Respiratory exam

Question 1

Introduction

Answer 1

Introduce yourself, confirm patient details- lung exam, will involve a feel of your chest and having a listen to your lungs
Examination couch, stethoscope wiped w alcohol wipes- PPE, Wash hands and expose chest- patient in semi supine condition (45 degrees)

Question 2

General inspection

Answer 2

Around bedside- o2, nebuliser, sputum cup (appearance?mucoid, purulent, mucopurulent, bloody)
General obs- distressed, tripod position, acc. muscles to breathe? Sternocleidomastoids, platysma, strap muscles neck) pursed lips? cachexia?
Level of consciousness- alert or altered level?
Audible noises- speech, wheeze, whistling, stridor- hoarse while talking?

Question 3

Inspection of hands

Answer 3

Clubbing- intrathoracic diseases, cancer, bronchiectasis, empyema, abcess, pul. fib, CF- also can be cardio (cyanotic congenital heart disease, gastro (Cirrhosis, inflam bowel disease, coeliac)
- nicotine staining
- small muscle wasting (compressed brachial plexus by lung tumour)
- peripheral cyanosis- XS o2 extraction in capillaries when blood flow slowed- cold exposure w low cardiac output or w/ venous obstruction, may be anaemia or cyanosis- temperature w dorsal hand
Tremor- hand out straight and fan fingers- fine tremor indicate B2 adrenoceptor agonist (salbutamol)
Flapping tremor co2 retention
Pulse- inc (tachycadia) may indicate resp disease (e.g severe astmha)- inc volume potentially co2 retention, pulsus paradoxus?
Resp rate- fingers over radial pulse (12-20 normal adult, tachypnoea fast rate resp)

Question 4

Face and neck

Answer 4

Central cyanosis- under tongue and mucous membranes- incomplete oxygenation of blood in lung diseases, mix of venous and arterial blood (ven/arterial shunts)
Anaemia- conjunctiva

JVP- indicate right heart problems secondary to chronic lung disease/ pulm embolism- in airflow obstruction, high pressure changes in thorax make difficult to access JVP
fixed/non pulsatile could be due to obstruction of SVC (mediastinal tumour)
Chest wall deformities- pectus excavatum, carnatum, scars- thoracotomy, sternotomy, lobotomy, kyphosis, lordosis, scoliosis?

Question 5

Palpation

Answer 5

JVP- hepatojugular reflex
Neck for cervical/ supraclavicular lymphoadenopathy
Trachea- possible deviation, palpate w ring and index in suprasternal notch- may deviate towards side of lesions (upper lobe/lung collapse, fibrosis or pneumonectomy)
away from lesion e.g tension pneumothorax, massive pleural effusion
Palpate apex beat- MC line, 5th IC space, can be deviated w lesions (impalpable in chest hyperexpansions secondary to chronic airflow obstruction)

Chest expansion- hands firmly on chest wall, skin under tension- thumbs off chest wall slightly so they are free to move, should meet in midline w expiration

Question 6

Percussion

Answer 6

Apices- anteriorly- supraclavicular fossa
posteriorly- sup to medial angle of scapular spine

Superior- 2ICS, midclav line
medial to scapular spine

Inferior- middle lobe (R), lingula (l)- 5th rib, MC line
5cm inferomediallly to inf angle of scapula

Lung bases- 7th ICS, MA line
t10, 5cm lateral to VB column

Question 7

Auscultation

Answer 7

Intensity and quality of breath sounds+ presence of additional sounds (crackles, crepitus, wheeze, rhonci and rubs)
- Diaphragm- breathe in and out w open mouth everytime stethoscope moved
Supraclavicular
Anterior
Axillar
Post. aspects of chest COMPARING ALL L AND R

Question 8

Vocal resonance

Answer 8

Stethoscope over post. patient’s chest wall, ask them to say 99 each time
Okay you can get dressed again
Thank you
HOUSE OFFICER’S HANDSHAKE- also look for sacral oedema

Question 9

Summarise

Answer 9

“Today I examined Mrs Smith, a 64-year-old female.
No peripheral stigmata of repsiratory disease, regular pulse and normal respiratory rate
normal symmetrical percussion note on f and b of chest, normal sounds on auscultation

“For completeness, I would like to perform the following further assessments and investigations.”

Measure o2 sats, and send off sputum sample

Question 10

Further assessments

Answer 10

Suggest further assessments and investigations to the examiner:

Check oxygen saturation (SpO2) and provide supplemental oxygen if indicated.
Check other vital signs including temperature and blood pressure.
Take a sputum sample.
Perform peak flow assessment if relevant (e.g. asthma)
Request a chest X-ray (if abnormalities were noted on examination)
Take an arterial blood gas if indicated (also see ABG interpretation)
Perform a full cardiovascular examination if indicated (e.g. cor pulmonale)