Respiratory Examination Year 2

Question 1

outline basic respiratory examination

Answer 1

• professionalism
• from end of the bed - patients general demaneour, quick feet to face
• hands including pulse, mouth, eyes
• lymph nodes of the neck
• trachea central
• examination of the chest - front and back, inspection, chest expansion, percussion, vocal remits and auscultation

Question 2

what are you looking at

Answer 2

• obvious oedema
• anatomical abnormality in the chest - are there any scars
• abnormality of respiratory movements- tachypnoea, obvious effort involving accessory muscles, SOB
• wheeze
• obvious neck pulsation, tracheostomy
• obvious cyanosis

Question 3

what medical equipment are you looking for around the bed

Answer 3

Intravenous infusion? Ambulant oxygen?

Ventilator? Tablets, Sputum pots

Question 4

describe what the hands, mouth, eyes look like and what should you d o

Answer 4

Hands: colour? Temperature/sweaty? Peripheral cyanosis? Tar staining? Clubbing? Koilonychia? Capillary refill.
Fine tremor, Coarse tremor.
Take the pulse: rate rhythm, character/volume.
Rate: count for 15 or 20 secs, multiply appropriately.
Rhythm: regular or irregular. If there is sinus arrhythmia (speeds up & slows down as breathes in and out) you should comment on this, but not pathological.
Character/volume: slow rising pulse of aortic stenoisis, collapsing pulse of aortic regurgitation, fast weak “thready” pulse of shock, assymetrical pulse of coarctation or vascular disease: you need experience for this!

Respiratory rate: this is special for the respiratory system. Either assess while doing pulse, or count after doing count. To count accurately needs 30 secs. Normal 12-20/min

Mouth. Sores around mouth, & at corners (angular stomatitis, or angular cheilosis), Central cyanosis, Glossitis? Mouth ulcers? (Soft palate & tongue movements)

Eyes: Mucosal pallor, pupils equal?, (scleral jaundice, xanthelasmata, arcus, squints & eye movements).

Question 5

name the lymph nodes

Answer 5

Submental
Submandibular
Parotid
Anterior cervical chain
Supraclavicular
Posterior cervical chain
Occipital
Post-auricular
Pre-auricular

Question 6

where do you usually examine the lymph nodes from

Answer 6

Usually examined from behind

Question 7

you don’t have to say the lymph nodes as you examine them but..

Answer 7

could be asked as a question

Question 8

How do you feel if the trachea is centra

Answer 8

Feel with fingers as low as possible.

Either put index & middle fingers into suprasternal notch, feeling the trachea, or put middle finger into suprasternal notch feeling the trachea, & index & ring fingers on heads of clavicles.

You must feel firmly enough to locate trachea exactly, but not so hard as to hurt.

Question 9

examination of the chest

Answer 9

Adequately exposed, reclining at 45 degrees.

Inspect chest for abnormalities: scars, injuries, drains, scoliosis/kyphosis/lordosis.

You should inspect front and back. You can inspect the front when you do the rest of the examination of the front, and inspect the back when you do the rest of the examination of the back.

Respiratory effort. If relaxed, one deep breath in and out: chest movements.

Obviously the JVP is relevant, we dealt with it in last lecture. The clinical lead-in should help you decide whether it is relevant, as in real life. The same applies to apex beat.

Question 10

describe how to do the chest expansion

Answer 10

From in front or behind.
Various variation of technique. Easier to show than to describe. Eg, plant little finger on chest wall round the sides, & pull the skin forward. Hands extended round the chest, so thumbs come close in front. Little fingers are the fixed points. Start in expiration, ask the patient to breath in fully. Thumbs should move apart, and then move back together when the patient breathes out again.

• can say to the examiner what side you what to do it on

Question 11

describe how to do percussion

Answer 11

Front: Percuss on clavicles first, using middle finger of dominant hand

Thereafter place non-dominant hand firmly on chest wall. The middle finger is your target (pleximeter), & should be pressed firmly against chest wall. Many people will place it over intercostal space.

Tap firmly with middle finger of dominant hand on middle phalanx of pleximeter. Tap firmly & springily, with lots of wrist action. Hear & feel the resonance.

Question 12

where do you percuss

Answer 12

Front: clavicles, then at least 3 pairs of places on front of chest, Plus L axilla (& I do R axilla as well)

Back: The patient must now sit forward, or swing over side of bed.

4 pairs of locations: lateral to spine, medial to scapulae. Get patient to cross arms over chest to move scapulae laterally.

Question 13

why do you test the right axial when percussing

Answer 13

• due to the middle lobe on the right lung

Question 14

what are the surface marking of the middle lobe

Answer 14

• horziontal fissure
• oblique fissure
• need to learn these rib markings as well

Question 15

posteriorly what part of the lung do you see the most

Answer 15

inferior lobe

Question 16

how do you test vocal remits

Answer 16

Use ulnar surface of hands.
Place firmly on chest wall using both hands, symmetrically.
Do it in 3 places on anterior chest, plus once in axillae.
Ask the patient to say nointy-noine, loudly & fruitily.

