12.11.29 Respiratory exam

Observation

• • Jaundice (metastatic Ca)

  • Steroid use

    • Oral thrush

    • Facies

  • Symmetry of chest movement - from end of bed

  • Chest shape

  • Sputum pots

    • Bronchiectasis => LOADS of sputum

  • Chest drain

    • Check water level is swinging (right site)

    • If it's bubbling, pneumothorax is not fixed yet

Signs of cancer

• • Key differential!

  • Check:

    • Nutritional status

    • SVC obstruction

      • Raised JVP

      • Swollen face

    • Horner's

    • Wasting of dorsal interossei

Tracheal deviation

• • Slight deviation to the right is normal

  • If you suspect deviation, check to see if the mediastinum is shifted, by checking the apex beat

Tracheal tug

• • KEY SIGN

  • Indicates hyperexpansion

    • COPD

    • Acute asthma

  • Can operate to remove a bit of lung => Reduced hyperexpansion

Palpation

• • Check chest expansion in three areas

  • Don't forget lymph nodes - do them now, rather than forgetting them at the end

  • Do tactile resonance for exam purposes

Percussion

• • Compare sides

  • Tap from the wrist and bounce straight back

  • Don't mute sound by resting other fingers on chest

  • Reduced percussion note

    • Pleural thickening

    • Consolidation

Auscultation

• • 1 - Breath sounds

    • Vesicular or bronchial

  • 2 - Crackles

    • Fluid (heart failure)

    • Pneumonia

    • Fibrosis

    • Bronchiectasis

  • 3 - Wheeze

    • Asthma

    • COPD

    • Cardiac wheeze (fluid in small airways)

  • 4 - Air entry

    • Collapse

    • Effusion

    • Pneumothorax

    • Musculoskeletal

Other systems to examine

• • Spine (mets)

  • Abdo (liver mets)

  • CVS (mets)

Cor pulmonale

• • Think laterally!

    • Raised JVP?

    • Peripheral oedema?

    • RV overload - heave?

Ventilation

• • CPAP treats HYPOXIA

  • BiPAP is used for COPD

  • Key question - "Can they get out of the house"

    • If not, they won't ever get off ventilation, so don't bother

Atypical pneumonias

• • Big three

    • Chlamydia psittaci

      • Causes psittacosis

    • Legionella pneumophila

      • Causes a Legionnaires' disease - very severe

    • Mycoplasma pneumoniae

    • Usually occurs in younger age groups and may be associated with neurological and systemic symptoms

  • Others

    • Chlamydophila pneumoniae

      • Mild form of pneumonia with relatively mild symptoms

    • Coxiella burnetii

      • Causes Q fever

    • Francisella tularensis

      • Causes tularemia

Causes of COPD exacerbations

• • Definition

    • Sustained worsening of the patient's symptoms from his or her usual stable state, which is beyond normal day-to-day variations and is acute in onset

  • Bacterial infection

    • Streptococcus pneumoniae

    • Haemophilus influenzae

    • Moraxella catarrhalis

  • Viral infection

    • Rhinoviruses

    • Influenza

    • Parainfluenza

    • Coronavirus

    • Adenovirus

    • RSV

  • MI

  • Pollutants

  • Cold ??

COPD subtypes

• • Blue bloater

    • Primarily bronchitis

    • Capillary bed is unchanged => Big VQ mismatch

      • Causes hypoxaemia, hypercapnia, polycythaemia

    • Hypoxia causes pulmonary vasoconstriction

    • Leads to

      • Cor pulmonale

      • Peripheral oedema

    • These patients end up dependent on hypoxic drive

  • Pink puffer

    • Primarily emphysema

    • Destruction of gas exchange surface but also capillary bed => Less VQ mismatch

    • Can compensate by puffing

    • => Maintain relatively normal blood gases

Sequential nephron blockade

• Use more than one diuretic, which different MOA

• Breaks resistance to diuretics in edematous states

• e.g. Furosemide + acetazolamide

• e.g. Loop diuretic + metolazone (thiazide)

Eisenmenger's syndrome

• • Combination of systemic-to-pulmonary communication, pulmonary vascular disease, and cyanosis

  • e.g. Reversal of flow down PDA, following pulmonary hypertension

• Causes differential clubbing (feet first) due to where the PDA comes off

CXR findings

• • Check for a fluid level in the costophrenic angles, to distinguish pleural effusion from breast shadowing

  • Fibrosis vs bronchiectasis

    • Both reticulonodular

    • Fibrosis

      • Pulls diaphragm up

      • Obscures R heart border

    • Bronchiectasis

      • Ring sign (dilated, inflamed, end-on airways)

      • Tram lines (dilated, inflamed, side-on airways)

Notes

• • Need >5 g/dl of deoxygenated Hb to cause cyanosis

    • => Harder to pick up if anaemic

  • CO2 flap = Asteristix

  • Senile tremor

    • Essential tremor tends to become worse with age

  • IPF is the most common cause of fibrosis

  • Fine vs Coarse crackles is so subjective it is meaningless

• Pancoast tumor

  • Tumour of the pulmonary apex

  • Characteristically causes Horner's syndrome

• Flecainide

  • • Very proarrhythmic in patients with:

      • CAD

      • CHF

      • Ventricular dysrhythmias

    • Used primarily in atrial fibrillation when concerns for proarrhythmias are not present

  • TIMI score

    • Used to categorize the risk of death and ischemic events in unstable angina or NSTEMI