Examination Flashcards
Explain a respiratory examination to a patient
“Today I’ve been asked to perform a Respiratory examination, do you understand what this will involve?”
• “The examination will involve me first inspecting your chest, then placing my hand on your chest to assess the movement while you breathe. Finally, I will listen to your breathing with my stethoscope. I will also need to briefly examine your lower legs and back”
• “Would you like a chaperone in the room?.”
• “Does everything I’ve said make sense? Are you happy for me to proceed?
• “Do you have any questions?”
How to prepare your patient for a respiratory exam.
Ask the patient to undress down to their waste behind the curtain- bra can stay on, offer a blanket
Adjust bed to 45degrees
Ask the patient to expose their lower legs
Ask the patient if they have any pain prior to proceeding
What are you looking for in a general inspection during a respiratory examination?
General Appearance
• Age
• Cachexia (loss of muscle mass)
• Oedema
• Pallor
• Cyanosis
Specific Respiratory Signs
• Shortness of breath
• Cough
• Wheeze
• Stridor
• Accessory muscle use
General bedside inspection during a respiratory examination
Oxygen
Sputum pots
Cigarettes
Vapes
Inhalers/nebulisers
Catheter
Mobility aids
Hand inspection during respiratory examination
Fine tremor
• Seen with excess salbutamol use
Asterixis
• A.k.a ‘flapping tremor’ – sign of CO2 retention
• Hands stretched outwards, cocked backwards for 30 seconds
Palpation
• Temperature
• Heart rate – Normal is 60-90
• Respiratory rate – Normal is 12-20. Top tip – take at the same time as palpating radial pulse
General Obs:
Colour
Tar staining
Skin changes ie thinning
Joint swelling or deformity
Finger clubbing
Face inspection during respiratory examination
• General
• Erythematous face – could represent polycythaemia or CO2 retention seen in COPD
• Eyes
• Conjunctival pallor – indicative of anaemia
• Horner’s syndrome – can be caused by a lung cancer affecting the apex of the lung – such as a Pancoast tumour
• Mouth
• Central cyanosis -hypoxaemia
• Oral candidiasis – steroid inhaler use
Jugular venous pressure
Measure the JVP with the patient positioned correctly at 45 degrees
Good measure of central venous pressure as there are no valves between the right atrium and the IJV
Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV - this should be <3cm in a healthy individual
Primary respiratory cause of a raised JVP is Pulmonary Hypertension as a result of right- sided heart failure
Elicit hepatojugular reflex if appropriate – in a healthy individual, it should transiently rise and then go back to normal, if the rise is sustained or >4cm, then this is deemed a positive result, i.e. a ‘raised’ JVP.
Trachea and cricosternal distance in a respiratory examination
Tracheal position:
Chin relaxed down
Find both lateral borders of the trachea with your fingers – may be uncomfortable for the patient
Ensure the space on each side is equal
If unequal -> tracheal deviation, deviates towards= collapse and away=a tension pneumothorax
Cricosternal distance
Distance between the suprasternal notice and cricoid cartilage – should be 3-4 fingers (width of patient’s fingers)- may need to use the patients fingers
If the distance is small, may represent hyperinflation. E.g. Severe COPD
What are you looking for during a detailed chest inspection during respiratory exam?
Scars:
Medial sternotomy scar – CABG/VR
Posterolateral thoracotomy scar – lobectomy/pneumonectomy
Chest wall deformities:
Asymmetry: May be caused by a pneumonectomy
Pectus excavatum: Caved-in appearance of the chest
Pectus carinatum: Sternum and ribs protrude outwards
Hyperexpansion: ‘Barrel chest’ - seen in COPD
Palpation of the chest during respiratory examination
Apex beat:
Palpate apex beat – fingers horizontally across the chest, should be in the 5th IC space, MC line
• May be displaced in RVH, large pleural effusion
Chest expansion:
• Wrap your hands around the patient chest, below the nipples, thumbs touching in midline. Do anterior and posterior
• Ask patient to take a deep breath – should move symmetrically up and out
• May be symmetrically reduced in IPF or unilaterally reduced in pneumothorax
Percussion:
• Non-dominant hand on chest wall, middle finger firmly pressed against chest wall
• Briskly strike the finger with your dominant middle finger, swinging your wrist
• Supraclavicular, infraclavicular, chest wall x 4 bilaterally, axilla
Resonant = lung
Hyper resonant = pneumothorax
Dull = consolidation
Stony dull = fluid eg pleural effusion
Auscultation of the chest
Auscultate with the diaphragm of your stethoscope:
• Anterior • Posterior • Axilla
Patient should be asked to breathe deeply in and out through their mouth. Listen to each lung region through inspiration and expiration.
Auscultate each side of the chest at each location to enable direct comparison.
Listen for:
Quality of breath
Volume of breath
Added sounds: wheeze, stridor, coarse crackles, fine crackles
Vocal resonance: ask the patient to say “99” whilst you auscultate over the lung fields (reduced = collapse, increased = consolidation)
Lymph node examination during a respiratory examination
Palpate the patients lymph nodes – patient should be sat in front of you with their chin pointing downwards:
Submental
Submandibular
Pre-auricular
Post-auricular
Superficial cervical
Deep cervical
Posterior cervical
Supraclavicular
Peripheral examination for a respiratory examination
Finally perform a general examination of the following areas:
Look for swelling and redness
• Lower legs – peripheral oedema, signs of DVT, erythema nodosum
• Sacrum - oedema
How to complete a respiratory examination
• Thank patient
• Cover patient up with a blanket / sheet / put clothes back on
• Leave the room and allow them time to re-dress
• Wash hands
• Summarise findings
• Suggest further assessments and investigations
• Sputum sample
• PEFR
• CXR
• ECG
