Respiratory examination Flashcards
What is the first part of any introduction to an examination?
Wash hands
Introduce yourself
Patient details (Name, DOB + age)
Explain a resp exam to a patient
I’ve been asked to examine your chest today, it’s going to involve me having a general inspection of your arms, face and chest before having a feel of your chest and back and having a listen with my stethoscope.
What else would you include in an intro?
Expose pt
Chaperone
Pain or discomfort
In a respiratory exam what do you inspect?
Bedside
General inspection of patient
Hands
Temperature
Radial pulse
Jugular venous pressure (JVP)
Face
Eyes
Mouth
Chest
When inspecting a bedside in a respiratory exam what might you see?
Inhalers
Nebs
O2 mask
sputum pot
When inspecting a patient generally in a respiratory exam what are you looking for?
Colour
Breathing
Comfort
Position
Purse-lipped breathing
SOB
Nutritional state
In what condition do you see pursed lip breathing?
COPD
In terms of a respiratory exam what might obesity suggest?
obstructive sleep apnoea
What does cachexic mean?
What does it indicate in a resp exam?
Wasting of muscle and fat
Malignancy
Cystic fibrosis
COPD
How might age impact your diagnosis in a resp exam?
Younger is more likely asthma or cystic fibrosis.
Older more likely COPD / interstitial lung disease / malignancy.
What might a dry cough indicate in a resp exam?
Asthma
ILD
What might a productive cough indicate in a resp exam?
Bronchiectasis
COPD
CF
What might additional breathing sounds indicate in a resp exam?
a) Wheeze
b) Stridor
c) Difference between the two
a) Asthma / COPD / bronchiectasis
b) Upper airway obstruction
c)Wheeze = expiratory whereas stridor = inspiratory
When inspecting the hands what are you looking for?
Finger clubbing;
Tar staining;
Wasting of the intrinsic muscles;
Features of rheumatological disease (joint swelling / tenderness);
Fine tremor;
Flapping tremor;
Skin changes;
Colour;
In a resp exam what can the following indicate?
a) Finger clubbing
b) Tar staining
c)Wasting of intrinsic muscles
d) features of rheum diseases
e) fine tremor
f) flapping tremor
a) Lung cancer / ILD / Bronchiectasis.
b) Increased risk of COPD/lung cancer.
c) T1 nerve invasion by an apical lung cancer.
d) Rheumatological diseases, such as rheumatoid arthritis
can be associated with pleural effusions + pulmonary
fibrosis.
e) Beta-2 agonist use (salbutamol).
f) Coarse flapping tremor suggests CO2 retention.
In a resp exam what can the following indicate?
a) Skin changes in the hands
b) Colour of the hands
c) Cool peripheries (temp of hands)
a) Bruising/thinning of skin are associated with long-term
steroid use (ILD/asthma/COPD).
b) Peripheral cyanosis suggest hypoxia.
c) Poor perfusion/peripheral vasoconstriction.
How do you asses for a flapping tremor?
How long in do you assess for it in the OSCE?
Ask patient to bend wrists + maintain for 15 seconds
5 seconds in OSCE
When palpating the radial pulse in a respiratory exam what are you assessing for?
How long do you assess them for?
BPM (rate)
Rhythm
RESP RATE
pulsus paradoxus
15 secs for HR and RR
What does a bounding pulse indicate?
CO2 retention
What is a normal RR?
Normal = 12–20 breaths/min
What is pulsus paradoxus?
What does it indicate?
The pulse wave volume decreases with inspiration
Asthma / COPD
What does a raised JVP indicate in a resp exam?
Fluid overload
Pulmonary HTN
When inspecting the face in a resp exam what are you looking for?
What do these signs indicate?
Conjunctival pallor - Anaemia.
Central cyanosis - Hypoxia
Horner’s syndrome - Pancoast tumour
Facial swelling - SVC obstruction.
What is Horner’s syndrome?
Ptosis
Constricted pupil (miosis)
Anhidrosis on affected side (half of face)
When inspecting the chest what do you look for?
Scars
Skin changes
Asymmetry (major surgery)
Deformities
What scars might you see in a resp exam?
What do the scars indicate?
What instructions should you give to patients?
Small mid-axillary scars = chest drains.
Horizontal postero-lateral scars = thoracotomy from lobectomy/pneumonectomy.
Ask to lift arms up
What can skin changes on the chest indicate in a resp exam?
recent/previous radiotherapy (erythema/thickened)
Why might chest asymmetry be present in a resp exam?
