Respiratory system examination


Respiratory system examination
Before starting
  • Introduce yourself to the patient.
  • Confirm his name and date of birth.
  • Explain the examination and obtain his consent.
  • Position him at 45°, and ask him to remove his top(s).
  • Ask him if he is in any pain or distress.
  • Ensure that he is comfortable.
  • Wash your hands.
The examination (IPPA)
General inspection
    • From the end of the couch, observe the patient’s general appearance (age, state of health, nu- tritional status, and any other obvious signs). In particular, is he visibly breathless or cyanosed? Does he have to sit up to breathe? Is his breathing audible? Are there any added sounds (cough, wheeze, stridor)?
    • Note:
      • –  the rate, depth, and regularity of his breathing
      • –  any deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine
      • –  any asymmetry of chest expansion
      • –  the use of accessory muscles of respiration and planting of hands
      • –  the presence of operative scars, including in the axillae and around the back
    • Next observe the surroundings. Is the patient on oxygen? If so, note the device (see Tables 40 and 41 in Station 113), the concentration (%), and the flow rate. Look in particular for inhalers, nebulisers, peak flow meters, intravenous lines, chest drains, and chest drain contents. If there is a sputum pot, make sure to inspect its contents.
Inspection and examination of the hands
  • Take both hands and assess them for temperature and colour. Peripheral cyanosis is indicated by a bluish discoloration of the fingertips.
  • Test capillary refill by compressing a nail bed for 5 seconds and letting go. It should take less than 2 seconds for the nail bed to return to its normal colour.
  • Look for tar staining and finger clubbing. When the dorsum of a finger from one hand is opposed to the dorsum of a finger from the other hand, a diamond-shaped window (Schamroth’s window) is formed at the base of the nailbeds. In clubbing, this diamond-shaped window is obliterated, and a distal angle is created between the fingers (see Figure 9). Respiratory causes of clubbing include carcinoma, fibrosing alveolitis, and chronic suppurative lung disease (see Table 8).
  • Inspect and feel the thenar and hypothenar eminences, which can be wasted if there is an apical lung tumour that is invading or compressing the roots of the brachial plexus.
  • Test for asterixis (see Table 9), the coarse flapping tremor of carbon dioxide retention, by asking the patient to extend both arms with the wrists in dorsiflexion and the palms facing forwards. Ideally, this position should be maintained for a full 30 seconds. Note that generalised fine tremor may be related to excessive use of B2 agonist.
  • During this time, assess the radial pulse and determine its rate, rhythm, and character. Is it the bounding pulse of carbon dioxide retention?
  • Indicate that you would like to measure the blood pressure.
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Cardiovascular and respiratory medicine
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Station 17 Respiratory system examination
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Figure9. Clubbing.Whenthedorsumofafingerfromonehandisopposedtothedorsumofafingerfromthe other hand, a diamond-shaped window is formed at the base of the nailbeds. In clubbing, this diamond-shaped window is obliterated, and a distal angle is created between the fingers.
Table 8. The principal causes of clubbing
Respiratory causes
Bronchial carcinoma
Fibrosing alveolitis
Chronic suppurative lung disease
Cardiac causes
Infective endocarditis Cyanotic heart disease
Gastrointestinal causes
Cirrhosis Ulcerative colitis Crohn’s disease Coeliac disease
Familial

Table 9. The principal causes of asterixis
Hepatic failure
Renal failure
Cardiac failure
Respiratory failure
Electrolyte abnormalities (hypoglycaemia, hypokalaemia, hypomagnesaemia) Drug intoxication, e.g. alcohol, phenytoin
CNS causes
Inspection and examination of the head and neck
  • Inspect the patient’s eyes. Look for a ptosis (an upper lid that encroaches upon the pupil) and for anisocoria (pupillary asymmetry). Ipsilateral ptosis, miosis, enophthalmos, and anhidrosis are strongly suggestive of Horner’s syndrome, which may result from compression of the sym- pathetic chain by an apical lung tumour.
  • Next inspect the sclera and conjunctivae for signs of anaemia.
  • Ask the patient to open his mouth and inspect the underside of the tongue for the blue discol-
oration of central cyanosis.
