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Respiratory System Examination - OSCE

this file includes the steps of examination of both the anterior and posterior chest.
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Respiratory System Examination - OSCE

  1. 1. Respiratory system examination
  2. 2. Before starting any examination …. 3P + 2E Privacy Permission Para-patient Exposure Explanation
  3. 3. Respiratory examination include 1. General examination related to chest 2. Examination of chest from anterior 3. Examination of chest from posterior
  4. 4. General examination
  5. 5. Genera examination related to respiratory system 1. General observations  RR, Body mass, Fever, confusion, mental status, distress and demeanour, jaundice? 2. Hands  Cubbing, peripheral cyanosis, tobacco staining, flapping tremor, fine tremor, yellow nails? 3. Neck  LAP, JVP, Accessory muscle use? 4. Face  Centra lcyanosis, ptosis or Hornor’s syndrome, bursing lips, nasal flare, anemia? 5. Chest  Chest expansions, deformities, pattern of breathing? 6. Abdomen  Sacral edema? 7. Legs  DVT, Bilateral odema?
  6. 6. Regarding General exam … • You must calculate RR in general examination .. • You must count RR in all patients with SOB • Accessory respiratory muscles are SCM, Trapezius and platysma.
  7. 7. Adverse signs of community acquired pneumonia • Confusion (altered mental status). • Blood pressure – diastolic <60 mmgH. • RR > 30 breaths/min. • Age > 65 years old.
  8. 8. What cause cyanosis? Central cyanosis • Arterial hypoxemia Peripheral cyanosis • Circulatory disorders • Severe central cyanosis • In patients with signs of anemia or hypovolemia you may not see cyanosis. • Patients with polycythemia become cyanosed at higher arterial oxygen concentration level.
  9. 9. BP and Pulse in respiratory system • Diastolic BP <60 mmHg is an adverse sign of CAP. • Hypotension is also seen in pneumothorax. • Pulsus paradoxicus is exaggerated pulse variation with respiration is seen in asthma (not indicate the severity) • Fall in pulse volume or systolic fall >10mmHg in inspiration is abnormal and indicate cardiac tamponade.
  10. 10. Cor pulmonale • Chronic hypoxia in COPD • Pulmonary arterial vasoconstriction • Pulmonary HTN • Right-sided heart dilation • Peripheral edema • Raised JVP
  11. 11. Causes of raised JVP in respiratory • Chronic hypoxia in COPD (PHTN) • Tension pneumothorax, • Severe acute asthma • Massive pulmonary embolism
  12. 12. SVCO • Red eye (unilateral) • Causes • 3Ts • Tumors (lung cancer, lymphoma, thymoma, mediastinal fibrosis) • Thrombus • Trauma
  13. 13. Examining chest from anterior
  14. 14. Inspection 1. symmetry 2. Expansion of chest 3. Deformities (scoliosis, kyphosis) 4. Shape of chest (tunnel shaped, barrel shaped, pigeon chest?) 5. Pattern of breathing 6. Accessory muscles 7. JVP 8. Scars 9. Masses (lipoma, metastatic tumor nodulels, neurofibroma) 10. Dilated veins (SVCO) 11. Vascular anomalies 12. Intercostal recession
  15. 15. Palpation 1. Tenderness 2. Apex beat 3. LNs (axillary, neck) 4. Trachea position and tracheal tag 5. Chest expansion (by tape measure or with hands) : for upper lobes and lower lobes. 6. Vocal fremitus
  16. 16. Palpitation • Bilateral reduced chest expansion is seen in severe COPD and diffuse pulmonary fibrosis. • Subcutaneous emphysema is a complication of intercostal drainage and it may complicates (1) severe acute asthma (2) pneumothorax and (3) rupture of esophageous. • Hamman’s sign is a cruching systolic sound indicate a mediatineal emphysema.
  17. 17. Tracheal tag • Measuring distance between suprasternal notch and cricoid cartilage • Normally it is 3-4 fingerbreadths (‫بالطول‬) • Less distance suggests hyperinflation
  18. 18. Position of trachea • Upper mediastinum shifting = change in tracheal position. • Lower mediastinum shifting = change in apex beat location.
  19. 19. Sites that needed to be percussed in anterior chest examination
  20. 20. Percussion • Resonant = normal lung • Hyper-resonant = COPD, Pneumothorax • Dull = consolidation, collapse, fibrosis • Stony dull = pleural effusion, hemothroax, hydatid cyst
  21. 21. Percussion • The percussion on clavicles is directly.
  22. 22. Vocal fremitus • Ask patient to say 44 (in Arabic) • Put your palm (base of fingers) in this areas • Increased vocal fremitus seen in consolidation and fibrosis. • Decreased (muffled) focal fremitus seen in pleural effusion and collapse (pneumothorax).
  23. 23. Auscultation 1. determine air entry to lung • Good air entry, diminished or absent • Determine breath sound • Vesicular • Bronchial • Vesicular with prolonged expiratory phase • Determine add sounds • Crackles • fine or coarse, • inspiratory early mid late or biphasic, • changing with cough) • Wheeze • Localized, diffused or scattered • Inspiratory, expiratory or biphasic • Changing with cough • Pleural rung • Pneumothorax click • Vocal resonance
  24. 24. Diminished vesicular breathing • Obesity; • Pleural effusion; • Marked pleural thickening; • Pneumothorax; • Hyperinflation (COPD); • Over area of occluded major bronchus;
  25. 25. Bronchial breath sound • They are audible In normal people, posteriorly over the right upper chest where the trachea is contiguous with the right upper bronchus. Other than this site this type of breath sound is considered abnormal • Causes 1. Consolidation 2. Collapse 3. Fibrosis 4. Over pleural effusion • Bronchial breathing exclude the possibility of lung cancer.