Pneumonectomy - usually for cancer
Thoracoplasty - rib removed / previously used to treat TB
What deformities might the chest have in a resp exam?
Barrel chest (COPD).
Pectus excavatum (chest sticks in).
Pectus carinatum (chest sticks out).
Severe kyphoscoliosis (hunched back).
What do you palpate in a resp exam?
Tracheal (windpipe) position
Apex beat
Chest expansion
How do you assess tracheal position?
Warn patient it’s slightly uncomfortable but will be over quickly.
Ensure the patient’s neck is relaxed (chin slightly downwards).
Dip index finger into the thorax, beside the trachea.
Gently apply side pressure to locate the trachea.
Compare this space to the other side.
What does a difference in space either side of the trachea indicate?
Deviation
What is indicated in the following?
a) trachea deviates AWAY …
b) trachea deviates TOWARDS …
a) Tension pneumothorax or large pleural effusions.
b) Lobar collapse, pulmonary fibrosis and
pneumonectomy.
What does a right ventricular heave indicate in a resp exam?
cor pulmonale = RHF secondary to chronic hypoxic lung diseases such as COPD/ILD).
How do you assess chest expansion?
Ask patient to exhale fully.
Place hands around the patient’s chest, inferior to the nipples.
Wrap fingers around either side of the chest.
Bring thumbs together in the midline (touching).
Ask patient to take 2 deep breaths.
What does normal chest expansion look like?
What is abnormal + what does that indicate?
Thumbs should move equally apart (3–5cm).
One thumb moves less (<2cm) =
?reduced expansion on that side.
Lung collapse/pneumonia.
Where do you percuss in a resp exam?
Supraclavicular (lung apices).
Infraclavicular.
Chest wall (3–4 locations bilaterally).
Axilla.
What is the best way to percuss in a resp exam?
Side to side for comparison
What do the following percussion notes indicate?
a) resonant
b) dullness
c) stony dullness
d) hyper resonant
a) Normal.
b) Increased tissue density -> consolidation / fluid / tumour
/ collapse.
c) Pleural effusion.
d) Decreased tissue density -> Pneumothorax.
What instructions should you give to a patient when auscultating in a resp exam?
Take deep breaths through their mouth.
Where do you auscultate in a resp exam?
Supraclavicular (lung apices).
Infraclavicular.
Chest wall (3–4 locations bilaterally).
Axilla.
What is the best way to auscultate in a resp exam?
Auscultate side to side for comparison
What are you assessing when auscultating?
Quality
Volume
Additional sounds
How do you assess vocal resonance?
Ask patient to say “99” as you place your stethoscope on chest
Why do we assess vocal resonance?
Helps to discriminate between dullness to percussion from pleural effusion and that from consolidation.
What do the following indicate?
a) Increased volume vocal fremitus over an area + dull
percussion note
b) Decreased volume vocal fremitus over an area + dull
percussion note
a) Increased tissue density -> consolidation / tumour /
lobar collapse
b) Fluid outside of the lung -> pleural effusion /
pneumothorax
What do you do after inspecting, palpating, percussing and auscultating the front in a resp exam?
Do the same on the back with the pt sitting forward
What else can you assess for in a resp exam?
What can they indicate?
Palpate lymph nodes
Assess for sacral oedema
Examine the ankles for pitting oedema, calves for DVT
Inspect legs for evidence of erythema nodosum
Lymphadenopathy may indicate infective/malignant pathology -> Lung cancer/TB/sarcoidosis.
Fluid overload in cor pulmonale.
Sarcoidosis
Upon completing the exam what are the first things you do?
Thank pt
Wash hands
To complete my exam….
I’d like to check the sputum pot / sample (volume, consistency, colour, odour), assess peak flow + spirometry, L/S blood pressure and oxygen saturations
? CXR, ABG, O2 req? if indicated
Summarise a normal resp exam
Today I performed a respiratory examination on ____ a __ year old ___
On general inspection, ___ appeared comfortable at rest.
There was no peripheral stigmata of respiratory pathology.
The pulse was __ bpm and was of normal rate and rhythm.
The respiratory rate was ___ breaths/minute.
There was no evidence of fine or flapping tremor.
On palpation, there was symmetrical chest expansion and no evidence of mediastinal shift.
On percussion, all lung fields were resonant.
On auscultation, vesicular breath sounds were present bilaterally with no added sounds.
To conclude, this is consistent with a normal respiratory examination
