Respiratory examination Flashcards
Describe the introduction
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the examination will involve using patient-friendly language.
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle.
Adequately expose the patient’s chest for the examination (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema.
Ask the patient if they have any pain before proceeding with the clinical examination.
What clinical signs should you look for on general inspection
Age: the patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as asthma or cystic fibrosis (CF) and older patients more likely to have chronic obstructive pulmonary disease (COPD), interstitial lung disease or malignancy.
Cyanosis: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position (sitting or standing leaning forward and supporting the upper body with hands on knees or other surfaces). Shortness of breath is a common feature of most respiratory pathology, however possible underlying diagnoses in an OSCE could include asthma, pulmonary oedema, pulmonary fibrosis, lung cancer and COPD. The inability to speak in full sentences is an indicator of significant shortness of breath.
Cough: a productive cough can be associated with several respiratory pathologies including pneumonia, bronchiectasis, COPD and CF. A dry cough may suggest a diagnosis of asthma or interstitial lung disease.
Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.
Stridor: a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage/chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that healthy individuals may have a pale complexion that mimics pallor.
Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated with right ventricular failure. Pulmonary oedema often occurs secondary to left ventricular failure.
Cachexia: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly associated with underlying malignancy (e.g. lung cancer) and other end-stage respiratory diseases (e.g. COPD).
What medical paraphernalia should you look for upon general inspection
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:
Oxygen delivery devices: note the type of oxygen device (e.g. Venturi mask, non-rebreathing mask, nasal cannulae) and the current flow rate of oxygen (e.g. 2L, 4L, 10L, 15L). Look for other forms of respiratory support such as CPAP or BiPAP.
Sputum pot: note the volume and colour of the contents (e.g. COPD/bronchiectasis).
Other medical equipment: ECG leads, medications (e.g. inhalers/nebulisers in asthma/COPD), catheters (note volume/colour of urine) and intravenous access.
Cigarettes or vaping equipment: smoking is a significant risk factor for lung cancer and chronic lung disease (e.g. COPD).
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
Describe general inspection of the hands
General observations
Observe the hands and note your findings:
Colour: cyanosis of the hands may suggest underlying hypoxaemia.
Tar staining: caused by smoking, a significant risk factor for respiratory disease (e.g. COPD, lung cancer).
Skin changes: bruising and thinning of the skin can be associated with long-term steroid use (e.g. asthma, COPD, interstitial lung disease).
Joint swelling or deformity: may be associated with rheumatoid arthritis which has several extra-articular manifestations that affect the respiratory system (e.g. pleural effusions/pulmonary fibrosis)
Describe assessment of finger clubbing
Finger clubbing
Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a respiratory OSCE station include lung cancer, interstitial lung disease, cystic fibrosis and bronchiectasis.
To assess for finger clubbing:
Ask the patient to place the nails of their index fingers back to back.
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
When finger clubbing develops, this window is lost.
What may a fine tremor indicate?
Fine tremor
Assess for the presence of a fine tremor:
Ask the patient to hold out their hands in an outstretched position and observe for a fine tremor which is typically associated with beta-2-agonist use (e.g. salbutamol).
Describe the flapping tremor
Asterixis (flapping tremor)
Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of a respiratory examination, the most likely underlying cause is CO2 retention in conditions that result in type 2 respiratory failure (e.g. COPD). Other causes of asterixis include uraemia and hepatic encephalopathy.
Whilst the patient still has their hands stretched outwards, ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
Observe for evidence of asterixis during this time period.
Describe palpation of temperature in the hands
Temperature
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion.
Excessively warm and sweaty hands can be associated with CO2 retention.
Describe palpation of heart rate in the hands
Heart rate
Assessing heart rate:
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Calculating heart rate:
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Describe some pulse abnormalities
Pulse abnormalities
Bounding pulse: can be associated with underlying CO2 retention (e.g. type 2 respiratory failure).
Pulsus paradoxus: pulse wave volume decreases significantly during the inspiratory phase. This is a late sign of cardiac tamponade, severe acute asthma and severe exacerbations of COPD (therefore it is unlikely to be relevant to most OSCE scenarios).
