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

• Inspect: finger clubbing - lung cancer, CF, bronchiectasis, pulmonary fibrosis; tar staining, yellow nails - smoking; intrinsic muscle wasting - T₁ invasion by apical lung cancer. Fine tremor due to salbutamol or asterixis (flapping of wrists during maintenance of extension) due to CO₂ retention.

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

• Inspect: raised JVP - SVC obstruction (non-pulsatile), cor pulmonale/right heart failure (pulsatile)
• Palpate: carotid pulse (for character and volume) - bounding in CO₂ retention; tracheal deviation (feel either side of the trachea) towards pathology - pulmonary fibrosis, lung collapse; devation away from pathology - tension pneumothorax, massive pleural effusion.

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

• Apex beat: deviation towards pathology - pulmonary fibrosis, lung collapse; deviation away - tension pneumothorax, massive pleural effusion.
• Expansion: put your hands around their chest so your thumbs are meeting. They should seperate equally on inspiration and touch again on expiration. Asymmetry - consolidation due to pneumonia, pneumothorax, lung cancer, lung collapse; reduced - COPD, bronchiectasis.
• Tactile fremitus - put the edges of your hands against the chest wall and ask the patient to say "ninety-nine". Increased - consolidation in pneumonia; reduced - pleural effusion, pneumothorax.

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.

• Dull - consolidation in pneumonia, fluid in pleural effusion
• Hyperesonant - usually in an expanded chest in COPD or bronchiectasis

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