  • Assess the jugular venous pressure (JVP) and the jugular venous pulse form (see Station 13). A
raised JVP is suggestive of right-sided heart failure.
Clinical Skills for OSCEs
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Station 17 Respiratory system examination
  • Examine the lymph nodes from behind with the patient sitting up. Have a systematic routine for examining all of the submental, submandibular, parotid, pre- and post-auricular, occipital, anterior cervical, posterior cervical, supra- and infra-clavicular, and axillary lymph nodes (see Station 9).
  • Palpate for tracheal deviation by placing the index and middle fingers of one hand on either side of the trachea in the suprasternal notch. Alternatively, place the index and annular fingers of one hand on either clavicular head and use your middle finger (called the Vulgaris in Latin) to palpate the trachea.
Palpation of the chest
Ask the patient if he has any chest pain.
  • Inspect the chest more carefully, looking for asymmetries, deformities, and scars.
  • Inspect the precordium and palpate for the position of the cardiac apex. Difficulty palpating for the position of the cardiac apex may indicate hyperexpansion, although this is not a specific
sign.
[Note] Carry out all subsequent steps on the front of the chest and, once finished, repeat them on the back of the chest. This is far more elegant than to keep asking the patient to bend forwards and backwards like a Jack-in-the-box. Pulmonary anatomy is such that examination of the back of the chest yields information about the lower lobes, whereas examination of the front of the chest yields information about the upper lobes and, on the right-side, also the middle lobe (Figure 10).
• Palpate for equal chest expansion, comparing one side to the other. Reduced unilateral chest expansion might be caused by pneumonia, pleural effusion, pneumothorax, and lung collapse. If there is a measuring tape, measure the chest expansion.
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Lower lobe
Upper lobe
Middle lobe
Figure10. Arightlateralviewdemonstratinglobar anatomy. Posterior assessment gives information about the lower lobes, whereas examination from the front looks at the upper and middle lobes (the latter only on the right).
Cardiovascular and respiratory medicine
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Station 17 Respiratory system examination
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Figure11. Palpatingforequalchestexpansion:upper,middleandlowerlobes. Percussion of the chest
  • Percuss the chest. Start at the apex of one lung, and compare one side to the other. Do not forget to percuss over the clavicles and on the sides of the chest. For any one area, is the reso- nance increased or decreased? A hyper-resonant or tympanic note may indicate emphysema or pneumothorax, whereas a dull or stony dull note may indicate consolidation, fibrosis, fluid, or lung collapse. If you uncover any variation in the percussion note, be sure to map out its geographical extent.
  • Test for tactile fremitus by placing the flat of the hands on the chest and asking the patient to say “ninety nine”.
Auscultation of the chest
  • Ask the patient to take deep breaths through the mouth and, using the diaphragm of the steth- oscope, auscultate the chest in the same locations as for percussion. Start at the apex of one lung, in the supraclavicular fossa, and compare one side to the other. Normal breath sounds are described as ‘vesicular’ and have a low pitched and rustling quality. Reduced breath sounds may indicate consolidation. Listen carefully for added sounds such as wheezes (rhonchi), crack- les (crepitations), bronchial breathing, and pleural friction rubs.
  • Test for vocal resonance by asking the patient to say “ninety nine”. Both consolidation and pleural effusions can lead to a dull percussion note, but in consolidation vocal resonance is increased whereas in pleural effusion it is decreased. Both vocal resonance and tactile fremitus (see above) provide the same sort of information.
Inspection and examination of the legs
• Inspect the legs for erythema and swelling. Palpate for tenderness and pitting oedema. A unilateral red, swollen, and tender calf suggests a DVT, whereas bilateral swelling may indicate right-sided heart failure.
Clinical Skills for OSCEs
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Station 17 Respiratory system examination
After the examination
  • Indicate that you would look at the observations chart, examine a sputum sample, measure the peak expiratory flow rate, and order some simple investigations such as a chest X-ray and a full blood count.
  • Cover the patient up and ensure that he is comfortable.
  • Thank the patient.
  • Wash your hands.
  • Summarise your findings and offer a differential diagnosis.