Respiratory Examination

The respiratory examination involves an assessment of how a patient's lungs are functioning. Like most examination, it is a systemic examination that looks for signs of respiratory compromise such as breathlessness, chest pain, haemoptysis or wheeze. It is one of the key clinical examinations of OSCE finals. Therefore it's important to have a slick and thorough approach. It is only once your are confident in performing this examination that you can look out for and identify signs of respiratory diseases such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, asthma, pneumonia etc.

Introduction

Wash hands

Wash your hands using the Ayliffe technique

2. Introduce yourself

Introduce yourself and give your name and grade

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“Hi, my name is John Smith and I am a 4th year medical student”

3. Check patient details

Clarify patient's identity by confirming name and asking for their DOB

4. Describe examination

Explain what examination you are performing and what it involves

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“I have been asked to perform a Respiratory examination on you today. This involves having a look at your hands and face, and having a feel and listen of your chest”

5. Gain verbal consent

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“Would this be ok with you?”

6. Offer a chaperone

Ask if they would like a chaperone

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“The exam involves you having to remove your upper garment. Would you like a chaperone for the exam?”

Peripheral Examination

Positioning patient at 45 deg

Initially lye the patient at 45 degrees and expose them from waist up

2. End of bed inspection

Inspect the patient from the end of the best and look for the following:

Patient

Breathing (tachypnoea, pattern of breathing, accessory muscles, nasal flaring, subcostal/intercostal recession)Cyanosis (central or peripheral)
weight loss (cachexia)
Chest shape (pectus excavatum/carinatum, barrel chest)

Adjuncts

eg. any supplemental O2 (%), IV lines, infusions, catheter

Paraphernalia

inhalers, nebulisers, sputum pots, walking aids

3. Inspect the hands

Inspect the hands and check for stigmata of chronic Respiratory disease

Skin

Peripheral cyanosis (Poor oxygenation)
Tar staining (Smoker)

Temperature

Cold hands - poor circulation (cor pulmonale)

Nails

Clubbing - Tumours (lung cancer, mesothelioma, pleural fibroma), interstitial lung disease (IPF), bronchiectasis, empyema, lung abscess, CF
Yellow nails - Yellow nail syndrome, tar staining
Koilonychia - iron deficiency

4. Check pulse and respiratory rate

Check the patient's pulse and resp rate. Time for 15 seconds and multiply by 4.

Tachycardia/tachypnoea
Irregular (AF)

5. Check for tremor and CO2 flap

Ask the patients to put their hands in front of them and check for tremor. Then ask them to cock their wrists back as if they were stopping traffic. Check for any flapping.

Asterixis (hypercapnia)
Tremor (excess use of beta-agonist or theophylline)

6. Inspect the face and neck

Next, inspect their eyes, mouth and neck for the following.

Eyes

Pale conjunctiva (anaemia)
Ptosis/miosis - Horners syndrome (Pancoast’s Tumour)

Mouth

Blue tongue (central cyanosis)
Oral candida (Steroid use)
Glositis - large tongue (iron deficiency)
Angular cheilitis - cuts to edge of lips (iron deficiency)

Neck

Raised JVP

Sign of fluid overload
Increased intrathoracic pressure - tension pneumothorax
SVC obstruction - raised and non waveform

Tracheal deviation

Towards lesion (lobe/lung collapse, fibrosis, pneumonectomy)
Away from lesion (tension pneumothorax, massive pleural effusion)

Cricoid-sternal space (reduced in hyperinflation eg. COPD)

Lymphadenopathy (Pancoast’s Tumour, Lung Ca, Lymphoma)

Chest examination (FRONT)

1. General Inspection at front

Inspect the chest again more closely and look for the following:

Breathing

Use of accessory muscle
Pattern of breathing
Paradoxical abdominal breathing - inward movement of abdomen in inspiration (severe COPD)

