Summary of Respiratory Examination
Basic flow of events
1. GIEP
2. Wash Hands
3. General inspection
4. Hands and arms
a. Fingernails
b. fingers
c. Dorsal aspect
d. Palmar aspect
5. Tremors
a. Flapping tremor
b. Fine tremor
6. Pulse rate / breathing rate
7. Face
a. Eyes
b. nose
c. mouth
8. Neck
a. Inspection
b. Palpation
i. Tracheal deviation
ii. Crico-sternal distance
9. Chest
a. Inspection
b. Palpation
i. Apex deviation
ii. Lung expansion
iii. Vocal tactile phremitus
c. Percussion
d. Auscultation
i. Vocal resonance
ii. Breathing sounds
10. Thank patient, wash hands and leave
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General inspection
As usual, check first for -
· Alertness
· Consciousness
· Position - should be 45deg
· Respiratory distress -
o know HOW to see if there is a respiratory distress.
§ In respiratory distress, the trapezius and sternocleidomastoid muscles contract during inspiration.
§ The accessory muscles assist in ventilation; they raise the clavicle and anterior chest to increase the lung volume and produce an increased negative intrathoracic pressure.
§ This results in retraction of the supraclavicular fossae and intercostal muscles. An upward motion of the clavicle of more than 5 mm during respiration has been associated with severe obstructive lung disease.[i]
· Obvious pain
o Look for any pleural pain, or pain in the throat / neck while breathing.
· Built
· Nutritional status
· Gross deformities
· Extra gadgets
o E.g oxygen masks, etc
Hands/arms
· Fingernails
o Clubbing
§ Check using all 3 methods
§ Respiratory causes of clubbing -
· Primary and metastatic lung cancer,
· bronchiectasis,
· lung abscess,
· cystic fibrosis,
· mesothelioma
o capillary refill
§ press for 30seconds , (in practice, 10sec is enough) the blood should return in less than 3 seconds.
o Cyanosis
§ Look for bluish tinge on the fingernails. By definition, cyanosis is evident in >2.5g/dL of reduced haemoglobin (O2 sats about 85%)
o yellow nail syndrome
§ (very rare syndrome that include pleural effusion, lymphoedema and yellow dystrophic nails)
§ Associated with chronic sinusitis, bronchiectasis and coughing.
· Fingers
o Look at tar staining. Yellow discolouration, usually at index finger and middle finger.
· Dorsal
o Any scars, swellings or discolouration
· Palmar
o Muscle wasting in the thenar and hypothenar eminences
o Jaundice at palmer crease
Tremors
Take care as this is very easily forgotten.
· Fine tremor
o Ask patient to put the arms horizontal to ground, and close eyes. Put a paper on the arm. If paper is shaking, fine tremor is present
o Indicative of B agonist drug usage such as salbutamol
· Flapping tremor (asterixis)
o Flapping when holding the hands upright and dorsiflexed with fingers abducted,
o Make sure you ask patient to close eye
o Push the patients hands towards dorsiflexed position to ensure full forsiflexion.
o Ask patient to hold in that position for 30 seconds.
o Positive sign is hands flapping
§ Positive sign seen in CO2 retention.
§ Also seen in hepatic failure.
Pulse rate / breathing rates
· Take the pulse rate.
o Ideally for one full minute - if insufficient time, take for 30sec and multiply by 2.
· Respiratory rate
o At the same time, take the respiratory rate PRETENDING like you are taking the pulse rate.
§ Reason being the patient can control their breathing. Must take unnoticed.
Face
· Eyes
o Pallor and jaundice
o Horner’s syndrome
§ signs
· Enophtalmous
· Anhydrosis
· Miosis
· Partial ptosis
§ Mechanism
· apical lung tumour compressing the sympathetic nerves in the neck
· Nose (use pen-torch)
o Nasal discharge
o Polyps
§ Associated with asthma
o Deviation of Nasal septum
§ Nasal obstructions
o Engorging of turbinates?
§ Suggests allergic conditions
o Any signs of inflammation
o obstructions
· Lips
o Peripheral cyanosis
o Hydration status -lips moist?
o Cleft lip
· Mouth
o Oral hygene
§ A broken tooth or a stump may predispose to lung absess or pneumonia.
o Cleft palate
o Tonsils - any inflammation? Any abnormalities like white patches? (strep throat)
o Uvula - any deviation?
o Pharyngeal inflammation
· Tongue
o Cyanosis
o Pallow
o Jaundice
o Central cyanosis
o Hydration status
Neck
· Tracheal deviation
o This is to check if the mediastinal position has shifted or not.
o Check for tracheal deviation using 3 fingers - put 2 outer fingers on a reference point (such as the 2 heads of the clavicles) and feel the trachea from the thyroid process to the mid-point of 2 reference points .
o The trachea will be deviated away from the lesion in case of…
§ Pleural effusion
§ Tension Pneumothorax
§ Gross cardiomegaly
o The trachea will be deviated towards (pulled towards) lesion in case of…
§ pneunectomy
§ Lung collapse
§ Upper love interstitial fibrosis
o The trachea can be either pushed or pulled in the presence of a large mass. (consolidation)
· Cricosternal distance
o Cricosternal distance is the distance between the cricoid cartilage to the sternum.
o Measure cricosternal distance by first finding the cricoids cartilage, and putting 3 fingers posterior to it. The cricosternal distance should be roughly more than 3 fingers (at least 4cm?)
o It is Decreased in hyperinflation (e.g. in long-standing asthma, or COPD)
· Tracheal Tug
oTracheal tug can be elicited by holding onto the cricoid process with the thumb and index fingers - and asking the patient to breathe in and out. when positive, the trachea will be pulled downwards with inspiration. it is rarely seen in Chronic COPD.
more commonly, in Aortic arch aneurism or lymphoma.