Feel for vibration.

Question 17

how do you do auscultation

Answer 17

Use diaphragm of stethoscope.

Listen above clavicles, (bell may fit better here), & otherwise in same places as percussion.

Breath sounds: present or absent.

Breath sounds: nature: vesicular or bronchial.

Added sounds: rhonchi (wheezes), coarse & fine crepitations (crackles), friction rubs etc.

Question 18

what are the bedside investigations

Answer 18

Look at sputum! ?Purulent? ? Blood?
Temperature
Oxymetry (pO2)

Question 19

what are non-bedside investigations

Answer 19

Arterial blood gas
CXR (& other imaging).
Pulmonary Function tests.

Question 20

describe asthma signs

Answer 20

Obvious respiratory effort. Audible rhonchi & wheeeze, esp expiratory.

Raised respiratory rate.
May be cyanosed.

Normally: trachea central, vesicular breath sounds all areas, loud rhonchi, but occasionally may be complicated by pneumothorax.

Question 21

what is the 
- temperature 
- sputum 
- sats 
- ABG 
- CXR
of asthma

Answer 21

Temp usually normal, but will be raised if infection.
Sputum: not purulent unless infection.
Sats: O2 may be reduced.
ABG O2 may be reduced. CO2 usually normal or low to start with: if goes up, this is more serious.
CXR: look for pneumothorax, pneumonia

Question 22

describe what the signs are of a pneumothorax

Answer 22

Either occurs through external injury, or internal rupturing of pulmonary bleb.
May be cyanosed.
Respiratory rate raised.
May be injury on chest wall eg stab wound. Don’t forget back!
Reduced chest movement on side of pneumothorax, & reduced chest expansion.
Trachea deviated away from side of pneumothorax, especially if tension.
Resonance increased over pneumothorax
Vocal fremitus absent over pneumothorax
Breath sounds absent on side of pneumothorax

Question 23

what is the pathology of lung collapse

Answer 23

The lung will collapse following development of a pneumothorax, as already discussed.

It can also collapse if the bronchus supplying it is chronically blocked without the formation of a pneumothorax

Possible causes: inhalation of foreign body, carcinoma, tuberculous lymphnode etc. etc.

The air in the lung distal to the obstruction will be absorbed: oxygen first, then nitrogen. This lung will thus gradually collapse, pulling the mediastinum over towards it, causing tracheal deviation towards the side of the collapse.

Breath sounds and chest expansion reduced on that side.

Question 24

what is the pathology of pleural effusion, haemothroax and empyema

Answer 24

Many causes of effusion: pneumonia, TB, carcinoma, autoimmune disease. Haemothorax often associated with injury.
If injury, broken ribs: may be in obvious pain
May be cyanosed.
Respiratory rate increased
Reduced movement on side of effusion/haemothorax
If haemothorax caused by injury: may be flail chest etc.
Trachea deviated away from effusion if large.
Dull to percussion over effusion.
Absent vocal fremitus over effusion
No breath sounds over effusion.
Empyema (pus in pleural cavity) as effusion, but with fever, septic shock etc. May be associated with pneumonia.

Question 25

what is the pathology of COPD

Answer 25

May be confused (CO2 retention). Flap. 
Sometimes clubbing.
Tar stains.
Fast bounding pulse if CO2 retention.
Respiratory rate raised.
Chest hyperinflated. Difficult to see chest movements, & reduced expansion: air trapped. Apex beat more difficult than usual to feel.
Trachea central
Percussion normal.
Vocal fremitus probably reduced.
Breath sounds reduced. Coarse crepitations (crackles).

Question 26

pathology pneumonia lobar

Answer 26

Looks ill. If septicaemic will look even iller, & will have low BP & tachycardia: shock.
Central cyanosis.
Fever, tachycardia, tachypnoea.
Purulent sputum, may be rusty or blood stained.
Chest movements may be reduced on side of pneumonia.
Trachea central.
Percussion dull over consolidated lobe
Vocal fremitus increased.
Bronchial breath sounds over consolidation.

If effusion or empyema forms these will modify the findings.

Bronchopneumonia: likely to affect most of the lungs.
Coarse crepitations. Less bronchial breathing.

Question 27

pathology of left sided heart failure

Answer 27

Short of breath. Cough productive of white frothy sputum, may be blood stained.
Better sitting up.
Tachypnoea.
Chest expansion normal. Trachea central.
Percussion & vocal fremitus normal
Vesicular breath sounds, with fine crepitations at bases.

Characteristic chest X-ray

Question 28

what is the pathology pleurisy

Answer 28

Depending on cause, a variety of signs. Special added sound: friction rub

Question 29

what is the pathology of pulmonary embolus

Answer 29

Notoriously difficult to diagnose
May be cough productive of bloodstained sputum.
May be signs of R heart failure with raised JVP.

Question 30

what is the pathology of neoplasia

Answer 30

May cause paraneoplastic syndrome, wasteing, clubbing, shortness of breath, block bronchus causing pneumonia, involve pleura causing effusion, pull or push on trachea, etc etc.