Respiratory examination

Question 1

Summary of approach to respiratory examination

Answer 1

Start with “wide angle lens” to make sure you pick up all the obvious peripheral clues first
“Spiral in” on the region of interest i.e. the chest
You should have the diagnosis before you use your stethoscope!

Question 2

Overall approach of respiratory examination

Answer 2

Introduction (without handshake: covid)
- study the hand and inspect whole patient
Examine extremities -esp. oedema
Expose the chest (consideration…)
Inspect front and back of chest
Examine the back of the chest: palpation, percussion, auscultation
Examine the front of the chest – as before

Question 3

What to look out for during initial impression in a respiratory examination

Answer 3

Cough (character)
Wheeze (expiratory whistling noise)
Stridor (inspiratory noise)
Laboured breathing
- (raised rate = “tachypnoea”,not breathlessness)
Pursed-lipped breathing in COPD
Nutritional state: obesity may suggest a hypoventilation syndrome
“Paraphernalia”: inhalers, nebulisers, sputum pots

Question 4

What is the general approach to examination?

Answer 4

Inspection
Palpation
Percussion
Auscultation

Question 5

What to do during inspection?

Answer 5

Face and skin
Hands and feet
Neck
Expose the chest fully (ask, be considerate, leave bras)
Chest wall
Study breathing movements

Question 6

What do you look for in the hands of a patient?

Answer 6

Digital clubbing
Tremor
- flapping (asterixis) in respiratory failure
- fine with beta2-agonists
Warmth, oedema, tobacco stains, coal dust tattoos

Question 7

Where is digital clubbing seen often?

Answer 7

Commonest cause lung cancer
Other respiratory diseases when it is seen:
- Pulmonary Fibrosis
(aka Fibrosing Alveolitis)
- chronic suppurative lung disease e.g. bronchiectasis, empyema

Question 8

What can be found on a patients pulse?

Answer 8

Bounding” with warm peripheries: CO2 retention
Don’t forget to check the respiratory rate - while the patient thinks you are counting the pulse!

Question 9

When inspecting face and neck what do you check for?

Answer 9

Complexion, cyanosis
Eyes
Neck
jugular venous pressure:
-elevated with peripheral oedema in cor pulmonale, and in superior vena cava obstruction, when fixed
trachea:
-deviation? tracheal “tug”?

Question 10

How is respiratory failure shown?

Answer 10

Central cyanosis (tongue, lips) - due to arterial desaturation (low PaO2)
Peripheral cyanosis much less reliable: reaction to cold, poor perfusion, anxiety etc

Question 11

What to check for when inspecting the chest wall?

Answer 11

Deformity, under- and over-inflation
- kyphoscoliosis, barrel chest in COPD (AP diameter = lateral diameter), flattening
Scars, radiotherapy changes, aspiration wounds
Dilated veins – SVC obstruction

Question 12

What to look for in chest wall movement

Answer 12

Rate, pattern (rhythm), prolonged expiration
Movement patterns:
Symmetry
Chest vs. abdominal
Use of “accessory” muscles
Assess expansion with your finger tips along the mid-axillary line and thumbs as pointers

Question 13

What must you do in a chest wall examination?

Answer 13

Need to examine front and back
Most signs in the back
Don’t get patient repeatedly sitting back and forward

Question 14

What are the causes of reduced chest wall movement?

Answer 14

Any lung, pleural or chest wall disease such as:
Kyphoscoliosis
ankylosing spondylitis
neuromuscular

Question 15

What to check for when palpating?

Answer 15

Neck (lymph nodes and trachea)
Notch-cricoid distance
Axillae
Apex beat
Chest wall movement

Question 16

What is the tactile vocal fremitus?

Answer 16

Say “99”
Feel vibrations with side of hands

Question 17

How can we inspect percussion?

Answer 17

Compare left versus right and one space to the next: ‘Square wave’ pattern
Resonance implies aerated lung tissue below
Horizontal sounding-finger
Do tactile vocal fremitus, vocal resonance if uncertain about presence of dullness
Absence of cardiac and hepatic dullness in emphysema

Question 18

Where is resonance lost in?

Answer 18

pleural effusion (“stony” dull)
consolidation/collapse/fibrosis
raised diaphragm
over the liver and heart except in emphysema

Question 19

Where is resonance increased in?

Answer 19

in emphysema
pneumothorax

Question 20

Where do we percuss posteriorly?

Answer 20

over trapezius
4-5 times each side
lateral chest walls (3-4 times each side)

Question 21

Where do we percuss anteriorly?

Answer 21

over the clavicles
in mid-clavicular line (4-5 times each side)

Question 22

Tips for stethoscope to remember?

Answer 22

“Everytime I put my stethoscope on your chest, take a breath in and out through an open mouth”
Hold your breath if you ask them to
“Don’t talk” while listening to carotids
Warm stethoscope in your hands while talking to patient
Know where the cleaning stuff is before taking your stethoscope into a patient bedspace
Don’t store it rolled up
Practice on yourself and others

Question 23

How do we auscultate?

Answer 23

Use the diaphragm because most of the sounds are high pitched
Ask the patient to take deep breaths through the mouth (demonstrate)
Compare one side with the other
Listen

Question 24

Where do we listen over when we auscultate?

Answer 24

over trapezius
4-5 times each side posteriorly (patent bending forward with arms forward)
in the mid-clavicular line (4-5 times each side)
over the lateral chest walls (3-4 times each side)

Question 25

What are normal breath sounds called?

Answer 25

Vesicular
loudest on inspiration, fading smoothly into expiration and dying out

Question 26

What is bronchial breathing?

Answer 26

Higher pitched, with distinct inspiratory and expiratory phases
heard over fibrotic or consolidated lung, above a pleural effusion
associated with “whispering pectoriloquy”

Question 27

What do wheezes suggest?

Answer 27

Airflow obstruction

Question 28

Features of crackles

Answer 28

more noticeable at the bases (small airway closure)
can be caused by
secretions in airways- clear or change on coughing
consolidation
fibrotic lung disease
heart failure

Question 29

How do we check for vocal resonance

Answer 29

Say “99”
Listen for increased resonance

Question 30

What is the whispering pectoriloquy?

Answer 30

Whisper 1,2,3
Listen for dramatic increase in volume around consolidated lung