Respiratory Examination

Question 1

How do you start an examination?

Answer 1

• Professional appearance. Introduction. Permission (can I possibly have a look at/listen to your chest). Wash hands.
• At this stage you will later be taught to do a general examination: Feet-to-face, hands, mouth, eyes, but this is not in the first-year material.
• Position the patient: sitting on couch at 45 degrees. Men: exposed from waist up. Women: bra on, otherwise exposed from waist up.
• Inspection: Chest abnormality: spinal curvature, pectus excavatum (chest curves outwards), pectus carinatum (chest curves inwards), scoliosis of spine, scars, drains, etc.

Question 2

Which first observations should be made?

Answer 2

• Observe: degree of respiratory effort, use of accessory muscles, can you hear coughs, sneezes, wheezes etc from the end of the bed? Cough productive of sputum, blood? Sputum pot (This is pathology: probably not examinable in first year!)
  Also count respiratory rate

Question 3

What should respiratory rate be and how long should you count it for?

Answer 3

• Respiratory rate: should be 12-20 per minute. Really you need to count for 30 secs: usually not possible in OSCE. Also, sometimes difficult to see chest movement in healthy person: much easier in ill people.

Question 4

Which lymph nodes of the head and neck should be examined and where from?

Answer 4

-	Usually examined from behind
o	Submental
o	Submandibular
o	Parotid
o	Anterior cervical chain
o	Supraclavicular
o	Posterior cervical chain
o	Occipital
o	Post-auricular
o	Pre-auricular

Question 5

How do you check if the trachea is central?

Answer 5

• Patient needs to be relaxed, head resting on head-rest, not turned to side. Feel trachea with one finger or two, as low as possible. Assess centrality relative to clavicular heads.

Question 6

How can chest expansion be performed?

Answer 6

• Chest expansion can be done on back (or on front for men sometimes)
• Place both hands on patient’s back

Question 7

How can you percuss the chest?

Answer 7

• You can percuss directly over clavicles. In general, use middle finger of dominant hand.
• Percuss positions shown in diagram by placing non-dominant hand firmly on chest, and percussing directly onto (usually) middle phalanx of middle finger. Mind scapulae at back: ask patient to cross arms in front of chest to move scapulae apart.

Question 8

How do you test the tactile vocal fremitus?

Answer 8

• Place ulnar border of both hands horizontally across both sides of chest. Four different levels front and back, also armpits.
• Ask patient to say “ninety-nine” or “nointy-noine”. (crossed arms again)
• Feel vibration.

Question 9

How do you auscultate the patient’s chest?

Answer 9

• Earpieces in ear, “forks forward”. You usually use the diaphragm for respiratory exam, except for listening in supraclavicular fossa, when bell may fit better.

Question 10

Where are the regions of the lungs auscultated on a patient’s front and back?

Answer 10

Right upper lobe (RUL) - upper 2/3 of front and upper 1/3 of back
Right middle lobe (RML) - lower 1/3 of front (except bottom right corner)
Right lower lobe - bottom right corner of front and lower 2/3 of back
Left upper lobe (LUL) - all of left front (except for pericardium region in centre left, and bottom left corner) and upper 1/3 of back
Left lower lobe (LLL) - bottom left front corner and lower 2/3 of back

Question 11

What are two additional auscultation positions?

Answer 11

Above clavicles and in axillae

Question 12

Describe the anatomy of the lobes.

Answer 12

• Oblique fissure both sides, at back, level of T4 spinous process, runs forward, and downwards, reaches 6th rib laterally, then runs along 6th rib and costal cartilage to the front.
• Horizontal fissure (Right side only!) in front at the level of 4th rib, runs horizontally backwards to meet oblique fissure at level of 5th rib approx. Remember that the ribs themselves are oblique.

Question 13

What must you do when you finish the examination?

Answer 13

• Thank the patient.
• Offer to help them get comfortable.
• Wash hands again.

