Respiratory Examination

Question 1

On general inspection, what are you looking for in the patients surroundings?

Answer 1

Indicators of respiratory pathology (e.g. inhalers/ other drugs, nebulisers, oxygen delivery devices, sputum pot)

Question 2

On general inspection of the patient, what are you looking for?

Answer 2

Weight loss, pain/ discomfort, breathlessness, positioning, use of accessory muscles

Question 3

On general inspection of the patient, what are you listening for in their breathing/ speech? What may these indicate?

Answer 3

Audible inspiratory stridor indicating upper airway obstruction

Expiratory wheeze indicating asthma

Hoarseness indicating laryngitis, lung cancer (causing laryngeal nerve palsy), laryngeal cancer

Pattern of speech e.g. do they interrupt speech flow to take a breath?

Spontaneous coughing/ ask patient to cough and listen to the sound (dry or productive)?

Question 4

On assessment of the hand, what are you looking/ feeling for?

Answer 4

Feeling for circulation (warmth and ventilation)

Finger clubbing

Tar staining

Flapping tremor

Fine tremor

Palpate radial pulse (rate and rhythm)

Question 5

What are common respiratory causes of finger clubbing?

Answer 5

Lung cancer
Mesothelioma
Pulmonary fibrosis
Any chronic suppurative lung disease (e.g. bronchiectasis (late stages), empyema, cystic fibrosis)

Question 6

What does a flapping tremor indicate? What other signs may accompany it?

Answer 6

Carbon dioxide retention

Also warm hands and bounding pulse

Question 7

What can cause a fine tremor?

Answer 7

Use of beta-agonist inhalers or nebulisers

Question 8

What does a tachycardia greater than 110/min in the context of asthma indicate?

Answer 8

Severe asthma attack

Question 9

What can cause polycythaemia?

Answer 9

Chronic lung disease or smoking

Question 10

What does pursed lips on expiration indicate and why?

Answer 10

Emphysema - patient trying to delay collapse of intrathoracic airways

Question 11

What respiratory pathology may Horner’s syndrome indicate?

Answer 11

Pancoast tumour

Question 12

On close inspection of the chest, what should you look for?

Answer 12

Scars
Shape (asymmetry, deformity (e.g. kyphoscoliosis), increased AP diameter (barrel shaped)
Pattern of breathing, use of accessory muscles, intercostal recession or undraping and posture

Question 13

What is a barrel shaped chest with limited lateral expansion an indicator of?

Answer 13

Hyper-inflated chest and air trapping e.g. COPD (airflow obstruction)

Question 14

What do prominent chest wall veins suggest?

Answer 14

SVC obstruction

Question 15

What is the posture like in patients in respiratory distress related to airflow obstruction?

Answer 15

Fix their rib cage and shoulder girdle by supporting themselves with arms straight out on bed

Question 16

What respiratory pathology might a raised JVP indicate?

Answer 16

Right heart failure secondary to chronic lung disease or pulmonary embolism

Question 17

What should you check for if there is history of injury or possible pneumothorax?

Answer 17

Subcutaneous (“surgical”) emphysema (crackling sensation felt under skin leaving from a pneumothorax or rarely a ruptured oesophagus

Palpate for rib fractures

Look for swollen neck

Flail chest

Tenderness

Crepitus over broken ribs

Question 18

How is mediastinal shift assessed?

Answer 18

Tracheal deviation and displaced apex beat

Question 19

What pathologies cause the trachea to deviate towards the side of the pathology?

Answer 19

Fibrosis, absorption collapse of lung, pneumonectomy

Question 20

What pathologies cause the trachea to deviate away from the side of the pathology?

Answer 20

Tension pneumothorax and pleural effusion

Question 21

What might hyper resonant percussion indicate?

Answer 21

Emphysema, large bullae or pneumothorax

Question 22

What might dull percussion indicate?

Answer 22

Collapse, consolidation, or fibrosis

Question 23

What might “stony” or very dull percussion indicate?

Answer 23

Pleural effusion, haemothorax

Question 24

What might dullness at the base of the lungs indicate?

Answer 24

Infection (consolidation), effusion, collapse (or a raised diaphragm)

Question 25

If areas of the chest are found to be “stony”, what tests could be done to exploit this?

Answer 25

Either tactile vocal fremitus or vocal resonance (the latter is preferred)

Question 26

How do you test for tactile vocal fremitus? What does increased or decreased fremitus indicate?

Answer 26

Palms of your hands on area of dullness and ask patient to say “99”

Increased fremitus = consolidation or fibrosis
Decreased fremitus = pleural effusion or collapse

Question 27

How do you test for vocal resonance?

Answer 27

Auscultate area of dullness and ask patient to say “one, one, one” and then compare with other side

Increased resonance suggests consolidation or fibrosis

Decreased resonance suggests pleural effusion or collapse
Do the same again but ask patient to whisper

Whispering is not heard over a normal lung but in consolidation the sound is transmitted

Question 28

What questions should you ask yourself as you auscultate?

Answer 28

1. Are breath sounds present? Are they vesicular in nature?
2. Are breath sounds equal on both sides?
3. Are there any bronchial breath sounds?
4. Are there any added sounds such as crackles, wheezes or pleural rub?

Question 29

Does the inspiratory or expiratory component dominate in vesicular breath sounds?

Answer 29

Inspiratory

Question 30

Is there normally a gap between inspiration and expiration?

Answer 30

No

Question 31

Is there normally a gap between expiration and inspiration?

Answer 31

Yes

Question 32

What causes decreased breath sounds?

Answer 32

When normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion)

Question 33

When may bronchial sounds be heard?

Answer 33

When small airways or alveoli have been damaged e.g. consolidation

Question 34

Describe bronchial sounds

Answer 34

Gradually increase through inspiration but stop near the end of inspiration (when air would normally be flowing round the alveoli i.e. there is gap between inspiration and expiration)

Expiratory component dominates

Question 35

Describe the sound of crackles

Answer 35

High-pitched, discontinuous sounds similar to the sound when rubbing hair between fingers

Question 36

What causes crackles?

Answer 36

Oedema or fibrosis

Question 37

Describe the sound of wheezes

Answer 37

Generally high pitched and musical

Question 38

What causes wheezes?

Answer 38

Small airway narrowing e.g. asthma

Question 39

Describe the sound of friction/ pleural rub

Answer 39

Like creaking leather (low pitched)

Question 40

What causes pleural rub?

Answer 40

Pleural inflammation e.g. pleurisy

Question 41

What glands should be examined for lymphadenopathy?

Answer 41

Submental, submandibular, tonsillar, deep cervical chain scalene nodes