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Outline the basic structure of a respiratory examination

- Introduction and explanation
- Inspection
- Palpatation
- Percussion
- Auscultation


What should you look for during a general inspection?

- Does the patient look unwell? Cachectic? In pain?
- Use of accessory muscles / work of breathing
- Look around the patient
- Look at the patient
- Listen (audible stridor, hoarsness, pattern of speach)
- If any pathological signs, think,
What is the underlying cause
How does this relate to history
Does it increase the likelihood of respiratory pathology


What would be used in more serious conditions a nebuliser or an inhaler?

A nebuliser


What is stridor?

- Loud, harsh, high pitched respiratory sound
- Usually on inspiration
- Upper airway obstruction


What is erythema nodosum?

Swollen areas of fat under skin. Typically on shins. Red/purple discolouration.
Associated with pneumonia, sarcoid, tb and IBS.


What should you do upon close inspection and palpatation?

- Examine hands - inspect
palpate for warmth and venodilation, flapping tremour and fine tremour, palpate radial pulse (rate and rhythm)
- Count respiratory rate
- Inspect face, eyes, mouth and pharynx


Where can you see central cyanosis?

- Lips
- Tongue


What are the respiratory causes of clubbing?

- Bronchial carcinoma
- Mesothelioma
- Chronic suppurative lung disease
Lung abcess
- Pulmonary fibrosis
- Cystic fibrosis


What is mesothelioma?

Cancer of the lining of the lungs (often linked to asbestos exposure)


What does a 'ruddy' complexion

Acutely low oxygen (due to increased levels of haemoglobin.


What is high haemoglobin called?



What are the clinical features of horner's syndrome?

- Unilateral miosis
- Partial ptosis
- Loss of sweating on same side (facial anhidrosis)


What does a fine tremor indicate?

Excessive use of B-agonists


What is a flapping tremor?

- Severe ventilatory failure with CO2 retention
- Hold hands outstreched
- Wrists cocked-back
- Look for a jerky, flapping tremor
- Associated confusion


What should you look at when inspecting the chest and neck closely?

- Scars - cardiac surgery, thoracotomy, chest drain scars
- Pattern of breathing
- Shape of chest
Deformity (kyphoscliosis / pectus excavatum)
Increase in A-P diameter ('barrel shaped')
- Prominant veins on chest wall (SVC obstruction)


What is pectus excavatum?

Structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally. This produces a caved-in or sunken appearance of the chest.
Affects lung function


What can SVC obstruction appear like?

Visible vein distribution on chest


What are the lymph nodes which need to be palpated during the respiratory examination?

- Postauricular
- Preauricular
- Occipital
- Periparotid
- Tonsillar
- Posterior cervical
- Supraclavicular
- Submental
- Anterior cervical
- Submandibular


What should you look for when palpating the chest?

- Subcutaneous ('surgical') emphysema (if appropriate)
- Palpate for rib fractures if appropriate (e.g history of chest trauma)


What is subcutaneous emphysema?

- Air in subcutaneous tissues
- Crackiling sensation under skin
- May be diffuse chest, neck, face swelling
- Consider trauma / pneumothorax


What is pneumothorax?

A collection of air in the pleural cavity, between lung and chest wall, resulting in collapse of lung on affected side.


What should be palpated/checked on the neck and chest?

- Tracheal position
- Cardiac apex
- Assessment for right ventricular heave


How should the trachea be palpated?

- On suprasternal notch
- Right middle finger 2cm superior to notch
- Gently press down and back
- Palpate spce to either side
- Should be central


What conditions result in displacement of the trachea towards the lesion?

- Lobar collapse
- Pneumonectomy
- Pulmonary fibrosis


What conditions result in displacement of the trachea away from the lesion?

- Large pleural effusion
- Tension pneumothorax


When palpating the chest how can you tell the lungs are expanding equally?

The thumbs should move apart equally


How should you percuss the chest?

- Percuss anterior, posterior and lateral chest
- Use middle finger / left hand
- Apply firmly to patient's chest
- Strike it's middle phalanx with the middle finger of right hand
- Percuss over intercostal spaces
- However percuss clavicles directly
- Compare left and right
- Listen to note produced


What does a resonant note indicate when percussing the chest?

Air / normal lung


What does a dull sound indicate when percussing the chest?

- Collapse
- Consolidation
- Fibrosis
(liquid or solid)


What does a hyper resonant sound indicate when percussing the chest?

- Emphysema
- Large bullae
- Pneumothorax