  26. 26. Crackles (rales, crepitations) • Pleural effusion do not produce crackles ( outside lung ). • Crackles caused by the opening of collapsed distal airways and alveoli • Crackles results from collapsed peripheral airways on expiration.
  27. 27. wheeze • Mainly heard during expiration • An inspiratory wheeze implies severe airway narrowing. • In general, expiratory wheeze is usually due to bronchial asthma, or COPD • Inspiratory wheeze is usually due to infection, tumour or foreign body. • Biphasic wheeze is usually due to infection and COPD
  28. 28. Pleural rub and pneumothorax click Pleural rub • Best heard at the end of inspiration and at the beginning of expiration. • Did not change with cough to be distinguished from crepitations • Pericardial rubs persist after patient stop breathing. Pneumothorax click • Heard in systole • Due to pneumothorax overlying heart
  29. 29. Sites that needed to be auscultated in anterior chest examination are the same that were percussed except the clavicles.
  30. 30. Vocal resonance • Ask patient to say 44 (in Arabic) 2 times (high and whisper) • Put your stethoscope in this areas • In normal lung, whisper is not heard, and it become heard at area of consolidation. • Spoken numbers are audible on area of consolidation and also normal lung, and become muffled on collapse (pneumothorax) or pleural effusion areas.
  31. 31. Auscultation • Lung sounds are bestheard with the bell (they are low pitch sounds) • The patient must be relaxed are breathing deeply from his muth. • Auscultate each side alternately. • avoid auscultation for 3 cm from the midline.
  32. 32. IF bronchial breathing, Then candidate may asked to do Egophony OR pectoriloquy
  33. 33. Egophony • Egophony is said to be present when the spoken word heard through the lungs is increased in intensity and takes on a nasal or bleating quality. • The patient is asked to say (eeee) as in 'bee' whiles the candidate listens to an area in which consolidation is suspected. If egophony is present, the (eeee) will be heard as (aaaa) as in 'bay'. This (e to a) change is seen in consolidation of lung tissue. The area of compressed lung above a pleural effusion often produces egophony.
  34. 34. Pectorloquy • Whispered pectoriloquy is the term for the intensification of the whispered word heard in the presence of consolidation of the lung. The patient is instructed to whisper (one-two-three) while the candidate listens to the area suspected of having consolidation. Normally, little or nothing may be heard when one listens to a normal chest. • However, if consolidation is present, the transmission of the spoken words will be increased, and the words will be clearly heard
  35. 35. Examining chest from back
  36. 36. Inspection 1. symmetry 2. Expansion of chest 3. Deformities (scoliosis, kyphosis) 4. Shape of chest (tunnel shaped, barrel shaped, pigeon chest?) 5. Scars 6. Masses (lipoma) 7. Intercostal recession 8. Rush (herpes zoster infection) 9. Winging scapula
  37. 37. • Penetrating injury affecting long thoracic nerve.
  38. 38. Palpitation 1. Tenderness 2. LNs (axillary, neck) 3. Chest expansion (by tape measure of with hands) 4. Vocal fremitus
  39. 39. Percussion
  40. 40. Auscultation
  41. 41. Clubbing in respiratory case means …..
  42. 42. Lung cancer, bronchiectasis, interstitial lung disease put in mind also congenital cyanotic heart disease inflammatory bowel diseases celiac disease
  43. 43. Skin lesions associated with respiratory diseases
  44. 44. Erythema nodosum (TB and sarcoidosis) Metastatic skin nodule of lung cancer raised firm non-tender, subcytaneous
  45. 45. Yellowish discoloration of nails …..
  46. 46. Jaundice , then think of : BRONCHIOECTASIS “yellow nail syndrome” is associated with lymphedema and exudative pleural effusion.
  47. 47. Using of accessory respiratory muscles
  48. 48. Early sign of airway obstruction severe COPD acute severe asthma
  49. 49. Paradoxical movement of chest and abdomen
  50. 50. Severe respiratory failure Bilateral phrenic nerve lesions
  51. 51. Using lips during expiration?
  52. 52. Increase end-expiratory pressure Reducing small airway collapse Improve ventilation
  53. 53. Stridor in children less than 2 years ?
  54. 54. Parainfluenza laryngeo-trachea-bronchitis
  55. 55. Hypertrophic pulmonary osteoarthropathy
  56. 56. Always associated with lung cancer usually squamous cell carcinoma.
  57. 57. Fine tremors
  58. 58. B agonists theophylline bronchodilators
  59. 59. How to confirm that a patient have SVCO
  60. 60. Raised his arm above head and observation of 1) fascial flushing 2) distension of neck veins 3) stridor
  61. 61. Displacement of cardiac apex without tracheal deviation
  62. 62. LVH scoliosis, kyphosis and pectus excavatum
  63. 63. Cardiac apex beat are hard to localized in …
  64. 64. Obesity, pericardial effusion poor left ventricular function lung hyperinflation (COPD)
  65. 65. Heave of RVH is due to -------- and best felt at -----------------------.
  66. 66. Pulmonary hypertension left sternal edge
  67. 67. Resonant note below 5th intercostal level at left side
  68. 68. Hyperinflation (COPD and severe asthma)
  69. 69. Bronchial breath sound is seen in all except a. lung cancer b. fibrosis c. consolidation d. at end of pleural effusion
  70. 70. Bronchial breathing exclude lung cancer
  71. 71. Mid expiratory squeak is seen in ……….
  72. 72. Obliterative bronchiolitis; a rare complication of RA.