Describe assessment of the respiratory rate
Respiratory rate
Assessing respiratory rate:
Whilst still palpating the radial pulse (but no longer counting it), assess the patient’s respiratory rate (palpation of the radial pulse at this stage purely to avoid making the patient aware you are directly observing their breathing, as this can itself alter the respiratory rate).
Note any asymmetries in the expiratory and inspiratory phases of respiration (e.g. the expiratory phase is often prolonged in asthma exacerbations and in patients with COPD).
Calculating respiratory rate:
Assess the patient’s respiratory rate for 60 seconds to calculate the number of breaths per minute.
Describe some respiratory rate abnormalities
Respiratory rate abnormalities
In healthy adults, the respiratory rate should be between 12-20 breaths per minute.
A respiratory rate of fewer than 12 breaths per minute is referred to as bradypnoea (e.g. opiate overdose).
A respiratory rate of more than 20 breaths per minute is referred to as tachypnoea (e.g. acute asthma).
Describe measurement of the JVP
- Position the patient in a semi-recumbent position (at 45°).
- Ask the patient to turn their head slightly to the left.
- Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
- Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).
What are the respiratory causes of a raised JVP
Respiratory causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Respiratory causes of a raised JVP include:
Pulmonary hypertension: causes right-sided heart failure, often occurring due to COPD or interstitial lung disease.
There are several other causes of a raised JVP that relate to the cardiovascular system (e.g. congestive heart failure, tricuspid regurgitation and constrictive pericarditis).
What is the difference between the liver flap and the CO2 retention flap
CO2 is more rapid- liver flap is like they are falling asleep
Describe inspection of the face
Inspect the face for any signs relevant to the respiratory system
Plethoric complexion: a congested red-faced appearance associated with polycythaemia (e.g. COPD) and CO2 retention (e.g. type 2 respiratory failure).
Describe inspection of the eyes
Inspect the eyes for signs relevant to the respiratory system
Conjunctival pallor: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
Ptosis, miosis and enophthalmos (technically a pseudoenopthalamos): all features of Horner’s syndrome (anhydrosis is another important sign associated with the syndrome). Horner’s syndrome occurs when the sympathetic trunk is damaged by pathology such as lung cancer affecting the apex of the lung (e.g. Pancoast tumour).
Describe inspection of the mouth
Inspect the mouth for signs relevant to the respiratory system
Central cyanosis: bluish discolouration of the lips and/or the tongue associated with hypoxaemia.
Oral candidiasis: a fungal infection commonly associated with steroid inhaler use (due to local immunosuppression). It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
Describe the scars that you may see on the chest wall
Scars
Closely inspect the chest wall for scars and other abnormalities:
Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
Axillary thoracotomy scar: located between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space. This surgical approach is used for the insertion of chest drains.
Posterolateral thoracotomy scar: located between the scapula and mid-spinal line, extending laterally to the anterior axillary line. This surgical approach is used for lobectomy, pneumonectomy and oesophageal surgery.
Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
Radiotherapy-associated skin changes: may be present in patients who have been treated for lung cancer. Clinical features can include xerosis (dry skin), scale, hyperkeratosis (thickened skin), depigmentation and telangiectasia.
Describe some different chest deformities
Asymmetry: typically associated with pneumonectomy (e.g. lung cancer) and thoracoplasty (e.g. tuberculosis).
Pectus excavatum: a caved-in or sunken appearance of the chest.
Pectus carinatum: protrusion of the sternum and ribs.
Hyperexpansion (a.k.a. ‘barrel chest’): chest wall appears wider and taller than normal. Associated with chronic lung diseases such as asthma and COPD.
Describe the assessment of tracheal position
Gently assess the position of the trachea, which should be central in healthy individuals (this can be uncomfortable, so warn the patient in advance):
- Ensure patient’s neck musculature is relaxed by asking them to position their chin slightly downwards.
- Dip your index finger into the thorax beside the trachea.
- Gently apply side pressure to locate the border of the trachea.
- Compare this space to the other side of the trachea using the same process.
- A difference in the amount of space between the sides suggests the presence of tracheal deviation.
What are the causes of tracheal deviation
Causes of tracheal deviation
The trachea deviates away from tension pneumothorax and large pleural effusions.
The trachea deviates towards lobar collapse and pneumonectomy.
Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique
