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Respiratory examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose and sit patient at 45⁰

General inspection

  • Observe from the foot of the patient’s bed
  • Do they look well/unwell?
  • Consider if they are alert, comfortable, breathless
  • Look for cachexic (malignancy, emphysema) or cushingoid (steroid use)
  • Observe the patient’s breathing
    • Note any use of accessory muscles (COPD, pleural effusion, pneumothorax, severe asthma)
    • Pursed-lip breathing (prevents bronchial wall collapse by keeping airway pressure high in severe airway obstruction/emphysema)
  • Listen for breathing noises
    • Speech abnormalities (e.g. in recurrent laryngeal nerve palsy)
    • Stridor (large airway obstruction e.g. mediastinal masses, bronchial carcinoma, retrosternal thyroid)
    • Wheeze
    • Cough (dry/productive/bovine)
    • Prolonged expiratory phase (asthma, COPD)
    • Clicks (bronchiectasis)
    • Gurgling (airway secretions)
  • Around the bed: oxygen, medication (e.g. inhalers, nebulisers), sputum pots (look at sputum), cigarettes

Hands

  • Examine for tremors
    • Fine tremor: patient should hold arms out straight, with their fingers spread (fine tremor may be caused by β2 agonists)
    • Asterixis (flapping tremor): patient should hold their arms out straight, with their wrists ‘cocked back’ (flap = CO2 retention)
  • Check perfusion
    • Look for peripheral cyanosis (hypoxia or hypoperfusion)
    • Check their capillary refill by pressing for 5 seconds then releasing the pressure and observe how long it takes for perfusion to return (>2 seconds is classed as hypoperfusion)
    • Are there hands sweaty/warm/clammy? (CO2 retention)
    • Look for small muscle wasting (Pancoast tumour)
  • Nails
    • Look for clubbing by asking the patient to place their two index finger nails together – Schamroth window test (idiopathic pulmonary fibrosis, lung cancer, CF, bronchiectasis)
    • Check for tar-stained fingers (smoker)

Pulse and respiratory rate

  • Radial pulse
    • Calculate rate over 30 seconds and also note rhythm (tachycardia may indicate: hypoxia in severe asthma or COPD, PE or infection)
    • Consider if there is a bounding pulse (i.e. increased up-stroke and down-stroke; CO2 retention)
  • Count respiratory rate while patient still thinks you are feeling pulse: tachypnoea (lung disease, infection, hyperventilation, fever, PE), bradypnoea (central nervous system depression)

Head and neck

  • Look at the patient’s face
    • Cushingoid features (steroid use)
    • Plethoric (secondary polycythaemia; Cushing’s syndrome; superior vena cava obstruction if facial swelling)
    • Features of autoimmune disease, e.g. telangiectasia/microstomia (systemic sclerosis), butterfly rash (SLE), lupus pernio (sarcoid), lupus vulgaris (TB)
  • Eyes
    • Ask permission from the patient then pull down the lower eyelid to look for conjunctival pallor (anaemia of chronic disease),
    • Look for Horner’s syndrome (ptosis, miosis, anhidrosis; Pancoast tumour)
  • Mouth: look for central cyanosis under tongue (hypoxia)
  • Neck
    • JVP: ask the patient to rest their head back and turn head slightly, then look for double pulsation of internal jugular vein – up to 3cm above sternal angle is normal (raised in cor pulmonale)
    • Tracheal deviation: place your right hand’s index and ring fingers on each clavicle head. Roll your middle finger over the trachea in the sternal notch. (Pneumothorax pushes to contralateral side; collapsed lung pulls to ipsilateral side.)
    • Cricosternal distance and tracheal tug: place your right hand’s index on the inferior border of the cricoid. Now place subsequent fingers in the midline until you reach the sternal notch (<3 fingers = lung hyperinflation). Note reduction in inspiration (‘tracheal tug’).

Chest

You should examine the front first and repeat everything on the back afterwards.