Shape

Hyperinflation or barrel chested, pectus excavatum/carinatum

Scar (Pneumonectomy scar, lobectomy, mastectomy)

2. Palpation of the chest at front

Palpate the chest for the following

Apex beat (Normally 5th IC space mid-clavicular line)

Displaced laterally (enlarged heart ?cor pulmonale)

Chest expansion

bilateral reduction - COPD and diffuse pulmonary fibrosis,
unilateral - effusion, collapse, pneumothorax

3. Percussion of the chest at front

Percuss the chest from the front. Make sure you percuss 6 places at the front and 2 places on the side on both the right and left side, comparing as you go along. Go down as far as the 6th rib.

Hyper resonant - pneumothorax
Dull - consolidation, collapse,
Stoney dull - effusion, haemothorax

4. Auscultation of the chest at front

Now listen to the front of the chest over the places you have just percussed. Ask the patient to take deep breaths in and out of their mouth.

Wheeze - narrowing of distal airways (COPD, Asthma)
Crackles - peripheral airway collapse (Early inspiratory - Bronchiolitis, Mid inspiratory - pulmonary oedema, Late inspiratory - pulmonary fibrosis, Pan Insp & Exp - Bronchiectasis)
Bronchial breathing - consolidation around airway (pneumonia, fibrosis)
Pleural rub - friction between parietal and visceral pleura (pneumonia, pulmonary infarction)

5. Vocal resonance and tactile fremitus at front

Then check for:

Vocal resonance (ask the patient to say “99” and listen with a stethoscope)
Tactile fremitus (ask the patient to say “99” and feel the chest wall).

Chest examination (BACK)

Now examine the the patient at the back.

6. General Inspection at back

Inspect the chest again more closely and look for the following:

Shape

Kyphosis, scoliosis

Scar (Pneumonectomy scar, lobectomy)

7. Palpation of the chest at back

Palpate the chest for the following:

Chest expansion

bilateral reduction - COPD and diffuse pulmonary fibrosis,
unilateral - effusion, collapse, pneumothorax

8. Percussion of the chest at back

Percuss the chest wall from the back. Make sure you percuss 6 places on both the right and left side going down as far as the 11th rib.

Hyper resonant - pneumothorax
Dull - consolidation, collapse,
Stoney dull - effusion, haemothorax

9. Auscultation of the chest at back

Now listen to the back of the chest. Make sure you compare the right side to the left. Listen over the 6 places you percussed on both the right and left side.

Wheeze - narrowing of distal airways (COPD, Asthma)
Crackles - peripheral airway collapse (Early inspiratory - Bronchiolitis, Mid inspiratory - pulmonary oedema, Late inspiratory - pulmonary fibrosis, Pan Insp & Exp - Bronchiectasis)
Bronchial breathing - consolidation around airway (pneumonia, fibrosis)
Pleural rub - friction between parietal and visceral pleura (pneumonia, pulmonary infarction)

10. Vocal resonance and tactile fremitus at back

Then check for:

Vocal resonance (ask the patient to say “99” and listen with a stethoscope)
Tactile fremitus (ask the patient to say “99” and feel the chest wall).

End of examination

Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

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“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”

2. State other exams for completion

Turn to the examiner and state what else you would do to complete the exam.

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“To complete the examination I would check the the patient’s O2 sats and BP. I would also get them to perform a Peak Flow and ask the nurses to perform an ECG.”

3. State what tests you would perform

Explain to the examiner what tests and investigations you would perform

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Urine

Dip - Proteinuria
Urine - Atypical pneumonia screen

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Sputum

MC&S

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Bloods tests

FBC - anaemia/infection
U&E - baseline
LFT - Signs of sepsis, signs of metastases
CRP / ESR - signs of inflammation
Atypical pneumonia screen

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Erect CXR

Pneumothorax, signs of consolidation/effusion/collapse, metastases. Cardiomegaly / pulmonary oedema.