Respiratory Exam

Question 1

General inspection from end of bed of the patient

Answer 1

• comfortable, calm, alert, breathless, any pallor, cyanosis, scars, cachexia
• general breathing: able to speak, use of accessory muscles (COPD, pleural effusion, severe asthma), purses legs
• normal speech (obstruction, laryngeal palsy), stridor (large airway obstruction, bronchial carcinoma), wheeze, cough (dry, bovine, productive), prolonged exploratory phase (asthma, COPD), clicks (bronchiectasis), gurgling (airway secretion)

Question 2

What do you look for around the bed?

Answer 2

• pt on oxygen?
• medications (MDI, nebulisers)
• peak flow meter
• sputum pots
• cigarettes
• walking aids

Question 3

What do you inspect the nails for?

Answer 3

• clubbing (Idiopathic pulmonary fibrosis, lung cancer, CF, bronchiectasis, sarcoidosis)
• hypertrophic pulmonary osteoarthropathy (HPOA, clubbing)
• tar stains

Question 4

What do you look for in the palms?

Answer 4

• peripheral cyanosis
• cap refill (septic shock)
• sweaty, red, clammy (CO2 retention)
• small muscle wasting (T1 nerve invasion by Pancoast tumour)
• cold (peripheral vasoconstriction/ poor perfusion)

Question 5

What else would you look for in the hands?

Answer 5

Tremor:

• fine (beta 2 agonist)
• flapping (CO2 retention in type 2 resp failure)
• ideally measure for 30 secs

Question 6

What should you do on inspection of arms?

Answer 6

• take radial pulse on R side (rate and rhythm)
• tachycardia may indicate hypoxia in severe asthma or COPD, PE, infection
• bounding pulse = CO2 retention
• pulsus paradoxes: pulse wave volume Dec with inspiration (asthma/COPD)
• count resp rate (High = fever, severe lung disease, hyperventilation)
• offer BP on both arms, lying and standing

Question 7

What do you look for in the head?

Answer 7

Eyes:

• conjunctival pallor
• Horner’s syndrome (pancoast tumour): ptosis, anhidrosis, miosis

Mouth:
- central cyanosis under tongue (hypoxia, cor pulmonary, hydration status, bronchiectasis)

Question 8

What do you look for in the neck?

Answer 8

• assess JVP (elevated in cor pulmonary, fluid overload)
• feel for tracheal deviation (pneumothorax pushes to contralateral side, collapsed lung to ipsilateral side)
• look for tracheal tug, cricosternal distance (<3 fingers), hyperinflation

Question 9

What do you look for in chest inspection?

Answer 9

• scars (MAL for chest drains, posterior chest lobectomy)
• skin changes (radiotherapy)
• deformities (Pectus carinatum: childhood asthma/ rickets. Pectus excavatum: Marfarn’s syndrome, barrel chest in emphysema or COPD)
• chest wall movements: mainly upwards (emphysema), asymmetrical (fibrosis, collapsed lung, pleural effusion)
• Breathing: powerful expiration (asthma, chronic bronchitis), hyperexpanded chest (COPD)

Question 10

What do you palpate for in a respiratory exam?

Answer 10

• palpate for apex best (5th ICS MCL)
• apex beat displaced in cor pulmonary, impalpable in COPD and pleural effusion)
• chest wall expansion (do in 2 places, upper and lower zone)

Question 11

What do you percuss for in a resp exam?

Answer 11

• compare L and R at same level
• DULL: pleural fluid, consolidation, lung collapse
• STONY DULL: large pleural effusion
• HYPER-RESONANCE: inc air space in emphysema, bronchitis, pneumothorax

Question 12

What do you auscultate in resp exam?

Answer 12

• start supraclavicular (with bell), end in axillae
• Dec air entry in consolidation, bronchial obstruction, emphysema

Added sounds:

• pleural rub: pulmonary infarction, pneumonia, pleural malignancy
• wheeze: bronchitis, COPD, asthma
• crackles: early inspiration (COPD), early to mid inspiration (pulmonary oedema, restrictive lung disease), fine (pulmonary oedema), coarse (pneumonia)

Vocal resonance:

• ask pt to say 99 (inc in consolidation, Dec in effusion/pneumothorax)
• can also do tactile Fremitus (also say 99)
• do on bad

Question 13

What else should you do after?

Answer 13

• feel for cervical lymph nodes
• palpate for sacral/peripheral oedema
• feel back of calves for signs of DVT

Question 14

How would you complete the exam?

Answer 14

• full history and exam
• SPOT-X (sputum, peak flow, oxygen says, temperature, chest x-ray, blood gases)
• basic observations
• peripheral pulses
• examine sputum
• peak flow
• ABG
• CXR
• provide oxygen if necessary