSOLIDATION
the chest auscultation breath sounds4
The chest: Auscultation(Breath sounds)
  • Amphoric breathing
    • Exaggerated bronchial quality
    • Very hollow (blowing over bottle)
    • LARGE CAVITY
the chest auscultation breath sounds5
The chest: Auscultation(Breath sounds)
  • Intensity of breath sounds
    • Normal or reduced
    • Reduced
      • COPD
      • Pleural effusion
      • Pneumothorax
      • Pneumonia
      • Large neoplasm
      • Pulmonary collapse
the chest auscultation breath sounds6
The chest: Auscultation(Breath sounds)
  • Added sounds
    • Continuous sounds (wheezes)
    • Interrupted sounds (crackles)
the chest auscultation breath sounds7
Continuous sounds (wheezes)

Musical

Inspiration +/- expiration

Airway narrowing

High pitched

Smaller bronchi

Asthma

Low pitched

Larger bronchi

COPD

Monophonic

Localized

Bronhial obstruction (Lung CA)

Stridor

Louder over trachea

Inspiratory

The chest: Auscultation(Breath sounds)
the chest auscultation breath sounds8
Interrupted sounds

(crackles)

Non-musical

Early inspiratory

Small airway disease

COPD

Medium coarseness

Late/pan-inspiratory

Disease in alveoli

Fine

Pulmonary fibrosis

Medium

LV failure

Coarse

Bronchiectasis

Retention of secretions

The chest: Auscultation(Breath sounds)
the chest auscultation breath sounds9
The chest: Auscultation(Breath sounds)
  • Pleural friction rub
      • Thickened pleural surfaces rub together
      • Grating sound
      • Causes
        • Pleurisy
          • Secondary to pulmonary infarction
        • Pneumonia
        • Malignant involvement of pleura
        • Spontaneous pneumothorax
the chest auscultation2
The chest: Auscultation
  • 2. Vocal resonance
    • Auscultation while patient speaks
    • Ability of lung to transmit sounds
    • Normal
    • Consolidation
      • Can hear “99”
      • Aegophony
        • Bee becomes bay
      • Whispering pectoriloquy
        • Can hear when whispers
the chest signs4
Hyperinflation

Increased AP diameter

Trageal tug

Apex not palpable

Hyperressonant percussion

Liver displaced downwards

No cardiac dullness

Soft heart sounds

The chest: Signs
the heart
The Heart
  • Measure JVP
    • Increased in RV failure
  • Listen to P2
    • Loud in pulmonary hypertension
the abdomen
The Abdomen
  • Liver examination
    • Displaced downward in hyperinflation
    • Enlarged in metastases (Lung CA)
other
Other
  • Pemberton’s sign
    • Lift arms over head one minute
    • SVC obstruction
      • Facial plethora
      • Cyanosis
      • Inspiratory stridor
      • Non-pulsatile elevation of JVP
other1
Other
  • Feet
    • Oedema
      • Cor pulmonale
    • DVT
      • PE