Question 14

What can affect respiratory effort/rate?

Answer 14

• Respiratory effort and respiratory rate can be affected by many things! Fever, asthma, pneumonia, pain, COPD, etc etc.

Question 15

What can affect trachea position?

Answer 15

• Trachea position: affected by pneumothorax, pleural effusion, collapse of lung, tumours etc.

Question 16

What can affect chest expansion?

Answer 16

• Chest expansion can be affected by COPD, musculoskeletal problems, maybe asthma (affect both sides) fractured ribs, collapsed lung, pneumothorax, pleural effusion, pneumonia, etc etc. (one side).

Question 17

What can affect percussion?

Answer 17

• Percussion. Normal is resonant. Extra resonant in pneumothorax. Dull in consolidation (pneumonia), pleural effusion, collapsed lung, etc etc.

Question 18

What can affect vocal fremitus?

Answer 18

• Vocal fremitus. Increased in consolidation (a bit counter-intuitive, this). Decreased in pneumothorax, pleural effusion, etc etc.

Question 19

What can affect breath sounds?

Answer 19

• Breath sounds. These are quite quiet normally, (vesicular breath sounds) and you will need to practice!
  o Increased in consolidation, and different in quality: bronchial breathing, like listening over trachea. Decreased in pneumothorax, pleural effusion, collapse etc. etc.
  o Also added sounds: fine crepitations (pulmonary oedema), coarse crepitations (pus in infections), rhonchi (wheezes, loudest in asthma).

Question 20

What in an examination would indicate pneumothorax/air in pleural cavity?

Answer 20

o Short of breath, tachycardia, may be cyanosed.
o On inspection, chest movements asymmetrical.
o Trachea deviated away from lesion, especially in tension pneumothorax.
o Chest expansion reduced and asymmetrical.
o Hyper-resonant to percussion on side of pneumothorax
o Vocal fremitus absent on side of pneumothorax
o Absent breath sounds on side of pneumothorax.

Question 21

What in an examination would indicate pleural effusion/haemothorax/fluid or blood in pleural cavity?

Answer 21

o Short of breath, tachycardia, maybe cyanosed.
o On inspection: chest movements asymmetrical.
o Trachea deviated away from lesion.
o Chest expansion reduced and asymmetrical
o Percussion over affected side dull.
o Vocal fremitus absent.
o Breath sounds absent.

Question 22

What in an examination would indicate lobar pneumonia?

Answer 22

o Acute inflammation of one lobe of one lung: infective cause. Classic cause is Streptococcus pneumoniae.
o Fever, looks ill, possibly delirium. Breathing may be painful.
o Short of breath, tachycardia, may be cyanosed.
o Trachea central
o Chest expansion possibly reduced.
o Percussion dull over affected lobe.
o Increased vocal fremitus over affected lobe.
o “Bronchial breathing” over affected lobe.

Question 23

What in an examination would indicate asthma?

Answer 23

o Obvious effort required to breathe: accessory muscles etc.
o Short of breath, tachypnoea, may be cyanosed.
o Expiratory wheezes may be heard from end of bed.
o Trachea central.
o Chest expansion possibly reduced
o Percussion normal resonance.
o Vocal fremitus normal.
o Breath sounds normal, with loud added sounds: rhonchi (wheezes).

Question 24

What in an examination would indicate left-sided heart failure/pulmonary oedema?

Answer 24

o Short of breath, tachypnoea, frothy sputum tinged with blood.
o Trachea central.
o Chest expansion normal.
o Percussion normal
o Vocal fremitus normal.
o Breath sound normal with added sounds: fine crepitations (crackles).

Question 25

What other conditions may also be picked up in a respiratory examination?

Answer 25

• Broncho-pneumonia
• Acute bronchitis.
• Chronic obstructive pulmonary disease.
• Atypical pneumonia.
• Interstitial lung disease.
• Etc. No room to describe these!