It can also be done by putting two fingers below the cricoid process, and your finger will be "pinched" when the patient breathes in.
more commonly, in Aortic arch aneurism or lymphoma.
It can also be done by putting two fingers below the cricoid process, and your finger will be "pinched" when the patient breathes in.
Chest
· Inspection
o Scars, swellings, discolouration
o Chest movement with respiration
§ Go to the foot of the bed, ask patient to breathe in and out deeply through the mouth.
§ Comment if equal, or not.
§ Chest movement on affected side reduced in -
· localised pulmonary fibrosis, consolidation, collapse, pleural effusion or pneumothorax.
§ Bilateral reduction of chest wall movement indicates a diffuse abnormality such as chronic obstructive pulmonary disease or diffuse pulmonary fibrosis.
o Paradoxical movement of ribs - Flail Chest
§ A flail chest is a chest configuration in which one chest wall moves paradoxically inward during inspiration. This condition is seen with multiple rib fractures.
o Gross deformities
§ Pectus carinatum
· Pectus carinatum, or pigeon breast, which results from an anterior protrusion of the sternum, is a common deformity but does not compromise ventilation
§ Pectus excavatum
· Pectus excavatum, or funnel chest, is a depression of the sternum that produces a restrictive lung problem only if the depression is marked. Patients with pectus excavatum may have abnormalities of the mitral valve, especially mitral valve prolapse
o Barrel chest
§ An increase in the anteroposterior diameter is seen in advanced chronic obstructive pulmonary disease. The anteroposterior diameter tends to equal the lateral diameter, and a barrel chest results.
§ Comment on the presence / absence of this by actually estimating the transverse diameter of the chest, and compare with the anteroposterior diameter of the patient’s chest.
· Palpation
o Localization of apex
§ This is another mediastinal shift check. In respiratory system, it is not AS important as in the Cardiovascular examination - you need not comment on the character.
§ Localize the apex as you would with cardiovascular examination.
§ The apex will be shifted in the same way as it would, for tracheal shift.
o Chest expansion
§ Place the hands firmly on the chest wall with the fingers extending around the sides of the chest.
§ The thumbs should almost meet in the middle line and should be lifted slightly off the chest so that they are free to move with respiration
§ As the patient takes a big breath in, the thumbs should move symmetrically apart at least 5 cm.
§ Reduced expansion on one side indicates a lesion on that side. The causes have been discussed above
o Tactile vocal phremitus
§ Instruct patient to say “ninety nine” when your hand touches the patient’s body.
§ Remember to perform on the apical part.
§ This maneuver examines the transmission of sound from the lungs to the surface of the body.
§ Increased vocal phremitus in…
· Consolidation
§ Decreased vocal phremitus in…
· Lung collapse
· Pleural effusion
· Pneumothorax
·
Auscultation
Auscultation
o Vocal resonance
§ Basically testing the same thing with tactile vocal phremitus - however this time you use your ears instead of your tactile senses.
o Breathing sounds
§ Auscultate for breathing sounds.
§ Comment if you hear a “normal vesicular sound” or “bronchial sound” etc.
§ Comment on the presence/absence of pleural rubs, crackles or rhonchi. Make sure you know what those are.
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o are short, discontinuous, nonmusical sounds heard mostly during inspiration.
o Also known as rales or crepitation, crackles are caused by the opening of collapsed distal airways and alveoli.
o A sudden equalization of pressure seems to result in a crackle.
o Coarser crackles are related to larger airways.
o Crackles are likened to the sound made by rubbing hair next to the ear or the sound made when Velcro is opened.
o They may be described as early or late, depending on when they are heard during inspiration.
o The most common causes of crackles are pulmonary edema, congestive heart failure, and pulmonary fibrosis.
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· Wheezes
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o They are produced by airflow through narrowed bronchi.
o This narrowing may be due to swelling, secretions, spasm, tumor, or foreign body.
o Wheezes are commonly associated with the bronchospasm of asthma.
Wheeze is what you hear WITHOUT a stethoscope- hence, do not report on Wheeze after auscultation. Rhonchi is the correct term to use. use Wheeze upon inspcetion / GPE..
· Rhonchi
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Rhonchi are lower-pitched, more sonorous lung sounds. They are believed to be more common with transient mucus plugging and poor movement of airway secretions.
· Pleural rub
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Signs of...
- Hyperinflation
- upon inspection, there may be barrel-chest (there may be not)
- chest expansion may be reduced bilaterally.
- decreased crico-sternal distance
- Absent cardiac dullness upon percussion of lungs on left parasternal edge.
- Liver will be pushed down - can be found through percussion
- tracheal tug
- paradoxical movement of lower ribs (that is, ribs moving in with inspiration - if you are a young, fit male I suggest you try inspiring until maximum, and try to inspire a little more - you will appreciate that your ribs will move inwards. if you are a girl, ask a fit male to demonstrate it for you ; )
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