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Respiratory examination

Check out the basics of examination.

General Examination

Say: "Patient looks generally well, pink on air, no evidence of dyspnoea or tachypnoea and no obvious scars, deformity or other abnormality."

Look to see if the patient is short of breath, on oxygen, has a nebuliser, inhaler, is intubated or anything that is aiding their breathing. Check for accessory muscle breathing (caused by anything that makes breathing more difficult) or an abnormal breathing pattern (e.g. Cheynes-Stokes respiration which is periodic dyspnoea, episodes lasting only for a few breaths at a time).

Hands

Say: "no finger clubbing, tar staining or asterixis present"'

  • Pulse: assess rate and rhythm (radial); and character and volume (carotid) - it's bounding in CO2 retention; do respiratory rate here; look for pulsus paradoxus - large decrease in BP during inspiration (small decrease is normal).

Say: "regularly regular pulse at a rate of 80 bpm, respiratory rate of 12, no abnormalities in character or volume"

Face

  • General: swollen face - SVC obstruction.
  • 'Eyes: anaemia (pull eyelids down); Horner's syndrome (ptosis of one eye, miosis of the other) - Pancoast tumour (apical lung tumour) on ptosed side; chemosis (conjunctival oedema) - hypercapnia.
  • Mouth: look for cyanosis; dental caries - can cause lung abscess.

Say: "No swelling, no anaemia in the eyes, no Horner's syndrome, no central cyanosis". You only need to comment on the other stuff if you remember it.

Neck

Say: "no raised JVP, carotid pulse of normal character and volume and no tracheal deviation"

Chest

Inspect

  • Shape - barrel chest - hyperinflation in emphysema; kyphoscoliosis; pectus excavatum (funnel chest); pectus carinatum (pigeon chest); scars; muscle wasting.
  • Breathing - tachypnoea - look for Cheyne-Stokes respiration (periodic dyspnoea and tachypnoea); dyspnoea; accessory muscle use - signs of fatigue; abdominal breathing (as opposed to diaphragmatic); recessions (more common in kids but essentially there are dips between the ribs and below the ribs on expiration - intercostal and subcostal) - laryngeal/tracheal obstruction

Say: "no abnormalities of the chest wall. No obvious tachynoea or dyspnoea or other evidence of trouble breathing".

Palpate

Say: "apex beat in the mid-clavicular line, 5th intercostal space, chest expansion normal and symmetrical, normal tactile fremitus".

Percuss

Start at the apices, working down the chest wall, alternating sides so you compare like with like. Percuss in axillae.

Say: chest is resonant with no dullness all over.

Auscultate

  • Breathing: go down the mid-clavicular line, listening to about six places overall and make sure you keep alternating side. Then, listen in the axillae, four places altogether. Crepitations/crackles (crackling sound on breathing)- usually a sign of consolidation (pneumonia) or fluid (heart failure); bronchial breathing (harsh, poor breath sounds_ - fluid in heart failure, consolidation in pneumonia, pulmonary fibrosis; rhonchi/wheeze (musical note) - acute asthma, COPD, bronchiectasis, CF, pulmonary fibrosis; pleural rub (grating sound) - PE, pneumonia (consolidation).
  • Vocal resonance: listen in the same places as for normal breathing but ask the patient to say "ninety-nine" as with tactile fremitus. Increased - consolidation in pneumonia; reduced - pleural effusion, pneumonthorax. You can do whispering pectolirquy (same as vocal resonance but they whisper "two-two-two") which is increased in consolidation.

Back

Do exactly the same as the front (that is inspect, palpate, percuss, ausculate) plus palpate for cervical lymph nodes. Usually you'll hear more in the back than the front so actually it's probably more important.

Extras

  • Look for pedal or sacral oedema - heart failure, IVC obstruction (with pedal)
  • Peak flow
  • Sputum pot