  • Inspect the chest closely, look at:
    • Chest wall
      • Scars (look under arms as well as on back)
      • Skin changes, trauma
      • Deformities (pectus carinatum may be related to childhood respiratory disease; pectus excavatum may be related to connective tissue disease; barrel chest in emphysema or COPD)
      • Kyphosis/scoliosis (restrict chest movements)
      • Radiotherapy tattoos
    • Chest wall movements
      • Mainly upwards (emphysema)
      • Asymmetrical (fibrosis, collapsed lung, pneumonectomy, pleural effusion, pneumothorax)
    • Breathing
      • In-drawing of intercostal muscles (generalised = hyperinflation; localised = bronchial obstruction)
      • Powerful expirations (asthma, COPD)
      • Hyperexpanded chest (COPD)

  • Palpation
    • Supramammary and inframammary chest wall expansion: grip very hard around rib cage with thumbs in the air almost touching in expiration. Watch thumbs move away from each other during inspiration (normally ≥5cm).
    • Feel for RV heave by placing the heel of your right hand over the patient’s left lower parasternal edge with a straight elbow (pulmonary hypertension)
  • Percussion: compare left with right – start above clavicles and progress down to axilla
    • Normally resonant
    • Dull = consolidation or collapse
    • Stony dull = pleural effusion
    • Hyperresonant = increased air space, e.g. in pneumothorax or emphysema

NB: the liver starts at the 5th intercostal space on the right.

How to… Percuss

  • Use your non-dominant hand as a firm base on the patient’s skin
  • Use your dominant hand’s middle finger to strike your non-dominant hand’s middle finger
  • Bend your dominant hand’s wrist to provide force (do not move the arm itself)
  • Deliver two quick blows at a time

  • Auscultation
    • Standard auscultation: ask patient to breathe in and out deeply through their open mouth. Compare sides in turn, starting in supraclavicular area and ending in axillae.
    • Vocal resonance: listen in all areas again while the patient repeats ‘ninety-nine’ (increased resonance = consolidation; decreased resonance = effusion/pneumothorax)
    • Listen for loud S2 over pulmonary valve area (loud pulmonary S2 = pulmonary hypertension)
    • Repeat all on back: now ask patient to sit over bedside with crossed arms and percuss, auscultate and assess vocal resonance again on the back

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Suggested percussion/auscultation positions
Decreased air entryEmphysema, pneumothorax, pleural effusion, collapse
WheezeAsthma, COPD
Coarse crepitationsBronchiectasis, consolidation
Fine inspiratory crepitationsPulmonary oedema
Fine end-inspiratory crepitations (like Velcro)Pulmonary fibrosis
Bronchial breathing (harsh breath sounds)Consolidation
Pleural rub (grating sound)Pleurisy, pulmonary infarction, pneumonia, pleural malignancy
Abnormal breath sounds

Finally

  • Cervical lymph nodes: examine for cervical lymphadenopathy from posteriorly while the patient is still sitting forward (infection, carcinoma, lymphoma, sarcoidosis)
  • Legs
    • Examine for peripheral oedema by pushing over the tibia for 10 seconds, then run finger over feeling for indent (cor pulmonale)
    • Feel calves (swollen/tender = DVT)

To complete

  • Thank patient and restore clothing
  • ‘To complete my examination, I would like to review the observations chart (particularly to see oxygen saturations), and measure peak flow (if asthmatic).’
  • Summarise and suggest further investigations you would consider after a full history

Why don’t you test your knowledge on examination findings?

How about some advanced signs?

Here’s some questions on some of the conditions you may see

Now it’s time for you to try some OSCE stations

  1. Start with a normal respiratory exam
  2. Now try some pathology
  3. Here’s a pneumonectomy station
  4. And a patient with pulmonary fibrosis
  5. Let us help you! Hundreds of stations available here.

Picture references

Peripheral cyanosis: 2011 James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

Clubbing: 2009 Desherinka, licensed under the Creative Commons Attribution-Share Alike 4.0 International, 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic license and GNU Free Documentation licence 1.2

Tar staining: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

Butterfly rash: 2003. Doktorinternet. Licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

Lupus pernio: M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara: Cutaneous lesions of the nose. In: Head & face medicine Band 6, 2010, S. 7, ISSN 1746-160X. doi:10.1186/1746-160X-6-7. PMID 20525327. (Review). Open Access

Cushing’s facial appearance: 2012. Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu and Pinar Kadioglu. Licenced under Creative Commons Attribution 2.5 Generic license

Horner’s syndrome: Nautiyal A, Singh S, DiSalle M, O’Sullivan J (2005) Painful Horner Syndrome as a Harbinger of Silent Carotid Dissection. PLoS Med 2(1): e19 doi:10.1371/journal.pmed.0020019

Pectus excavatum: 2006 Ahellwig, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license and GNU Free Documentation licence 1.2

Pectus carinatum: 2010 Tolson411, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license, edited

Barrel chest: 1912. Cabot R, Clarke R. Physical diagnosis. New York William Wood and Company

Peripheral oedema: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

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