RESPIRATORY EXAMINATION - Examination notes

Respiratory Examination
Prepare patient
· Introduction
· Position semi-recumbent at 45º with whole chest exposed
General Inspection
General signs:
· Cachexia, cyanosis, sputum pot contents, rate & depth of breathing, stridor/wheeze, use
of accessory muscles. Ask to cough & note character (dry, barking, productive, bovine).
Hands & Wrist
Peripheral cyanosis
Clubbing (many causes including):
· Cyanotic congenital heart disease
· Infective endocarditis
· Atrial myxoma
· Lung Ca
· Chronic lung suppuration
o Lung abscess or empyema
o Bronchiectasis or CF
· Idiopathic pulmonary fibrosis
· Pleural mesothelioma
· Asbestosis
· IBD
· Cirrhosis
· Coeliac disease
· SB lymphoma
· Thyrotoxicosis (acropachy)
· Idiopathic/familial
· Rarely:
o Pregnancy
o 2º Hyperparathyroidism
Tar staining of fingers
Wrist tenderness (HPOA- Hypertrophic pulmonary osteoarthopathy)
Wasting & weakness (test strength of spreading digits) of small muscles (?lung Ca affecting
brachial plexus)
Wrist flap (Extend both for 30s – ?CO2 narcosis)
Radial Pulse
· Rate & rhythm. ?Tachycardia ?Pulsus paradoxus
Face
Eyes: Horner’s – ipsilateral ptosis, small pupil, enophthalmos, ↓facial sweating (apical lung Ca)
Sinuses: Tenderness
Nose: Patency
Mouth: Cyanosis
Voice: Hoarseness (recurrent laryngeal nerve palsy)
Neck
Trachea - ?midline
Posterior Chest
Inspect
· Scars – thoracotomy?
· Shape of chest
o Barrel chest: ↑AP diameter
compared to lateral diameter –
asthma, COPD
o Pectus carinatum (pigeon chest):
localised outward bowing of
sternum/costal cartilages – rickets,
chronic childhood respiratory
disease
o Pecus excavatum (funnel chest):
localised depression of distal
sternal – development defect
o Harrison’s sulcus: linear depression
of lower ribs just above costal
margin – asthma, rickets
· Spine deformity
Palpate
· Cervical LN
· Chest expansion
o Upper lobes – watch clavicles from behind & above to see if R=L
o Lower lobes – encircle chest & check ­thumb separation (>5cm) on breathing
· Tactile vocal fremitus (“99”)
Percuss
· Back & axillae: stony dull for effusion, hyperresonant for hyperexpansion, PTX
Auscultate
· Breath sounds
o Vesicular (normal over lung)
o Bronchial (normal over trachea)
· Adventitious sounds
o Stridor
o Wheezes – exp>insp usually. Imply
airway narrowing. Fixed wheeze - ?lung
Ca
o Crackles (high freq = crepitations, low
freq = rales)
Early inspiratory crackles – COPD
Late/pan-inspiratory crackles
· Fine – pulmonary fibrosis
· Medium - LVF
· Coarse - Bronchiectasis, retention of secretions
· Vocal resonance
o Muffled over normal lung, aegophony or whispering pectoriloquy over consolidation
Anterior chest
Inspect
· Radiotherapy marks
· Subcutaneous emphysema
· Upper chest expansion
Percuss
· Supraclavicular regions, clavicles, ant chest
· Liver upper edge (usually 5icsmcl)
· Auscultate
· As shown.
· Note a pleural rub (pleurisy, PE, pneumonia) or displaced apex beat
Assess for Right Heart Failure
Inspect JVP – if elevated then:
· Check for Pemberton’s sign for SVC obstruction (arms over head >1min → facial plethora)
· Auscultate the heart
· Palpate/Percuss the liver
· Examine the legs for oedema
Other
Temperature
Recent chest x-ray
PEFR/Spirometry