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